Decisions and therapeutic project
Therapeutic project
Admission to the ICU 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 of them can cause complications but also suffering for the patient. This is the reason why it is essential that the therapeutic project be adjusted to the patient’s unique and constantly changing health situation but also to its wishes and values. For this reason, the testimonies of family members are extremely valuable to the care teams in order to better understand who the patient is and what he or she would like for him or herself.
French law provides for two possibilities to collect the wishes of an unconscious patient in the context of decisions about a therapeutic project: the trusted person and the advance directives. Advance directives are a way to write down your wishes in advance in case you are unable to give your opinion. They can be written on plain paper, use the template proposed by the Ministry of Health or use the specific form for resuscitation proposed by the French Resuscitation Society.
Unreasonable obstinacy (or relentless treatment)
During the stay in the intensive care unit, the evolution of the patient’s state of health may lead to questions about the appropriateness of the treatments in progress. The absence of expected benefit despite heavy and sometimes aggressive care for the patient may lead to limiting the use of certain treatments or interrupting others, or even to limiting treatment to ensure comfort. Indeed, in France, unreasonable obstinacy is prohibited by law. The best possible care sometimes requires a subtle balance to be found, but rest assured that the intensive care teams are very vigilant on this point. Do not hesitate to submit your doubts, concerns or possible misunderstandings about the care of your loved one to them.
Limiting and stopping treatment
When a patient will not benefit from certain treatments, or no longer benefits from the treatments that have been put in place, and in order to minimize the discomfort, pain and anguish they cause, these treatments may not be started or may be discontinued. Since 2004, and more recently in 2016, the Léonetti and Claeys-Leonetti laws provide a framework for what is known as decisions to “limit and stop treatment” (LAT). These decisions are made in consultation with the entire health care team and an outside consultant, taking into account the patient’s expressed wishes and informing the patient’s family and friends. These decisions are re-evaluated every day according to the evolution of the patient’s condition.
Withdrawal of certain life-sustaining treatments can accelerate the dying process. Where appropriate, health care teams initiate or reinforce palliative care, care aimed at comfort and relief of symptoms. Since 2016, French law has authorized “deep and continuous sedation until death,” allowing the end of life to be as comfortable as possible for the patients involved.
The role of relatives in treatment limitations
Decisions to limit and/or stop treatment are medical decisions based on a 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. The testimonies of relatives are crucial to making the most appropriate decisions for each patient, and their opinion is systematically sought, however the decision remains medical, thus avoiding placing the burden of these decisions and their consequences on the relatives.
If a trusted person has been designated by the patient, the law provides 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 discussed, it is important that the relatives be able to reflect the patient’s wishes and values by putting their feelings and their own wishes aside as much as possible. Talking with the health care team or a psychologist can help you sort things out and help you build for your loved one the care plan best suited to what he would have wanted for himself.
