A new legal frame for end of life in France

After an important public debate, the law of 22 April 2005 on the rights of the patient and on the end of life has been voted in, in France.¹ It gives us an alternative to the Dutch euthanasia model.² The purpose of this law is to develop palliative care (organised with a specialised palliative unit, development of the networks of care and valuation of the acts of palliative care), to form healthcare professionals for terminally ill patients, to make them more sensitive to such situations and, finally, also to inform public opinion and jurists. Decrees of application were published on 7 February 2006.

From now on, a collective and transparent procedure is compulsory when it requires limiting or interrupting a treatment. All the decisions of the limitation or cessation of treatment must be motivated by a valid reason and must be registered in the medical file. Decisions that used to be made in secret before now have to be made with full knowledge of the facts by all those who are brought into contact with the patient.

The law clarifies that the physician has to do everything he or she is able to do to provide the patient comfort by relieving the patient from pain and suffering, by assisting him or her morally, and this, thanks to measures adapted in their state. The physician has to refrain from any unreasonable stubbornness in carrying out investigations or administering therapeutics, and can refuse to start or pursue any treatments that seem useless, disproportionate, or only aim to preserve life artificially.

According to article L1111‐4 of the code of public health, when a conscious patient is not at the end of his life and refuses care that is putting his life in danger, the physician has to consult a colleague and ask the patient, after a reasonable delay, if he stands by his decision. The cessation of treatment is not the stopping of care, notably hydration, nursing and so on.

In the case of an unconscious patient, any intervention or investigation, or any stopping of treatment will not be allowed without a collective procedure. The decision will take into account the wishes that the patient has expressed before, and in particular in early directives if drafted. The medical team has to consult the “person of trust”, as well as the family, or, by default, one of his close relations.³ The role of the person of trust is important because his opinion should prevail over any other non‐medical opinion.

Article L1110‐5 of the public health code clarifies that every person has the right to receive care aimed at relieving pain. In any circumstance, pain must be prevented, estimated, taken into account and treated. The law of 22 April 2005⁴ completes that obligation in the same way. If the physician notices that he can relieve the suffering of a terminally ill patient “only by applying a treatment which can hasten his death, he has to inform the patient of it, the reliable person, and the family or, in defect, one of his close relatives”. The procedure has to be registered in the medical file.

This law creates a new legal frame in France for the medical exercise at the end of life; this has always been tricky for physicians. A physician who satisfies the obligations of transparency and applies a collective procedure would not be penalised, as opposed to a physician who would relieve himself from these obligations. Besides, the possibility of the patients drawing up early directives has been established. So, when the patient is unconscious, the directives will provide knowledge of the patient's opinion.