Do we need (good) laws for end of life in ICUs?

Abstract

The exchange of correspondence between S. Maggiore, M. Antonelli and A. Giannini in a recent issue of ICM was quite important and timely [1, 2]. No one will argue that, in daily ICU practice, end-of-life decisions are difficult and sometimes excruciating to make. And, as correctly asserted by Giannini, research in end-oflife strategy, education and training of young intensivists, scientific societies’ recommendations and consensus statements, and improved communication within all ICU care providers are essential tools we have to develop and to implement. However, we must also admit, with S. Maggiore and M. Antonelli, that physicians need to have judicial protection when they take those decisions. Society, by and large, asks ICU doctors to withdraw futile care for hopeless patients, when intensive care means only the prolongation of agony. But one cannot reasonably expect them to do so if they potentially can face accusation of euthanasia, murder, assassination or poisoning. It doesn’t help to know that, in such cases, the judges are usually lenient [1, 3], and that severe sentences are rather scarce. This is where clear and good legislation is necessary. The debate over euthanasia has, so far, nearly totally occupied the public arena and media headlines. Actually, withdrawal of life support in ICUs, which has nothing to do with euthanasia, is numerically much more important and frequent, as shown by several recent surveys [4]. It is time for national laws to address the issue of end-of-life decisions in ICUs, where 20% of all deaths take place, at least in the USA, according to a recent epidemiologic study published in the New England Journal of Medicine. In April 2005, the French Parliament voted such a law (called “Leonetti,” from the name of the Member of Parliament who drafted it), after the lay press reported the withdrawal of mechanical ventilation in a case of locked-in syndrome [5]. This law now authorizes the stopping of life support when deemed futile, if the patient requests it. However, it goes further, also allowing physicians to withdraw all “active treatments,” in the case of incompetent patients, if some precisely defined safeguards are respected: after seeking the advice of family members, with the decision being taken collectively with other physicians, and written in the medical charts. Administration of opiates according to the “doubleeffect” standard is also allowed. But a question still remains: how could “bad laws,” as Dr Giannini calls them, be avoided? The answer is to be found in a public debate and the weight of national scientific societies. It is their (our) role to alert the policymakers and jurists as to the importance of the issue and to provide them with examples, state of the art and consensus statements [6]—in a word, with any form of guidance on a difficult and, so far, hidden matter. Obviously, this can be done efficiently and convincingly only if the concerned bodies (scientific societies, ethics committees, task forces, and so forth) have started their own thinking well in advance, to be prepared when society is facing one of these cases the media love to report. References