Communiqué
Published 7 December 2021

End of life: importance of writing advance directives

Plateforme de Communication Rapide de l'Académie

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End of life: importance of writing advance directives

Press release of the National Academy of Medicine [1]

December 7, 2021

Anyone has the right to indicate in advance his wishes concerning the conditions of his end of life following an illness or for any other reason (traffic accident …), in case he would one day be unable to make it known.

By drafting these advance directives [2], people of full age (3) can therefore express themselves, at any time in their life, regarding the continuation, limitation, stopping or refusal of treatment or medical procedures. The directives ensure that the patient’s wishes are respected and that the actions of caregivers are guided by them.

These directives can be revised and revoked. They must be written [4], dated and signed, mentioning the identity of their author. They can be drawn up according to a model, but without obligation [5], and they should be easily accessible. They may be kept by a third party: a trusted person, a family member, a close friend, a practitioner, a health establishment, a medico-social establishment. They can also be integrated into the personal medical file.

Since the law of February 2, 2016 [6], creating new rights for patients and people at the end of their life, implementation of the advanced directives is binding on the medical profession that must apply them. Their content takes precedence over opinions or testimonies of the trusted support person or relatives. Health professionals may only waive them in the event of a life-threatening emergency, while the situation is being assessed, and when these directives appear to be “inappropriate or inconsistent with the medical situation”. In this case, a collegial procedure is followed.

In the absence of advance directives, the doctor must get the opinion of the trusted support person, or any other opinion from the family or close friends. Based on this opinion, this professional makes his decision in the light of the medical situation.

The purpose of advance directives is not only to respect the choices of people who are unable to express their wishes, but also to protect relatives by preventing a possible disagreement between them.

Practice shows that our fellow citizens are unaware of this means of expressing their wishes. The same applies to health professionals, who are not sufficiently familiar with the most recent legislative provisions [7].

An educational policy should be implemented to encourage all citizens, whatever their age, to think about the end of their life, and thus to remove the psychological and technical obstacles.

Advance directives must be explained and made as accessible as possible. Everyone should know that they can, at any time or during hospitalization, write advance directives in anticipation of an end-of-life situation altering their   discernment.

Health professionals, especially general practitioners, must be prepared to express themselves on advance directives in their practice, in order to best support their patients in their writing.

The National Academy of Medicine stresses accordingly the need to:

– Periodically conduct large-scale public information campaigns, including the youngest, on advance directives,[8] using all available means of information (media, social networks, but also documents distributed in general practitioners’ offices, health establishments, pharmacies, town halls, notary’s offices, etc.);

– Include, among health studies skills, customized learning, training in the personalized   formulation of advance directives;

– Train and raise awareness among all categories of health professionals, in order to remedy their lack of knowledge in this field;

– Reinforce the essential information role of general practitioners and referral doctors, by distributing to them the necessary documents on advance directives.

[1] Press release of the Academy’s Rapid Communication Platform validated by the members of the Board of Directors on December 6, 2021.

[2] Art. L 1111-11, 1111-12, 1111-15 of public health code

[3] A person who is the subject of a legal protection measure with representation relating to the person may draw up advance directives with the authorization of the judge or the family council

[4] When the author of the advance directives is unable to write and sign himself, two witnesses may attest to the document.

[5] Art. R 1111-18 of Public Health Code; see in particular www.service-public.fr/particuliers/vosdroits/F32010, www.parlons-fin-de-vie.fr/je-minteresse-a-la-fin-de-vie/les-directives-anticipees/, www.has-sante.fr, www.conseil-national.medecin.fr

[6] N° 2016-87

[7] According to a survey carried out by the National Centre for Palliative and End-of-Life Care (CNSPFV) in 2021, 60% of respondents know that there is a law governing the end of life, 48% have heard of advance directives and 18% have written them. 91% of those questioned had not discussed it with their doctor. Senate, hearing of Dr. Sarah Dauchy, President of the CNSPFV’s Orientation Council, 7 April 2021, minutes of the Social Affairs Committee.

[8] The CNSPFV conducted two information campaigns on existing end-of-life arrangements in 2018 and 2019, CNSPFV Activity Report 2019, www.parlons-fin-de-vie.fr

Académie nationale de médecine