[Terminal medical interventions: psychosocial, medical, ethical and legal aspects].

We give an overview of the available medical solutions to help a patient with refractory symptoms at the end of his life. Patient "competence" must first be evaluated and, even if their diagnosis is difficult, organic mental disorders and depression must be diagnosed and adequately treated to allow a real, personal and honest dialog. Administration of high doses of morphine is frequently used at the end of life not only to fully relieve pain but also to accelerate death, even if this is not clearly stated. This technique is not devoid of hypocrisy and high doses of morphine can have quite unpleasant side effects. Treatment withdrawal or withholding is generally not sufficient to allow a correct end of life. The arrest of ventilation, dialysis, artificial nutrition and even more hydration must often be coupled with techniques inducing unconsciousness, which makes imprecise the limits between such a "passive" ending of life and "active" euthanasia. The technique of terminal sedation, frequently based on the use of midazolam, has been more recently introduced in some palliative care units. Such a "controlled sedation" is supposed to allow a "natural" death by inducing a profound sleep. In opposition with active euthanasia, which allows a quiet and rapid death at a moment chosen by the patient himself, this technique of "sedation" has an undetermined duration, has legal implications which could be viewed as quite similar as the ones of euthanasia, and, moreover, this prolonged agony can be extremely stressful and distressing for the family. Medical-assisted suicide is allowed in The Netherlands under the same conditions as euthanasia. Death is generally obtained after a few hours but the technique is not always successful and the process of death can sometimes be prolonged and uncomfortable. This technique can nevertheless be preferred by some physicians and patients. As compared to active euthanasia, the proportion of medically-assisted suicides (1/6) is low in The Netherlands. Euthanasia is the only technique able to induce a peaceful and rapid death. The proportion of various techniques to actively induce death is probably quite similar in our country than in The Netherlands but, most of the time, these interventions occur at the very end of life when the patient is no longer able to participate in the decision process and thus occur without his explicit request. We think that, as for all medical decisions, the use of one or the other of these various techniques should be selected after a quiet and free discussion between the patient and his physician, preferably in advance and not in a situation of emergency and panic.