how long before death?

Sedation is defined by the recourse to means, most often medicinal, to relieve and soothe a suffering patient. Sedation takes into account the comfort of the patient and his environment to help relieve his physical and psychological pain. It is often used to practice care and reduce the pain felt by the patient, especially during a visit to intensive care. Depending on the level of consciousness of the patient, the sedation can be deep and continuous until death, palliative or light. During light sedation, the person may appear to be asleep but opens their eyes and/or reacts when spoken to and/or touched. In deep and continuous sedation until death, she only allows death to occur under conditions of improved comfort for the person.

What is continuous deep sedation?

Since February 2016, the Claeys-Leonetti law offers in France a right to “deep and continuous sedation” until death for terminally ill people. This practice consists of putting a patient to sleep deeply so as to ensure that he is no longer in pain when his death is imminent and inevitable. During deep sedation, the person sleeps and does not respond to voice or touch.

What is palliative sedation?

During palliative sedation, the patient’s state of consciousness is lowered using medication to relieve pain. This sedation can be continued until loss of consciousness and death of the patient. We then evoke the term continuous or deep palliative sedation.

What are the differences between deep sedation and euthanasia?

“The sedation aims to alter consciousness profoundly while theeuthanasia is intentionally causing death“, explains Maître Muriel Bodin, lawyer at the Paris Bar, specializing in health law. In its care pathway guide for January 2020, the HAS noted six features to differentiate deep and continuous sedation maintained until death from euthanasia: the intention, the means to achieve the result, the procedure, the result, the temporality and the legislation.

	Deep and continuous sedation maintained until death	Euthanasia
Intention	Relieve intractable pain	Respond to the patient’s request for death
Medium	Altering Consciousness Deeply	cause death
Procedure	Use of a sedative drug in appropriate doses to achieve deep sedation	Use of a lethal dose drug
Results	Deep sedation continued until death due to natural disease progression	Immediate patient death
Temporality	Death occurs in a time that cannot be predicted	Death is caused quickly by a lethal product
Legislation	Authorized by law	Illegal in France

What does the law say in France?

It’s here Claeys-Leonetti law of February 2016 which allowed the establishment of deep and continuous sedation until the death of patients at the end of life. This deep sedation is put in place after thestopping treatment. This is what Jean Leonetti called “the right to sleep before dying so as not to suffer” (article L. 1110-5-2). In 2005, the Leonetti Law relating to the rights of patients and the end of life wished proscribe a possible “unreasonable obstinacy” from the medical profession to a “artificial prolongation of life” of the patient (Articles 1 and 9), including when the latter is unable to express his wishes. In 2022, the Kouchner law has allowed anyone with an incurable disease to decide itself whether to continue or discontinue treatment. “She also has the possibility of appointing a trusted person regarding her health, in particular to inform the medical profession of her choices if she is no longer able to do so”specifies the lawyer in health law.

What are the conditions for requesting deep sedation?

According to the law of February 2, 2016, deep and continuous sedation maintained until death (SPCMD) cannot be administered only at the request of the patient in the following two cases:

→ his vital prognosis is engaged and the treatments administered to him do not alleviate his suffering;

→ he voluntarily decides to stop treatment, which exposes him to unbearable suffering.

In another case, the patient is unconscious and cannot express his will. The doctor can set up the SPCMD under the refusal of aggressive treatment, unless the patient had objected to it in his advance directives. “It is very advisable to write advance directives. A lawyer can help you write them and enforce them when the time comes”comments Maître Muriel Bodin.

In accordance with the recommendations of the HAS, the establishment of deep sedation (SPCMD) responds to a defined protocol:

► Installation: the realization of a SPCMD imposes be able to call on a team specializing in palliative care, a referring doctor specializing in palliative care must be easily reachable. At home or in nursing homes, setting up a SPCMD requires being able to reach a doctor 24 hours a day, a nurse who must be able to travel. Failing this, hospitalization at home may be considered.. It is also necessary to be able to ensure the continuous presence near the patient of members of the entourage capable of alerting. Setting up a SPCMD at home or in an nursing home requires having a fallback bed reserved in a health establishment. Finally, instructions in the event of an unexpected event or emergency must be left in writing.

► Initiation of sedation: The drug recommended in 1^D intention is injectable midazolam. Opioids alone should not be used to induce sedation, they will be continued or reinforced to control pain and dyspnea. The nurse then begins the administration and titration of the drugs in the presence of the doctor.. Then the doctor is in charge of monitoring the patient until he is stabilized.

► Maintenance and monitoring: injections of midazolam are continued throughout the SPCMD. The healthcare team checks the pulse and breathing rate and provides clinical assessment (depth of sedation, degree of relief, monitoring of adverse effects) twice a day at home, 3 times in hospital or nursing home. Only treatments that contribute to maintaining the patient’s comfort are continued. Artificial hydration and nutrition should be discontinued. Comfort care (mouth care, hygiene, etc.), in which relatives can participate if the patient has expressed the wish, is essential.

What drugs are used for continuous deep sedation?

Sedation is achieved thanks to sedatives which are prescribed according to a well standardized protocol. It always combines the prescription of analgesics aimed at relieving any pain induced by the disease and the cessation of treatment. HAS recommends the administration of midazolampowerful sedative, in first intention of a deep and continuous sedation.

► In 1st intention: the recommended drug is injectable midazolam : the intravenous route is recommended, regardless of age and location. The possibility of awakening, especially during treatment, is anticipated by the timely injection of an additional dose of analgesic and sedative. In the event of difficulty in supplying midazolam, the diazepam and the clonazepam can be used as a temporary remedy.
► In 2nd intention: in case of insufficient efficacy of midazolam and except in a particular situation, neuroleptics are the second-line drugs of choice, including:

• the chlorpromazine in case of intravenous sedation;
• the levomepromazinemore sedative, in case of subcutaneous sedation.

Depending on the 2nd-line sedative drug, midazolam will be continued or gradually discontinued. In case of insufficient efficacy of second-line drugs, transfer to an inpatient department is recommended.

How long does sedation last before death?

Unlike euthanasia, which causes death immediately, the time to death under sedation is unpredictable.

What are the side effects ?

It is not the sedation itself that causes death, but the progression of the disease. Deep and continuous sedation is simply intended to relieve the patient’s suffering. The latter is plunged into a state of sleep such that it no longer reacts to stimuli. The doses of medication used do not expose him to potential side effects. Sedation only allows death to occur under conditions of improved comfort for the person

What is the price and reimbursement?

“The price of deep sedation depends on the place where it is performed. At home, it is the cost of home visits by the medical team in charge of monitoring the patient who will die at home. This can last several days since it “There is no foreseeable outcome. If it is in the hospital, you have to count the price per day, minus the social security cover”, indicates the lawyer specializing in health law.

Sources: Websites of the Ministry of Health and the High Authority for Health (HAS)