Here again, we had to act quickly. No sooner had the proposal, Friday March 13, been formulated by the National Consultative Ethics Committee (CCNE) to set up “ethical cells” than their implementation was launched, under the responsibility of “regional ethical spaces “, Which have existed for several years. At the start of the week, Professor Grégoire Moutel set up, for Normandy, a team of 9 people, constituting one of the first of its kind in France.
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“We have four functions, he explains: help professionals in difficulty of decision; ensure the dissemination of recommendations; mediate between caregivers and families; and after the crisis, learn from everything we are going through. “
The situation of older people
Questions already go back to this team, made up in particular of several doctors but also of a philosopher, a sociologist and a representative of a patient association. During these first hours, they mainly focus on the situation of the elderly.
“At the beginning of the week, some doctors from Samu asked us if it was possible that they would no longer be referred to certain patients coming from nursing homes, when they are in a serious geriatric state Explains Grégoire Moutel. Tuesday March 17 and Wednesday March 18, it was the staff of these establishments themselves who contacted the ethics unit in Normandy, concerning three people. All very old, in a very degraded physical state and affected by the coronavirus.
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“The staff at these retirement homes do not know how to cope. Families also obviously find it difficult to accept that they are considering not transferring their loved one to the hospital and to consider the end of their lives. ”, specifies Grégoire Moutel. Faced with this, he tries, with his team, to keep a crest line: listen, advise, remind existing managers, without ever making a decision in place of the others.
“In the field, many ignore, for example, the framework of the Claeys-Leonetti law on end of life, which prohibits relentless therapy, explains the Norman practitioner again. I also encourage establishments to see if their residents have established advance directives where their wishes are set for their end of life.. “
Vital emergencies and disabilities
These cells, in Normandy and elsewhere, are also preparing for a saturation of resuscitation services. And the choices that doctors will be forced to make between several patients due to lack of resources. It is already starting in some resuscitation services in eastern France: in Alsace, the ethics unit should also be set up by Friday March 20.
In the Bouches-du-Rhône, it has already emerged. “ We agreed that for difficult decisions, we would never talk about triage, explains, in Marseille, the philosopher Pierre Le Coz. It’s a military term that is too violent for civilian populations. Our objective, during these difficult times, will be to provide support, including psychological, to caregivers. We know that every decision will necessarily involve a little arbitrariness but between an absolute arbitrariness and a relative arbitrariness, it is better a relative arbitrariness “
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The Marseille ethics unit plans to meet at least once a week, every Tuesday. “For later, we will see,” continues the philosopher. The requests will probably multiply, and we will have to adapt our responses to each. We cannot just say that we must respect the dignity of the person. Everyone is different. Thus, we may be overwhelmed with requests, but we must take this risk. “
Four working groups in Paris
But the questions that the “regional ethical spaces”, particularly mobilized for this crisis, are trying to answer, sometimes also go beyond the dilemmas of caregivers confronted with a vital emergency. This is the case in Paris, where the Ile-de-France ethical area has launched four working groups linked to the coronavirus, including one on disability and old age.
“We identify the questions and share our thoughts widely with the 12,000 people in our network”, explains Sébastien Claeys, in charge of this working group. ” We have specific questions that arise in people with disabilities, such as the role of their caregiver. Should these auxiliaries, for example, only take care of one person to limit contamination, but at the risk of neglecting the others? In an institution, how to manage a disabled person who is very dependent and infected? How do you deal with the loneliness of older people? “, Details this researcher.
He adds : “Basically, we are at the moment of ethical reflection in action, whether these are vital questions or not. Yes, we are in an emergency. But in an emergency, we must act. And for that, we must never give up asking questions. “
A text to guide doctors
To inform their decisions, doctors can rely on a text, delivered Tuesday 17 to the Directorate General of Health and sent to hospitals. Entitled “Prioritizing Access to Critical Care in the Context of a Pandemic,” it sets out principles for “screening” patients requiring resuscitation care.
This document is based in particular on a “clinical frailty score”. Familiar with hospital staff, it allows patients to be classified according to their state of health, from the “very fit” person to the “terminally ill” person.
If, in a context of crisis, age can constitute a criterion – a very young person could be considered as a priority compared to a very old person -, it is not decisive on its own.