Quality Palliative Care or Physician-assisted Death: A Comment on the French Perspective of End-of-life Care in Neurological Disorders

Abstract

Conflating physician-assisted death with palliative care is a growing concern in medicine. Palliative care is symptommanagement medical care without actively shortening the end-of-life trajectory of a terminal illness. Physician-assisted death intentionally shortens the dying process to bring about preplanned death as the means of relieving suffering. Physician-assisted death may be conflated with palliative care where this practice is illegal, eg, France. The Revised French Code of Medical Ethics states that when the decision to withdraw or withhold treatment is made in accordance with applicable law, and even if the patient has brain damage precluding an assessment of suffering, physicians must use the treatments, including analgesics and sedatives, to maximize the quality of end of life, safeguard the patient's dignity, and comfort relatives. This revision, which in France has the force of law, appears to uphold the Hippocratic Oath to alleviate suffering and deliver compassionate care. Additional analysis raises questions: (1) what type of treatment is being withdrawn or withheld? (2) What type of brain damage or neurological disability might preclude the assessment of suffering? (3) What type of suffering (eg, physical, psychosocial, existential, etc.) must be treated? (4) What measure of proportionality is applicable to ensure that sedatives and analgesics will not be the proximate causation of death? The legislation assumes potential suffering from treatment withdrawal which disrupts the current ethical paradigm on withdrawing versus withholding treatment. This legislation also applies to neurologically disabled patients incapable of requesting euthanasia but for whom a treatment limitation decision has been made. Re-evaluation of the double-effect principle, intention, and causation of death precludes using the term palliative care. The two-step process (ie, treatment withdrawal and administration of sedatives and analgesics) should be considered physician-assisted death in some neurologically disabled persons. The revision implicitly paves the way to organ donation euthanasia in neurological disorders.

Distress from voluntary refusal of food and fluids to hasten death: what is the role of continuous deep sedation?: Figure 1

“…There is a growing trend to practise physician-assisted dying (death) (PAD) under the premise of providing quality palliative care in consensual and non-consensual life-ending situations 1. The WHO envisages palliative care as a comprehensive system of managing pain and distressing symptoms without intending to shorten the end-of-life (EOL) trajectory 1.…”

“…The WHO envisages palliative care as a comprehensive system of managing pain and distressing symptoms without intending to shorten the end-of-life (EOL) trajectory 1. In assisted dying, the EOL trajectory is shortened to relieve suffering 1.…”

Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life

“…42,[64][65][66] We have argued elsewhere that inflicting an additional burden of distressful symptoms to dying patients through withdrawing constitutive life-support treatment to end life or hasten death is PAD (euthanasia). 15,67 However, the onset of new lethal pathophysiology will result in death without the need for withdrawing constitutive life-support treatment or causing additional distress in dying patients, that is natural death. Justice Breyer in Washington v Glucksberg (concurring in judgments) reminded the medical profession that the primary goal of medicine in these patients should be the provision of optimal ''palliative care, including the administration of drugs as needed to avoid pain at the end of life.''…”

“…We have previously addressed the administration of sedatives to induce continuous deep sedation until death and its relation to PAD. 4,15 We examine the general application of pathophysiological differentiation of causation of death to evaluate the permissibility of deactivating durable MCS devices. Sulmasy has proposed that the pathophysiology causing death may be a useful criterion to distinguish PAD from natural death when discontinuing biotechnological devices.…”

“…3 We have discussed, elsewhere, the distinction between a physician's act of commission and act of omission in the causation of death in other end-of-life situations. 14,15 Deactivating a cardiac device is viewed medically and legally as an act of commission rather than an act of omission. [16][17][18] Therefore, in different situations, deactivating durable MCS devices can have different legal and ethical consequences.…”