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Recommendation of the Council of Europe No. 1418/1999 on "Protection of the human rights and dignity of the terminally ill and the dying" ("Charter of rights of the dying").

The mission of the Council of Europe is to protect the dignity of all people and the rights that can be deduced from it.

Progress of the medicine at present enables to cure many so far incurable or killer diseases; improvement of medical methods and development of resuscitation techniques enable to prolong the life of a human individual and postpone the moment of their death. In consequence, however, the quality of life of a dying man and the loneliness and suffering of both the patient and their close persons and those who take care of them are often disregarded.

In 1976, in resolution No. 613 the Parliament Assembly declared that "the dying ill person wishes the most of all to die in quiet and dignity, if possible in comfort and with support of their family and friends." In recommendation No. 779 of 1976 it added that "prolongation of life should not be the only objective of the medical practice which must also deal with alleviation of suffering simultaneously."

Since then, convention on protection of human rights and human dignity with regard to application of biology and medicine has formulated important policies and prepared the path without dealing with specific needs of terminally ill or dying people.

The obligation to respect and protect the dignity of all terminally ill and dying persons is derived from the sanctity of human dignity in all periods of life. Respect and protection find their expression in provision of adequate environment enabling a man to die in dignity.

As experience with suffering often showed in the past and in presence, these measures must be made particularly in the interest of the most vulnerable members of the society. As a human being begins its life in weakness and dependency, so does it need protection and support when dying.

Basic rights derived from the dignity of terminally ill or dying persons are endangered today by many factors:

  • Insufficient availability of palliative care and good painkilling therapy.

  • Frequent neglecting of therapy of physical suffering and disregarding the psychological and spiritual needs.

  • Artificial prolongation of the process of dying either by inadequate use of medicinal procedures or continuation of therapy without the patient's consent.

  • Insufficient continuous education and low psychological support of the nursing staff providing the palliative care.

  • Insufficient care and support of relatives and friends of terminally ill patients or dying persons, who could otherwise contribute to alleviation of human suffering in its various dimensions.

  • Concerns of the patient regarding the loss of autonomy, of becoming dependant on the family and institutions and becoming a burden for them.

  • Missing or unsuitable social and institutional environment that would allow them for peaceful parting with relatives and friends.

  • Insufficient allocation of funds and resources for care and support of terminally ill or dying persons.

  • Social discrimination that is inherent to dying and death.

The Assembly calls the member states to set forth in their law the necessary legislative and social protection to prevent from these dangers and concerns, which the terminally ill or dying people may be confronted with in the legal order, particularly:

  • Dying with unbearable symptoms (e.g pains, suffocation, etc.).

  • Prolongation of dying of a terminally ill or dying person against their will.

  • Dying alone or in negligence.

  • Dying with fear of being a social burden.

  • Limitation of life-sustaining therapy for economic reasons.

  • Insufficient allocation of funds and resources for adequate supportive care of terminally ill or dying persons.

The Assembly therefore recommends that the Committee of Ministers calls the members states of the Council of Europe that they in all aspects respect and protect the dignity of terminally ill or dying people by:

Recognizing and defending the title of terminally ill or dying people to a complex palliative care and by adopting relevant measures:

  • To ensure that the palliative care is recognized as a legal title of an individual in all member states.

  • That all terminally ill or dying persons enjoy equal access to reasonable palliative care.

  • To encourage the relatives and friends to accompany the terminally ill and dying persons and that their efforts are supported by professionals. If it proves that family or private care is insufficient or overloaded, alternative or complementary forms of medical care must be available.

  • To establish outpatient teams and network for provision of palliative care to provide home care at any time where it is possible to take care of terminally ill or dying persons in ambulatory form.

  • To provide for cooperation of all persons participating in care of a terminally ill or dying patient.

  • To develop and declare qualitative standards for care of terminally ill or dying persons.

  • To ensure that terminally ill or dying persons, unless they wish otherwise, receive adequate palliative care and pain relief, even though such therapy may result in the relevant individual in adverse (side) effects in shortening of such individual's life.

  • To ensure that the nursing staff is trained and conducted so that each terminally ill or dying man can be given medical, nursing and psychological care in accordance with the highest possible standards in a co-ordinated team cooperation.

  • To establish and extend the existing research, educational and training centres for the discipline of palliative medicine and care as well as for interdisciplinary thanatology.

  • To provide, at least in major hospitals, for building of specialized departments of palliative care and thanatological clinics which could offer palliative medicine and care as an integral part of each medical activity.

  • To ensure that the palliative medicine and care is embedded in the public awareness as an important objective of medicine.

By protecting the right of the terminally ill and dying persons to self-determination and by adopting necessary measures:

  • To enforce the right of a terminally ill or dying person to true, complete but sensitively given information regarding their health condition, while respecting the individual's wish not to be inform, if any.

  • That each terminally ill or dying person has the opportunity to consult also other doctors than their regular attending physician.

  • To ensure that no terminally ill or dying person is treated and cured against their will, that their decisions are not influenced by other persons and that nobody exerts pressure on them. Measures must be considered to achieve that such decisions are not made under economic pressure.

  • To ensure that refusal of a certain therapeutic procedure is respected, if formulated in a written living will - statement of a terminally ill or dying person which currently is not able to express their opinion. Further, it must be ensured that the validity criteria of such statements are specified as to the scope of advance directives, but also in respect of appointment of attorneys and the scope of their powers. At the same time it must be ensured that any decisions made by the attorney by deputy of the patient unable to express their opinion, based on previous manifestations of will or assumed will of the patient, are recognized only provided that in the current acute situation the patient does not make other expression of their will or where such will cannot be identified. In such event there must be a clear connection with what the relevant person said in the period shortly before the decision-making or, more exactly, shortly before the person began dying, in adequate situation, without other person's influence or pressure, and still with preserved mental abilities. Finally, it should be ensured that representative decisions based only on general value judgements valid in relevant society are not respected, and that in disputable cases decision is always adopted in favour of life and its prolongation.

  • To ensure that express wishes of a terminally ill or dying person regarding certain therapeutic procedures are respected regardless of substantial therapeutic responsibility of the physician, unless contradicting the human dignity.

  • To ensure that in the event where no previous expression of the patient's will is available, their right to life shall not be breached. A catalogue must be prepared of therapeutic procedures that must be provided under any circumstances and that must not be neglected.

To preserve the regulation forbidding intentional killing of terminally ill or dying people and at the same time:

  • Recognize that the right to life, particularly in relation to terminally ill and dying persons, is guaranteed by the member states in accordance with Article 2 of the European Convention on Human Rights reading that "no-one should be deprived of life intentionally".

  • Recognize that the wish to die, expressed by a terminally ill or dying person, by no means establishes a legal title to death from the hands of other person.

  • Recognize that the wish to die, expressed by a terminally ill or dying person, by no means establishes in itself a legal justification of any activity resulting in intentional death.

The text of this Recommendation was adopted by the Parliament meeting on 25 June 1999 at its 24th session by large majority of votes, with 6 votes against.




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