In France, the Leonetti law, first law on EOL management, was published in 2005 (13). According this legal text, medical care, whose only purpose would be the prolonged artificial maintenance of life, could be stopped to offer a dignified EOL for patients with no medical issue. Physicians could administrate treatment to relieve pain in terminal care patients even if a secondary effect of this one was to shorten life and had to inform and state in medical record on this eventuality. As for unconsciousness, decision had to be taken after collegial meeting, associating all care givers (Ph., nurse) and if available an external opinion. The Leonetti law introduced also trusted persons concept who was named by the patient, and the notion of advances directives. This law was, recently, enriched and intended to frame our medical exercise accurately concerning the way to relieve patients. In February 2016, the Claeys-Leonetti law was published authorizing deep and continue sedation with analgesia until death after collegial briefing (14). This new law reinforced also the important part of advances directives, and the place of trusted person, if the patient is unconscious. It clearly mentioned the possibility to stop artificial feeding and hydratation in case of deep sedation. The French Ethic National Committee auditioned SFAR, about WW life sustaining therapy in France in April 2018 and they recommended to evaluate the Claeys-Leonetti law impact because of a large practical heterogeneity between Ph. (15). Our study is the first step in this way, owing to have an evaluation of EOL in our French ICU. The need for this approach has been already realized in other countries.
For example in 2017, a German study was published about clinical practices, limits and opinions about EOL decisions (16). The survey consisted in 59 questions to German anesthesiologists, the goal was to analyze points how to improve EOL management. Seventeen thousand forty four anesthesiologists were contacted, 821 anesthesiologists (4,8% participation rate) participated to this survey, 541 results were analyzed and showed that many points could be improved: encourage writing of advances directives, organize more ethics meetings into the ICU and highlights absence of nurses education to EOL care, absence of support to families and mostly absence of standard procedures for EOL management. Other survey also evaluate the practice in Italian ICUs (17). The survey consisted in 29 questions for Italian intensivists. Physicians declared that WW life sustaining treatments decisions result from consensus only in 58% of them against 81% reported in our study. Compared to our data, the lack for sedation protocol and management for life support (hydratation and nutritional stop) was also quite important respectively 20% and 4%. We reported, the first French survey conducted on EOL management which took into account a large number of medical caregivers. Indeed, the rate of responder is significantly higher than the two previous European studies (16%), moreover it probably underestimates the real number of intensivists really involved in the problem because the survey was sent to all the French anesthesiologists even if they didn’t conduct any intensive care activity.
We expressed a large number of practices concerning every field of EOL care: decisions making, advance directive, presence of psychologist support for families or caregivers, comfort care such as pursuit of feeding, hydratation or mechanical ventilation, terminal sedation, service protocol use and monitoring. The mean result for all procedures is the large practical heterogeneity between French caregivers in front of EOL. Caregivers are not globally satisfied with the way to conduct EOL. Explanation could be by the lack of protocol for management. Half of Rdt feel they precipitate death; fifty percent of Ph. declare the need to supplementary monitoring way for helping management. This displeasure on EOL management is essential to understand because it can have a negative impact, it could be a source of conflict between caregivers or between medical and paramedical teams and could improve burn out risks. Rdt feels mostly uncomfortable with EOL management, so several measures can be taken to improve their practices: they should be systematically associated with seniors during meeting decisions, information to family and could benefit of training with simulation cases to improve their attitude towards families, sedation management and comfort care. This situation deserves to be teaching such as any other intensive care situations. We could then expect the homogenization of practice, according to guidelines support, could be potentially beneficial in this way. The instauration of standardize protocol for EOL care including sedation protocol, airway management, hydratation and feeding pursuit may improve patient’s care, team satisfaction and could also facilitate family information. Moreover, 63% of Ph. declare not having daily psychologist presence to help them, paramedical team or family in case of needed situation. This psychologist support, associated to free access to ICU and implication of family members in EOL care such as comfort care could improve acceptance of EOL process, caregivers feeling and relationship between caregivers and family.
Our study was conducted from October 2016 to October 2017, only a few months after the publication of the Claeys-Leonetti law. However only 88% of Ph. reported a stop in life sustaining therapy after collective meeting. Moreover only 66% noticed decision in medical sheet and only 34% of them tried to collect advance directive whereas these measures were proposed since 2006. This non accordance with the law could be explained probably by different ways however the cultural negative vision of death for caregivers could be a potential explanation. Forty two percent always associate medical third in discussion as legally which means that majority of intensivist never do or not systematically. Legally medical third is a doctor outside the unit who does not know the patient. During collective meeting patient medical history is exposed to this one to give an objective opinion concerning EOL decision. Medical third opinion is an important point in EOL decision but as reported, his presence is not systematic probably secondary to organization difficulties.
As all surveys, our study get some limitations. Firstly, it’s a declarative study, some data are lacking because of incomplete data, 71% of Ph. answer the entire survey. Even with a large number of answers, we could expect that only care givers concerned by this problem answered the survey and it could be a potential bias for analysis. We conducted this survey only during a few months after the new law publication, and we could not have an idea on the knowledge and practice of participant for this one. It would also be interesting to conduct a new practical evaluation several months after law publication. Endly, we reported in this study the medical doctor vision of EOL, but it will be of interest to have the opinion of other care givers particularly nurse particularly who are directly impacted by this care.