April 24, 2020 (LifeSiteNews) — Controversy broke out in France at the end of March when a government decree made an anti-epileptic drug — clonazepam, Rivotril in France, known as Klonopin in the U.S. — available outside its specific marketing authorization, in order for it to be used on patients with respiratory distress in the context of the COVID-19 epidemic. Critics say the drug can now be used to kill off the fragile and the elderly.
One of the reasons for their fears is that there is a formal contraindication for use of the molecule in case of respiratory distress, on which it acts as an aggravating factor.
A number of health professionals, at least one member of the National Assembly, and countless Twitter accounts have accused and are still accusing the French government of promoting euthanasia through the widespread use of this drug, especially among the dependent elderly living in specialized care homes, the “EHPAD” network.
Deaths in these institutions attributed to the coronavirus (but not always tested; testing in France remains at a very low level compared to neighboring Germany) reached 8,393 this Friday as compared with 13,852 deaths in hospital since the beginning of the crisis. In comparison, with more declared cases of COVID-19, Germany has attributed 5,321 deaths to the virus to date. The statistic should be compared, however, with the 26,000 elderly people who died during a heat wave in France in 2003.
Since the beginning of confinement in France on March 19, residents in EHPADs can return to their families only after a complex administrative and medical process, and in practice, the move is next to impossible. Some of the institutions have turned into death traps, with the coronavirus spreading among carers and inmates despite the fact that the residents are confined to their rooms and have received no visits by government regulations since March 11 — a measure that has caused widespread distress and depression, especially among those who are not able to understand the reason why.
Given that people above 75 rarely get treatment other than oxygen and palliative care if they are admitted into hospital with the coronavirus, and that EHPAD residents are not even sent to hospital when they fall ill after having been infected, the general impression is mounting that the elderly are being refused proper care.
Things are not all that clear-cut: doctors point out that at age 90 and often with a number of serious physical complaints, going through the harrowing experience of two to three weeks of artificial respiration, associated muscle loss, and the difficulty of being rehabilitated is not a reasonable choice.
A note to EHPAD directors on March 16 published this week by Le canard enchaîné (a weekly that has revealed many scandals in the past) even appeared to make a rule of not sending COVID-19 patients to hospital for resuscitation, adding to the general sentiment that the elderly are expendable.
Whatever the philosophy behind present general practice in France, possibly a very ugly one, there is a difference between hastening the death of a patient with a heavily loaded shot of anxiolytics and sedatives and accompanying him with proportionate treatment that may as an unintended consequence somewhat shorten a life that is certainly reaching its end.
Official government sources and experts were quick to reject the accusation that the use of Rivotril would be a means of lessening the burden on health carers by expediting patients to the other side. They insisted that the expanded authorization of the use of the anxiolytic and sedative drug in the coronavirus crisis had no intention of facilitating euthanasia. There were many calls of “misinformation.”
The unofficial daily of the French episcopate, La Croix, published a soothing statement in this regard intended to reassure the public; it is completely “out of place,” it wrote, to suggest that there is an “intention on the part of the authorities to pave the way for the disguised euthanasia of elderly people residing in retirement homes or EHPADs.”
What is certain is that the COVID-19 epidemic has already triggered a shift in the relationship connecting old age, suffering, and death. According to Odile Guinnepain, an experienced palliative care nurse who founded an anti-euthanasia group under the name “Our hands shall not kill,” easy access to clonazepam can only compound the problem.
In a telephone conversation with LifeSite, she explained that the people most severely affected by coronavirus-related bacterial super-infections are in a state of respiratory distress that leads to suffocation and panic: suffocation leads to panic, and panic makes the suffocation worse. Presently, the drug most commonly used today to relieve these states — but also in resuscitation procedures — midazolam (Hypnovel in France, Dormicum in the U.S.), is lacking. Carers faced with elderly people certainly needed an alternative medicine to help them overcome their panic attacks and suffering associated with COVID-19-related infections, she said — even in cases where patients will best the infection.
On March 28, the government therefore provisionally authorized the off-label use (marketing authorization for a drug for specific conditions) of the anti-epileptic Rivotril to compensate for the shortage of other molecules. At the same time, the inscription of this drug on the list of molecules that can be prescribed only in a hospital setting was overridden to allow its distribution by private practitioners, particularly in EHPADs.
In the absence of other drugs, the move was a good thing in itself, Guinnepain explained, as long as death is not sought for itself. But what she said made clear that whether they want to or not, many carers will actually be pushing patients into death.
Clonazepam is a molecule that is not well known to most carers, doctors, or nurses, especially when used by injection — only the older generation of doctors and nurses ever had experience of its use as an anxiolytic and sedative, since it was replaced by Dormicum, which is easier to dose and creates no addiction. Clonazepam is effective but easily subject to overdosage, the more so because its elimination time by the body is slow — much slower than that of Hypnovel, which general practitioners are used to handling. An overdose means increased respiratory distress, increased risk of death, or even certain death.
In older, frail people, the risk of overdose is even greater. It was made worse in the present situation by an astonishing recommendation from the SFAP (the highly respected French Society for Accompaniment and Palliative Care) concerning Rivotril: the protocol proposed in particular to doctors in EHPADs in the present crisis provides for almost lethal doses of the drug.
The suggested dosage is up to three times too high, according to Guinnepain, who underscored that doctors and nurses unfamiliar with the drug would not realize this. Blindly following the recommendation would in a number of cases quickly plunge patients into coma and multiply the number of deaths.
In short, it does look as if the government authorities, assisted by incongruous recommendations, were seeking to facilitate the increase of the number of victims, and not just any victims, but those who cost society dearly, those who no longer produce.
Odile Guinnepain added that for many carers, especially in the present crisis, the absence of suffering has today become synonymous with unconsciousness — or at least the incapability of expressing suffering.
In a context where dying people often do not even get to see a priest, and where panic can become worse because of pangs of conscience at the hour of death, giving them massive doses of sedatives that will be difficult to reverse makes sure that they will not be able to obtain the spiritual assistance, and the pardon that they need. It is also a way out that will make carers accustomed to giving a dying person a shot to make them unconscious; how many will notice, asked Odile Guinnepain, that death follows very soon and sometimes too soon?
Guinnepain offered LifeSite a statement that makes clear the grave questions at issue. Here below is its full translation.
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Contrary to what has been widely read and heard, both Rivotril* and Hypnovel* are not drugs that euthanize patients, nor are they used intentionally for this purpose. It is simplistic and dishonest to reduce their use to this; such a reductionist opinion cannot be allowed to spread.
As part of the specific symptom of acute respiratory distress associated with COVID-19 (suffocating, to be clear), it is administered (supplemented with small doses of morphine) to relieve the perception of the sensation of thirst for air and the associated anxiety, which are unbearable for the patient to experience. This in itself is a very good thing.
It is therefore not the drug that is euthanasic, it is the use that is made of it through the dosage and proportionality of its administration as well as the lack of ethical or moral enlightenment with which it is used; it is therefore on these issues that clarification is needed.
Health professionals working in EHPADs and in home care have little knowledge and experience of the use of these treatments, which were initially intended to relieve anxiety or reduce alertness, but are presently used as sedatives, for two major reasons:
– Professionals are poorly trained in their use and monitoring, and even less in their proportionate use (both doctors and nurses). Training in the practice of these treatments takes time, and there is often no one to do it with the necessary precision. Moreover, their monitoring is time-consuming, and neither nurses nor Hospice or city doctors have that time.
– The second reason is cultural. Indeed, we are today in a culture of “zero suffering and/or pain;” and this is what the carers are aiming at. Of course, our duty is to do everything we can to relieve suffering patients to the best of our ability; except that, objectively, zero suffering (in global care offered to the patient) does not exist. Every patient, at the heart of illness, be it in palliative care or in agony, always experiences a form of suffering (whether physical, psychic, intellectual, spiritual, social, etc.) that is visible, perceptible or not. Our role as caregivers is therefore not to eliminate the suffering (which would inevitably lead to the elimination of the patient: zero suffering zero equals the death of the patient) but to make it bearable or acceptable; and, once we have managed to relieve the patient by a proportionate dosage of treatments, the time has come to continue the accompaniment other than chemically. Here, in discussion with the patient, one can seek to understand the other sources of suffering that the patient is experiencing and that contribute to increasing the physical symptoms of pain or discomfort. The response to this suffering is therefore not only chemical; it is through a relationship with others, with one's family, with God, etc.; which is not possible when the patient is put in a state of unconsciousness by sedation.
However, in our culture today, it is believed that only the state of unconsciousness responds to the relief of suffering (unconsciousness = zero suffering); the person is visibly relieved and, for the caregivers, this is the main thing. However, the patient often dies quite quickly from the consequences of the treatment due to a disordered and/or unsuitable dose. Since the treatment is not proportionate to the relief of the symptom alone, once the person has lost consciousness together with “normal” breathing, everyone benefits.
However, in neuropsychological sciences, nothing shows that even unconscious, the patient is free from suffering: it is only that he is no longer able to express or manifest it.
Finally, to be precise, the manifestations of a suffering face or agitation are not only a sign of physical pain; they can also be a sign of a struggle against the sedative effect of a treatment, or some other struggle; it is up to us professionals to seek and always to continue to seek to understand what is behind it, with confidence and intuition.
On the other hand, and this is the moral dimension of the problem, since the caregivers do not, in all sincerity, have an “euthanasic intention” in administering the treatments, then this does not pose any problem; in fact, they are sure that the treatment was correctly adjusted when the patient is no longer conscious. This is the question of the double effect which, according to Church doctrine, is morally permissible. However, beware of confusion regarding the principle of double effect: as Pius XII recalled in 1957, “an act with a double effect is morally good, – if the very act which gave rise to the bad effect is good or at least indifferent; – if the agent directly aims at the good effect of the act, tolerating only the bad effect; – if the good effect is not obtained by the bad effect.”
In concrete terms, the implementation of an analgesic or sedative treatment studied, calculated and monitored to be proportionate to the symptom, may nevertheless lead to the death of the patient due to a consequence that could not be anticipated or is still unknown. In this case, death is an accidental consequence. There is no underlying euthanasic drift in this act.
On the other hand, an overdose of narcotics or a disproportionate dose of narcotics, administered for the purpose of ending the patient's life or for the purpose of relieving pain (or suffering) with the same effect of killing the patient is, in both cases, morally wrong. Whatever the intention, it is the act of alleviating the suffering person with respect for his or her life that is good. It is not the intention that makes the act good.
Hence the importance of not trying to sedate but to relieve in a proportionate way; if there is deep sedation necessary for a symptom that is truly refractory to any other treatment, then it is of last resort and, in spite of everything, proportionate to the symptom; it must be punctual and not terminal or definitive.
This error of appreciation seriously misleads the carers today; it is this that leads them into euthanasia drifts that will be uncontrollable with COVID-19, particularly in EHPAD’s. Caregivers with little experience in the field are victims of this situation and suffer enormously. In EHPADs, they are currently denied hospitalization for their elderly patients with COVID-19 and in respiratory distress, because of their age or lack of space. They watch them die in front of their eyes from appalling choking attacks, which they are powerless to deal with due to lack of appropriate treatment and training. The decree on Rivotril is therefore a good thing if its practical implementation meets the criteria explained above.
For the government, however, it is simpler to respond to their request for authorization to use treatments “to relieve” than to adapt the health system to the care of contaminated elderly people.
Article 3 of the Claeys/Leonetti law in 2016 legalized deep and terminal sedation under certain conditions of suffering. The theory that this was to be framed by this law is disintegrating in practice, as we see here!
Here it is not the carers who are responsible, but those who impose on them a situation where they have no other choice!