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European Study Highlights Frequency Of Medical End-of-life Decisions In Terminally Ill Patients (p 345)

July 30, 2003

Authors of a study in this week's issue of THE LANCET illustrate how medical end-of-life decisions frequently precede dying in a range of European countries.

There are few data about the frequency of end-of-life decisions made involving doctors and terminally ill patients. Medical decision-making for patients with life-threatening diseases entails a balanced consideration of medical, ethical, psychosocial, and societal aspects. These considerations and the legal background in each country could modify end-of-life decision-making practices and attitudes of doctors, patients, and other people involved. Medical end-of-life decisions include: whether to withhold or withdraw potentially life-prolonging treatment-eg, mechanical ventilation, tube-feeding, and dialysis; whether to alleviate pain or other symptoms with, for example, opioids, benzodiazepines, or barbiturates in doses large enough to hasten death as a possible or certain side effect; and whether to consider euthanasia or doctor-assisted suicide, which can be defined as the administration, prescription, or supply of drugs to end life at the patient's explicit request.

Agnes van der Heide from Erasmus University, Rotterdam, The Netherlands, and colleagues assessed over 20,000 deaths in six European countries (Belgium, Denmark, Italy, The Netherlands, Sweden, and Switzerland). Around half of deaths were of people aged 80 years or older. The investigators used a questionnaire to establish which deaths involved end-of-life decisions of attending physicians.

Around a third of deaths happened suddenly or unexpectedly and did not therefore involve end-of-life decisions. Such decisions were common among the remaining two-thirds of deaths, ranging from 23% in Italy to half of deaths in Switzerland. Administration of drugs with the explicit intention of hastening death varied between countries: about 1% or less in Denmark, Italy, Sweden, and Switzerland, 1"¢82% in Belgium, and 3"¢40% in the Netherlands. Large variations were recorded in the extent to which decisions were discussed with patients, relatives, and other caregivers.

Co-author Luc Deliens comments " Our study has illustrated how, in six European countries, doctors have reported that end-of-life decision-making precedes dying for many of their patients. Variance in types of end-of-life decisions and decision-making characteristics should be further explored to enhance understanding of end-of-life care in modern medicine, in which the pursuit of a peaceful death seems to be widely recognised as an important goal, in addition to more traditional goals such as curing disease and avoiding premature death."

A public-health article in this week's issue (p 395) by Bregje Onwuteaka-Philipsen and Dutch colleagues presents new data on the rate of euthanasia, physician-assisted suicide, and other end-of-life decisions in the Netherlands in 2001. The investigators replicated interview and death-certificate studies done in 1990 and 1995 to investigate whether end-of-life practices had altered throughout the late 1990s. They report that the demand for physician-assisted death had not risen among patients and physicians since 1995; the authors comment how patients and physicians have become more reluctant in their attitude towards this practice over the past few years.

A public-health article in this week's issue (p 395) by Bregje Onwuteaka-Philipsen and Dutch colleagues presents new data on the rate of euthanasia, physician-assisted suicide, and other end-of-life decisions in the Netherlands in 2001. The investigators replicated interview and death-certificate studies done in 1990 and 1995 to investigate whether end-of-life practices had altered throughout the late 1990s. They report that the demand for physician-assisted death had not risen among patients and physicians since 1995; the authors comment how tients and physicians have become more reluctant in their attitude towards this practice over the past few years.

Lancet