In France, a person suffering from an incurable illness can request to benefit from deep and continuous sedation maintained until death (SPCMD). It differs from euthanasia.
Sedation is defined by recourse to means, most often medicinal, to relieve and soothe a suffering patient. Sedation takes into account the comfort of the patient and their environment to help them relieve their physical and psychological pain. It is often used to provide care and reduce the pain felt by the patient, particularly during a stay in intensive care. Depending on the patient’s level of consciousness, sedation can be deep and continuous until death, palliative or light. During mild sedation, the person may appear to be asleep but opens their eyes and/or responds to being spoken to and/or touched. In deep and continuous sedation until death, she only allows death to occur in conditions of improved comfort for the person.
What is deep, continuous sedation?
Since February 2016, the Claeys-Leonetti law has offered France a right to “deep and continuous sedation” until death for terminally ill people. This practice involves putting a patient into deep sleep to ensure that they are no longer in pain even though their death is imminent and inevitable. During deep sedation, the person sleeps and does not respond to voice or touch. This deep sedation is put in place after thestopping treatments. This is what Jean Leonetti called “the right to sleep before dying so as not to suffer” (article L. 1110-5-2). In 2005, the Léonetti law relating to the rights of patients and the end of life wished proscribe a possible “unreasonable obstinacy” from the medical profession to “artificial extension of life” of the patient (articles 1 and 9), including when the latter is unable to express his wishes. In 2022, the Kouchner law allowed any person suffering from an incurable illness decide for herself whether to continue or stop treatment. “She also has the possibility of designating a trusted person regarding her health, in particular to inform the medical profession of her choices if she is no longer able to do so”specifies the health law lawyer.
What is palliative sedation?
During palliative sedation, the patient’s state of consciousness is lowered using medication to relieve pain. This sedation can be continued until the patient loses consciousness and dies. We then evoke the term continuous or deep palliative sedation.
What are the differences between deep sedation and euthanasia?
“There sedation aims to profoundly alter consciousness while theeuthanasia consists of intentionally causing death“explains Maître Muriel Bodin, lawyer at the Paris Bar, specializing in health law. In its January 2020 care pathway guide, HAS noted six characteristics making it possible to differentiate deep and continuous sedation maintained until death from euthanasia: the intention, the means to achieve the result, the procedure, the result, the temporality and the legislation.
| Deep and continuous sedation maintained until death | Euthanasia | |
| Intention | Relieve refractory suffering | Respond to the patient’s request for death |
| AVERAGE | Alter consciousness profoundly | Cause death |
| Procedure | Use of a sedative medication with appropriate doses to achieve deep sedation | Use of lethal dose medication |
| Result |
Deep sedation continued until death due to the natural evolution of the disease |
Immediate death of the patient |
| Temporality | Death occurs in a time frame that cannot be predicted | Death is caused quickly by a lethal product |
| Legislation | Authorized by law |
Illegal in France |
What are the conditions for requesting deep sedation?
According to the law of February 2, 2016, deep and continuous sedation maintained until death (SPCMD) cannot be administered only at the patient’s request in the following two cases:
→ his vital prognosis is compromised and the treatments administered to him do not alleviate his suffering;
→ he voluntarily decides to stop treatment, which exposes him to unbearable suffering.
Another scenario is that the patient is unconscious and cannot express his will. The doctor can implement the SPCMD as a refusal of relentless therapeutic treatment, unless the patient has objected to it in his advance directives. “It is very advisable to draft advance directives. A lawyer can help you draft them and enforce them when the time comes”comments Maître Muriel Bodin.
In accordance with HAS recommendations, the implementation of deep sedation (SPCMD) follows a defined protocol:
► Implementation: carrying out a SPCMD requires be able to call on a team specialized in palliative care, a referring doctor specializing in palliative care must be easily reachable. At home or in a nursing home, setting up a SPCMD requires being able to reach a doctor and a nurse 24/7 who must be able to travel. Failing this, home hospitalization may be considered.. It is also necessary to be able to ensure the continued presence of members of the entourage capable of alerting the patient. Setting up a SPCMD at home or in a nursing home requires having a reserve bed reserved in a health establishment. Finally, instructions in the event of an unexpected event or emergency must be left in writing.
► Initiation of sedation: The medicine recommended in 1D Intention is injectable midazolam. Opioids alone should not be used to induce sedation, they should be continued or increased to control pain and dyspnea. The nurse then begins administering and titrating the medications in the presence of the doctor.. Then the doctor is responsible for monitoring the patient until he is stabilized.
► Maintenance and monitoring: midazolam injections are continued throughout the SPCMD. The healthcare team checks the pulse and breathing rate and ensures the clinical evaluation (depth of sedation, degree of relief, monitoring of adverse effects) twice a day at home, 3 times in the hospital or nursing home. Only treatments that contribute to maintaining the patient’s comfort are continued. Artificial hydration and nutrition should be stopped. Comfort care (mouth care, hygiene, etc.), in which relatives can participate if the patient so wishes, is essential..
What medications are used for deep and continuous sedation?
Sedation is obtained thanks to sedatives which are prescribed according to a well-standardized protocol. It always combines the prescription of analgesics aimed at relieving all pain induced by the disease and the cessation of treatments. The HAS recommends the administration of midazolampowerful sedative, as first intention of deep and continuous sedation.
► In 1st intention: the recommended medication is injectable midazolam : the intravenous route is recommended, regardless of age and location. The possibility of waking up, particularly during treatment, is anticipated by the occasional injection of an additional dose of painkiller and sedative. In the event of difficulty in supplying midazolam, the diazepam and the clonazepam can be used as a temporary remedy.
► In 2nd line: in the event of insufficient effectiveness of midazolam and outside a particular situation, neuroleptics are the second-line drugs of choice, including:
- there chlorpromazine in case of intravenous sedation;
- there levomepromazinemore sedative, in case of subcutaneous sedation.
Depending on the second-line sedative drug, midazolam will be continued or gradually stopped. In case of insufficient effectiveness of second-line drugs, transfer to an inpatient department is recommended.
How long does sedation last before death?
Unlike euthanasia which causes immediate death, the time to death in the context of sedation is unpredictable.
What are the side effects?
It is not the sedation itself that causes death, but the progression of the disease. Deep, continuous sedation simply aims to relieve the patient’s suffering. It is plunged into a state of sleep such that it no longer reacts to stimulation. The doses of medication used do not expose it to potential side effects. Sedation only allows death to occur in conditions of improved comfort for the person.
What is the price and reimbursement?
“The price of deep sedation depends on the place where it is practiced. At home, it is the cost of home visits by the medical team responsible for monitoring the patient who will die at home. This can last several days since it there is no foreseeable outcome If it is in hospital, you have to count the price per day, less social security coverage. indicates the lawyer specializing in health law.
Sources: Websites of the Ministry of Health and the High Authority of Health (HAS)
