Steps, signs, care, how long before death?

The end of life is the moment when a person has a serious, incurable disease and arrives at a stage when treatments can no longer cure it. At that time, the objective is no longer to treat, but to accompany the person, relieving their pain and respecting their choices until death. The end of life can be done in the hospital, at home, or in a palliative care unit.

What is the exact definition of “end of life”?

As the Ministry of Health recalls, in France, a person is said to be at “end of life” when they suffer from a condition or serious and incurable disease,, in advanced or terminal phaseand therefore when his vital prognosis is committed. The medical profession can no longer cure it. This person can benefit fromPalliative care support until the end of his days. This support will be different if the sick person is at home, in the accommodation establishment for dependent elderly people (EHPAD) or in the hospital.

The signs of an end of life are extremely variable depending on the people. However, the terminal phase that leads to death may be preceded by certain Annuctor signs Like for example:

• A loss of appetite (the person can refuse to drink or eat or become unable to swallow),
• excessive fatigue or sleep (the person tends to sleep a lot or doze),
• a weakening of the whole body and a drop in muscle tone (the person is unable to make movements),
• difficulties in breathing or an obstruction of the bronchi (the person can breathe irregularly (breathing of cheyne-stoked), “moan” (produce a hoarse sound while breathing), or make sleep apnea …)
• A decrease in acuity or mental confusion (the person speaks less and less, replies with difficulty or has incoherent words …)
• social isolation, anxiety or even depression (the person loses his interest in the world around him)
• physical signs like Pallor, cold ends, purplish “marbled” skin which translates a slowdown in blood circulation.

What are the steps to support the end of life in France?

The principle posed by law in France is that The sick person, conscious and in a state to express their will, can refuse any investigation or treatment Even if this refusal puts his life in danger. On the other hand, If the person is not at the end of his life, the doctor has the obligation to do everything to try to convince her to accept essential care. If a sick person is no longer in a state of expressing their will, they must have beforehand Designate a “trusted person“. Each adult can designate a trusted person who is consulted in case they are no longer able to decide. Write early guidelines In order to express, in anticipation, its wishes as to the organization of its end of life. These can be entrusted to the trusted person. The Ministry of Solidarity and Health has entrusted to the National Center for Palliative Care and the End of Life (CNSPFV), the mission of supporting patients, caregivers, relatives and health professionals.

According to the definition of the World Health Organization of 2002, Palliative care corresponds to all the care provided to people with serious illnesschronicle, “scalable or terminal, bringing into play its vital prognosis”, regardless of its age. Palliative care in no way replaces curative care, but they complete them. The referring doctor – generally hospital – the attending physician as well as the healthcare team who accompanies the sick person and his entourage, direct to the mode of care most suited to the situation. An interactive map of palliative care structures is available on the CNSPFV website. A telephone line is available to patients and relatives to inform and guide: 01 53 72 33 04 (cost of a local call).

A patient at the end of his life can, if desired, end his days at home. He can therefore benefit from home palliative care carried out by a multidisciplinary medical team, either:

• By using A home hospitalization health establishment (HAD) which achieve, on medical prescription, technical and complex management.
• By using a Home Nursing Service (SSIAD) Who can, on a medical prescription, carry out nursing care and the toilet, often in HAD relays, especially when the patient’s needs are lighter.
• By using Liberal nurses Who can, on medical prescription, carry out nursing and toilet.
• By using palliative care networks who provide the coordination of all stakeholders.

The decision to carry out this care is always taken by the attending physician, with the agreement of the patient and his family. These care is taken care of 100% by health insurance.

According to the latest figures from the National Center “End of life – Palliative Care”, 65% of patients die at the hospital in France. A person at the end of their life can benefit from palliative care in a hospital, either,

• Being treated in a palliative care unit (USP): A healthcare team (doctors, nurses, psychologists, nursing assistants, physiotherapists, dieticians …) takes care of a patient at the end of life. In France, there are 139 USP, the equivalent of 1,500 beds devoted to the care of patients at the end of their life.
• By benefiting from support from a mobile palliative care medical team who intervenes on request and who travels to the hospital. This team is generally made up of a doctor, a nurse and a psychologist specializing in palliative care. In France, there are 424 mobile palliative care teams.

A person at the end of their life can spend the rest of their days in an accommodation establishment for dependent elderly people (EHPAD) and benefit from “Comfort” care provided by EHPAD medical staff trained in palliative care. These care aim to relieve pain, to ease physical suffering, to safeguard the dignity of the sick person and to support those around him. Depending on the needs of the sick person, the EHPAD can also request the help of a mobile palliative care team to support a resident. If the locals allow, the resident’s family can benefit from a room within the EHPAD to stay at the bedside of their loved one. In the most complex cases, support for the end of life will not be able to be done in nursing homes and the patient must be transferred to a hospital structure, either in a palliative care unit or in a hospital with beds identified in palliative care (LISP).

What are the drugs used for an end of life?

The pains felt during the end of life can be relieved, depending on their intensity, by analgesics bearing 1 (paracetamol, aspirin, non-steroidal anti-inflammatory drugs), level 2 (dextropropoxyphene associated with paracetamol, codein, sublugal buprenorphine or tramadol) or level 3 (opioids: morphine, fentanyl, hydromorphone and oxycodone). In case of pain related to intense cancer: Strong opioid treatments (morphine, oxycodone, fentanyl, tapentadol …) are recommended by WHO, particularly after the failure of the analgesics of previous bearings. Among other frequent symptoms at the end of life:

• shortness of breath can be relieved by benzodiazepines or morphine,,
• the obstruction of the bronchi can be reduced by corticosteroid therapy,
• Nausea and vomiting can be calmed by antiemetics, corticosteroids or anxioxylitics (Lorazepam, Alprazolam)
• anxiety and depression can be treated by a follow up psychological, antidepressants (fluoxetine) or Anxiolytics (bromazepam …)

What is a deep and continuous sedation?

There Law of February 2, 2016 Allows you to better respond to the demand to die in dignity by a better management of suffering, and by clarifying the use of deep and continuous sedation, until death, in terminal phase. Deep and continuous sedation cannot be administered than at the patient’s request And must be carried out at home, within a accommodation establishment for dependent elderly people or within a health establishment. Attention, Deep sedation is different from euthanasia.