Admission to intensive care is a sign of the seriousness of the patient’s situation, but also of the intensity of the treatments implemented. These treatments are not always sufficient to save life; no treatment is harmless, and all can lead to complications and suffering for the patient. That’s why it’s essential that the therapeutic plan is tailored to the patient’s unique and constantly evolving health situation, as well as to his or her wishes and values. To this end, the views of loved ones are extremely valuable to care teams, enabling them to better understand who the patient is and what he or she would like for him- or herself.
Under French law, there are two ways of gathering the wishes of an unconscious patient when it comes to making decisions about a therapeutic project: the the trusted person person (personne de confiance) and advance directives (directives anticipées). Advance directives are a means of writing down one’s wishes in advance, in the event of incapacity to give one’s opinion. They can be written on plain paper, using the template proposed by the Ministry of Health, or using the specific form for resuscitation proposed by the French Resuscitation Society
During a patient’s stay in intensive care, the evolution of his or her state of health may lead us to question the appropriateness of current treatments. The lack of expected benefit, despite heavy and sometimes aggressive treatment, may lead to the use of certain treatments being limited, or others discontinued, or even limited to treatments designed to ensure comfort. In France, unreasonable obstinacy is forbidden by law. Ensuring the best possible care sometimes requires striking a subtle balance, but rest assured that our intensive care teams are very vigilant on this point. Don’t hesitate to share your doubts, concerns or misunderstandings about your loved one’s care with them.
When a patient will not benefit from certain treatments, or no longer benefits from treatments that have been put in place, and in order to keep the discomfort, pain and anguish they cause to a minimum, these treatments may not be undertaken or may be stopped. Since 2004, and more recently in 2016, the Léonetti and Claeys-Leonetti laws have provided a framework for what are known as “treatment limitation and cessation” (LAT) decisions. These decisions are made in consultation with the entire healthcare team and an outside consultant, taking into account the patient’s expressed wishes and keeping the patient’s family and friends fully informed. These decisions are re-evaluated every day as the patient’s condition evolves.
Discontinuing certain life-sustaining treatments may accelerate the dying process. In such cases, care teams implement or reinforce palliative care, aimed at comfort and symptom relief. Since 2016, French law has authorized “deep and continuous sedation until death”, enabling the end of life to be as comfortable as possible for the patients concerned.
Decisions to limit and/or discontinue treatment are medical decisions based on multi-professional and multi-disciplinary consultation (the “collegial procedure”), taking into account the patient’s initial condition, pathology, prognosis (possible futures in the patient’s situation), possible therapies and their inherent risks, as well as the patient’s wishes and values. Relatives’ input is crucial to making the most appropriate decisions for each patient, and their opinion is systematically sought. However, the decision remains a medical one, thus avoiding placing the burden of these decisions and their consequences on the relatives.
If a trusted person person has been designated by the patient, the law stipulates that his or her testimony takes precedence over that of other family members. In all cases, when a decision to limit or stop treatment is being discussed, it is important that family members are able to testify to the patient’s wishes and values, putting their own feelings and wishes aside as far as possible. Discussions with the care team or a psychologist can help you to sort things out, and help you to build the care plan for your loved one that is best suited to what he or she would have wanted for themselves.