Admission to intensive care reflects the seriousness of the patient's situation, as well as the intensity of the treatments implemented. These treatments are not always life-saving; no treatment is harmless, and all of them can lead to complications and suffering for the patient. This is why it is essential that the therapeutic plan be tailored to the patient's unique and constantly evolving health situation but also to his or her wishes and values. To this end, the testimonies of loved ones are extremely valuable to care teams, enabling them to better understand who the patient is and what he or she would like for him- or herself.
Under French law, there are two ways of gathering the wishes of an unconscious patient when it comes to making decisions about a therapeutic project: the trusted support person and advance directives. Advance directives are a means of writing down one's wishes in advance, in the event of incapacity to give one's opinion. They can be written on plain paper, using the template proposed by the French Ministry of Health , or using the intensive care care-specific form proposed by the French-language intensive care society.
During an intensive care stay, changes in the patient's state of health may lead to questions about the appropriateness of current treatments. 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 limiting treatment to ensure comfort. In France, unreasonable obstinacy is forbidden by law. Ensuring the best possible care sometimes requires striking a subtle balance, but rest assured that our intensive care care teams are very vigilant on this point. Don't hesitate to share your doubts, concerns or misunderstandings about your loved one's care with them.
When a patient will not benefit from certain treatments, or no longer benefits from treatments that have been put in place, and in order to keep the discomfort, pain and anguish they cause to a minimum, these treatments may not be undertaken or may be stopped. Since 2004, and more recently in 2016, the Léonetti and Claeys-Leonetti laws have provided a framework for what are known as "treatment limitation and cessation" (LAT) decisions. These decisions are made in consultation with the entire healthcare team and an outside consultant, taking into account the patient's expressed wishes and keeping the patient's family and friends fully informed. These decisions are re-evaluated every day as the patient's condition evolves.
Discontinuing certain life-sustaining treatments can accelerate the dying process. If this is the case, care teams implement or reinforce palliative care, care aimed at comfort and symptom relief. Since 2016, French law has authorized "deep and continuous sedation until death", enabling the end of life to be as comfortable as possible for the patients concerned.
Decisions to limit and/or discontinue treatment are medical decisions based on 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. Relatives' input is crucial to making the most appropriate decisions for each patient, and their opinion is systematically sought. However, the decision remains a medical one, thus avoiding placing the burden of these decisions and their consequences on the relatives.
If a trusted support person has been designated by the patient, the law stipulates 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 being discussed, it is important that family members are able to express the patient's wishes and values as far as possible, putting aside their own feelings and wishes. Discussions with the care team or a psychologist can help you to sort things out, and help you to build for your loved one the care plan best suited to what they would have wanted for themselves.