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End of life: Monaco presents its draft bill

4 February 2020 - 16h32

Currently, the rules about the end of life in Monaco are ruled by the medical code of ethics. A draft bill initiated by the department of Health and Social Affairs has been dropped off on the National Council desk. It contains many specific dispositions and clarifies certain notions.

Broaching the problem of the end of life is broaching the fundamental questions of society: ethics, medical, moral, humans, scientific, commented Didier Gamerdinger. The government advisor-minister of Health and Social Affairs clarifies: “This is a text about life, not death. (…) It will trace the legal frame to accompany the relation between the medical staff and the patient.” The fundamental aim is to reduce the suffering. This text gathered the Ordre des Médecins and the diocese of Monaco and pursuits two major objectives: the reduction of the pain and the refusal of the use of intensive medication, as it is explained in the draft bill motives: “Medecine and law have in common the pursuit of the same purpose: to protect the human being”. “Performing a medical procedure or treatment intentionally causing the death of the person is contrary to the spirit of medicine, even when the person is at the end of life. Likewise, it is of the very essence of the right to protect the human person with this particularity that the protection which it offers tends to be reinforced when the person is in a situation of particular vulnerability which is clearly the case of the person in end of life”.

Palliative care

Didier Gamerdinger insists that the end of life is currently ruled, without any other regulatory texts, by the medical code of ethics, especially its 36 and 37 articles that command the doctor, on one side, to prescribe necessary palliative care to ease the suffering and on the other side, to refrain from the use of intensive medication. It is therefore advisable to have a law and to define diverse notions. Keeping in mind these two concerns: respect the dignity of the sick person that should have a worthy end of life and ease the suffering. To aim this target, the person should accesss to palliative care when she is in an advanced stage of a serious and progressive condition endangering her vital prognosis whatever her life expectancy, being understood that suffering can be physical but also mental.

On this point, Didier Gamerdinger insists: “We have to tailor-made and constantly review the protocols”. And to underline: “You have to respect the person, take the time, dialogue, alleviate suffering”. But palliative care is not only physical pain, Doctor Jean-François Ciais, head of the support and palliative care service of the CHPG, confirms: “There is also moral, existential suffering, worries on the future of the family, a very global suffering”. He also recalls that palliative care is not only practiced on the elderly but also on patients suffering from progressive diseases, cancers of course, but many others.

Nothing on possible euthanasia

These palliative cares are the subject of a precise definition: they are active and continuous care practiced by an interdisciplinary team in a health establishment, a medico-social establishment or at home. They aim to relieve the physical and mental suffering of the person in advanced or terminal phase of a serious affection without hastening or delaying his death, to safeguard his dignity, to help him maintain the best possible quality of life and to offer him, and those around him, the necessary support. “They must never be practiced to cause or accelerate death, insists Didier Gamerdinger, it is not a question of reducing the suffering by putting an end to life”. And he underlines: “There is nothing in the text on a possible euthanasia: it is not the role of the doctor whose vocation is to treat, nor of the Department which must listen and relieve, nor of the society which must come to the aid of the patient and not accelerate his disappearance”. But what solution exists in the case of a suffering so-called resistant, that is to say endured by the patient in advanced or terminal stage of a serious, irreversible and incurable condition? The response of doctor Ciais: “This pain, which is not improved by the usual treatment can be relieve with other medication or stronger doses. A choice that can be justified with the patient agreement”.

Palliative sedation continues

The text also deals with the specific provisions foreseen concerning continuous palliative sedation when the person is in the terminal phase of a serious, irreversible and incurable condition and his prognosis engaged in the short term. It is a sedation whose depth is regularly adapted, it is indicated, to relieve the suffering of the person with a view to ensuring certain comfort, including during painful care and which can be maintained continuously until the natural occurrence of his death. A strictly supervised practice which requires the agreement of the patient or his representatives, insists Doctor Ciais, clarifying that some prefer to face the pain.

As Didier Gamerdinger said, the bill defines therapeutic persistence. It states as a principle that medical acts and treatments cannot be carried out or continued on a person when they result from unreasonable obstinacy, except when the doctor considers that this act or treatment is appropriate in the circumstances.

The end of life declaration supervised and assisted by a doctor

The authors of the bill wanted a well-framed declaration of end-of-life will. This declaration should only intervene when the person is confronted with his situation of illness to express an enlightened will “which cannot be the case when he expresses himself in advance at a time when he is not yet sick”. “We can’t project ourselves,” sums up Didier Gamerdinger. It will only be valid if it is written by a person of full age suffering from a serious, irreversible and incurable condition and who is assisted to do so by a doctor of his choice. This declaration must be made in writing, signed and dated. If the patient cannot write, there is the possibility of calling a witness. “This declaration is a possibility available to patients, it is not an obligation. The assistance of a doctor is important, it allows you to make your choice, to use the right medical terms which can be precious later, it is a privileged moment of exchanges between patient and doctor,” explains the Doctor Ciais.

The role of volunteers’ patients’ support

 The draft bill offers a legal framework for associations whose purpose is to support people in palliative care in order to enable their volunteers to intervene in the health facilities. It also provides the special provisions for three situations: minors, adults under guardianship to be represented, and finally people who can not express their will. “This bill mainly protects patients, it is in line with international good practices,” said doctor Ciais. Questionned about the CHPG palliative care size, he admitted it was a bit small, however, last year, 91 patients have been welcomed and the mobile palliative care unit which intervenes in other services is very helpful.

As for this bill, which many consider to be very balanced, it is now up to the National Council to examine it in committee before it arrives in public session.

Noël METTEY

© Manuel Vitali – Direction de la Communication

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