Admission to intensive care reflects both the seriousness of the patient’s condition and the intensity of the treatments being provided. These treatments cannot always save a person’s life. No treatment is without risk, and any treatment may cause complications or suffering. This is why the goals of care and treatment plan must be continually adjusted to the patient’s individual and changing condition, as well as to their wishes and values. The accounts provided by family members and friends are extremely valuable to the care team, helping them understand who the patient is and what the patient would want for themselves.
French law provides two ways of establishing the wishes of an unconscious patient when decisions about goals of care are being made: the designated trusted person and advance directives. Advance directives allow people to record their wishes in advance in case they later become unable to express them. They can be written in any form, based on the template provided by the French Ministry of Health, or completed using the intensive-care-specific form provided by the French Intensive Care Society.
During an intensive care stay, changes in the patient’s condition may lead the team to reconsider whether ongoing treatments remain appropriate. If burdensome and sometimes invasive treatment is not expected to provide any benefit, the team may decide not to use certain treatments, to stop others, or to focus exclusively on comfort. French law prohibits what it calls “unreasonable persistence with treatment”. Providing the most appropriate care can sometimes require a delicate balance, but ICU teams are particularly vigilant about this issue. Do not hesitate to share any doubts, concerns or questions you may have about your loved one’s care.
When a treatment would not benefit a patient, or is no longer providing benefit, it may be withheld or stopped in order to minimise the discomfort, pain and distress it causes. Since 2004, and more recently since 2016, the Leonetti and Claeys–Leonetti laws have governed what are known in France as decisions to limit or withdraw treatment. These decisions are made collectively by the care team, with input from an external consultant, taking account of the patient’s expressed wishes and keeping those close to the patient fully informed. They are reviewed every day as the patient’s condition evolves.
Stopping certain treatments that are artificially sustaining life may hasten the dying process. Where this occurs, the care team will introduce or intensify palliative care—care intended to provide comfort and relieve symptoms. Since 2016, French law has permitted “deep and continuous sedation until death”, helping ensure that the patients concerned are as comfortable as possible at the end of life.
Decisions to withhold and/or withdraw treatment are medical decisions based on consultation between professionals from several disciplines—the French “collective decision-making procedure”. They take account of the patient’s previous health, current condition, prognosis, available treatments and their inherent risks, as well as the patient’s wishes and values. The accounts given by family members and friends are essential to making the most appropriate decision for each patient, and their views are always sought. However, the final decision remains a medical one, so that relatives do not have to carry the burden of the decision or its consequences.
If the patient has appointed a designated trusted person, French law states that this person’s account takes precedence over that of other family members. Whenever a decision to withhold or withdraw treatment is being considered, it is important for those close to the patient to describe the patient’s wishes and values while setting aside, as far as possible, their own feelings and wishes. Speaking with the care team or a psychologist can help you separate the two and contribute to a plan of care that is as consistent as possible with what your loved one would have wanted for themselves.