Seven major new changes to end-of-life and palliative care in France, including opening access and adding new legislation to assist dying, are outlined in a new government bill.
The plans are due to be examined in a special session in the Assemblée nationale on April 22 before being considered by the entire chamber on May 27.
The law, known as the ‘loi relatif à l'accompagnement des malades et de la fin de vie’ (‘law for the support of patients and end-of-life’ care), was presented to the cabinet office on April 10.
Read also: Macron announces plans for allowing aid for sick to die in France
It comes after a citizens’ debate with 184 members of the public and then-Prime Minister Elisabeth Borne concluded with a majority of 75% that assisted dying should be legal in France, with conditions.
The main measures in the bill have now been published on government legal website Legifrance.
The key proposals are:
1. New access to assisted dying
The new rules on assisted dying are expected to be among the most intensely-debated proposals of the bill.
It states: "Assisted dying consists of authorising and accompanying the provision of a lethal substance to a person who has expressed a request for it, so that they can administer it themselves or, if they are physically unable to do so, have it administered by a doctor, a nurse or a volunteer they designate.”
To be eligible, a person must meet all five of these conditions:
Be 18 or over
Be of French nationality or reside legally in France
Be suffering from a serious and incurable condition with a short or medium-term life-threatening prognosis
Be suffering physical or psychological pain linked to this condition, which is unbearable when the person is not receiving treatment or has chosen to stop receiving treatment
Be capable of expressing his or her wishes in a free and informed manner.
The procedure will be free of charge for patients.
2. Assisted dying rules for doctors
Access to assisted dying is also set to outline rules for doctors, who must give the ‘green light’ for the procedure to take place.
The bill states that the doctor must not be a close relative of the patient, and must also:
Inform the patient of the procedure
Let them know all possible treatments and support systems available
Offer the patient all possible palliative care options and ensure that they have access to it
Ensure they know that they can withdraw their request "at any time"
The doctor must then decide if the patient meets the five criteria (above). To do this, they must “obtain” the opinion of several carers, including:
At least one other doctor who has not been following the patient’s case until now
A medical ‘auxiliary’, such as a nurse of care assistant
A specialist in the patient’s condition, if the doctor themselves is not a specialist
The original doctor has the final decision.
If the patient is granted their request, they must then take two days to consider it, before repeating the request. Once the decision has been made, the patient can cancel their request at any time if new information leads doctors to consider that the conditions “were not fulfilled or cease to be fulfilled”.
If the patient’s request is denied, they can challenge the decision in the administrative court.
3. Rules for the administration of a ‘lethal substance’
Once the request has been approved and confirmed, the doctor will prescribe the ‘lethal substance’ that will end the patient’s life. The doctor will then decide, with the patient, on “the doctor or nurse responsible for accompanying the patient to administer the lethal substance”.
Only this professional, rather than the patient themselves, can collect the substance from a pharmacy or medical establishment. The date and place of the procedure is then confirmed between the carer and patient.
If the procedure takes place more than three months after the original doctor’s ‘green light’ has been given, the situation must again be assessed to ensure the ‘free and informed’ nature of the process.
Only then may the procedure begin, in the presence of the patient’s family if they wish.
The doctor or nurse sets up the process, and the lethal substance is then administered by the patient themselves, except if there is a “physical impossibility” (total paralysis, for example). In this case, the patient can give permission for the professional - or another ‘voluntary’ person - to administer it.
Once the procedure begins, the doctor or nurse is not required to “remain at the patient's side", but they must stay "close enough to be able to intervene in the event of difficulty".
4. A conscience clause for healthcare professionals
The bill also provides for a ‘conscience clause’ for healthcare professionals, who will be allowed to refuse to help - or be involved in the care of - a patient who requests assistance in dying.
They can also refuse to administer the lethal substance, or be present when the substance is being given - unless they had previously confirmed to the patient that they would be there.
The bill states: “A healthcare professional who does not wish to participate must inform the person of their refusal without delay, and provide the names of healthcare professionals likely to do so.”
In contrast, volunteer carers who are willing to help will be able to register with the overseeing commission (see point 5, below). They will not be able to charge fees for any services rendered in connection with assisted dying.
5. Rules for an assisted dying commission
The bill also provides for the creation of an ‘assessment and control commission’, which will be part of the Ministry of Health. The commission will ensure proper procedure is followed and the correct paperwork is filed at each stage.
Any suspicion of a crime or offence must be referred to the courts, while any possible ‘breach of ethical or professional rules’ must be referred to the disciplinary chamber of the relevant association (such as the medical association or nursing association.
The commission will also be required to submit an annual report to the government and parliament, including any recommendations for changes to the system.
It comes after two senators delivered a report to the government in June 2023, stating their belief that introducing assisted dying in France would be “dangerous”.
Read more: Introducing euthanasia in France would be dangerous, say senators
6. New ‘supportive care’ concept
The bill does not only focus on end-of-life care. It also has a section on palliative care.
This introduces a new, broader definition of ‘supportive care’, which - it states - aims “to provide comprehensive care for the patient in order to preserve their dignity, quality of life and well-being".
This includes anticipating and responding to the patient's physical needs, including pain relief; and their psychological and social needs.
This should be in place via a “personalised support plan…as soon as the diagnosis of a serious illness is announced", especially when it comes to pain relief and follow-up care.
7. A new type of facility: support homes
The bill also introduces the concept of a new kind of “medico-social establishment”, called “a support home" (maisons d'accompagnement).
Similar to a hospice, these small-scale ‘homes’ will aim to "welcome and support people at the end of their lives and their families".
They will aim to bridge the gap between home and hospital, for patients who are no longer able to remain at home, but do not need the highly-medicalised care of a full-time hospital.
The government has said it would ideally like to have at least one new home in every department by 2034.
