Bill no. 1081 on the development of palliative care and support for people at the end of their lives

Monaco • Comparative law

Bill no. 1081 on the development of palliative care and support for people at the end of life (2023-6, 13 September 2023) was tabled in Public Session on 12 October 2023 and referred to the Committee on Social Interests and Miscellaneous Affairs (CISAD).

It is based to some extent on the provisions of the French Code of the Public Health.

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SUMMARY

Under Monegasque law, support for people at the end of their lives and the relief of their suffering through palliative care are provided for in articles 36 and 37 of the Code of Medical Ethics (Code de déontologie médicale) approved by Ministerial Decree no. 2012-312 of 29 May 2012.

The doctor, on the one hand, "must refrain from any unreasonable obstinacy in investigations or treatment", the latter being able to "refrain from undertaking or continuing treatments which appear to be unnecessary, disproportionate or which have no other purpose or effect than the artificial maintenance of life", and on the other hand, "must accompany the dying person until his last moments, ensure through appropriate care and measures the quality of a life which is coming to an end, safeguard the dignity of the patient and comfort his relatives."

Purpose of Bill 1081:

• enshrines and specifies in law the provisions of the Code of Medical Ethics aimed at "alleviating suffering" ;
• "provides a legal framework for associations whose purpose is to support people in palliative care, to enable their volunteers to work in healthcare establishments".
• creates the "declaration of the wills of end of life"(déclaration des volontés de fin de vie), which can be drawn up as soon as a life-threatening condition is diagnosed, with the assistance of a doctor. The system is significantly different from the French system of "advanced directives" ("directives anticipées") which allow expressing the will to pursue, limit, refuse treatments or medical acts, in advance (art. L.1111-1 and L.1111-2 French Code of the public health, hereinafter "CSP").

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IN DETAIL

¤ INTRODUCTORY PROVISIONS

• The right to respect for patients' dignity (art. 1) [Article L1110-2 CSP]
• The right to benefit from the most appropriate medical procedures and treatments, as well as from therapies of recognised efficacy that guarantee the best possible health safety and the best possible relief of suffering in the light of current scientific knowledge. These treatments must not involve risks that are disproportionate to the expected benefits. Healthcare professionals must use every means at their disposal to implement the right to a dignified end of life accompanied by the best possible alleviation of suffering. (art. 2) )[Article L1110-5 CSP]

¤ BEST POSSIBLE ALLEVIATION OF SUFFERING

• Suffering must, in all circumstances, be prevented, taken into account, assessed and treated. (art. 3) [Article L1110-5-3 CSP]
• The right of people in the advanced or terminal stages of a life-threatening illness to have access, whatever their life expectancy, to palliative care and appropriate support. (art. 4)

Palliative care

— General provisions

• Definition of palliative care: "active and continuous care provided by an interdisciplinary team in a health establishment, a medico-social establishment or at home. Its aim is to relieve the physical or psychological suffering of people in the advanced or terminal stages of a life-threatening condition, without hastening or delaying their death, to safeguard their dignity, to help them maintain the best possible quality of life and to offer them and their families the necessary support." - Obligation to raise awareness/train healthcare professionals. (art. 5) [Article L1110-10 CSP]
• In the event of complications, the nursing staff of the interdisciplinary team may implement the palliative care prescribed, including sedation, pending the arrival of the doctor, subject to compliance with the rules on consent. (art. 6)
• Specific provisions relating to consent, in addition to Law no. 1.454 of 30 October 2017 on consent and information in medical matters (art. 7) [Article L1111-4 CSP]

— Special provisions in the presence of refractory suffering

• In the presence of refractory suffering in a person in the advanced or terminal phase of an irreversible and incurable disease, with a life-threatening condition, all the analgesic and sedative treatments necessary to relieve it, even if they may have the undesirable effect of shortening life, are given to the person, subject to compliance with the rules relating to consent. (art. 8) [Article L1110-5-3 CSP]

Support

• Any association whose purpose is to support people in palliative care, which has drawn up a charter defining the principles that its volunteers must respect in their work and which has taken out insurance to cover its civil liability, may enter into an agreement with a healthcare establishment or medico-social establishment setting out the conditions under which its volunteers will work in the said establishment to support people in palliative care, including providing them with services. The agreement may also set out the conditions under which they will work in the homes of these people. The agreement may also set out the conditions under which volunteers may work in the homes of these people. (art. 9 to 14) [Article L1110-11, Article L1112-5 CSP]

¤ THERAPEUTIC OBSTINACY

Unreasonable obstinacy

• Redefinition of unreasonable obstinacy (see art. 36 of the Code of Medical Ethics): "Unreasonable obstinacy results from medical acts and treatments which, in the light of scientific evidence, appear to be unnecessary or disproportionate". (art. 15) [Article L1110-5-1 CSP]
• Rules governing consent to the implementation or continuation of any medical act or treatment resulting from unreasonable obstinacy. (art. 16)

Declaration of the wills of end of life

• All persons of full age suffering from a life-threatening condition may, where their consent is first required for the performance of a medical procedure or treatment pursuant to Law no. 1.454 of. 30 October 2017, as amended, draw up, with the assistance of a doctor of their choice, a declaration of their end-of-life wills intended to apply in the event that they are unable to express their wishes on medical decisions relating to the end of their life concerning the implementation or continuation of medical acts and treatments, including palliative care. The medical procedures or treatments concerned by this declaration may then only be carried out or continued in accordance with this declaration. (art. 18)
• Conditions governing the form and content, conservation, revision and revocation of the declaration. (art. 18 to 21)
• The legislator's decision to depart from the French system of advance directives, which can be drawn up by people in good health, was based on the fact that "feedback from experience (....) (has) shown that in practice (...) they are often difficult to implement or they lapse. Moreover, the wishes expressed may change over time and according to circumstances. This is why the Commission considered it wiser to reserve the drafting of these declarations for people already suffering from a life-threatening condition, so that they can express their wishes in full knowledge of the facts". (Report of the CISAD Committee).

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