Elsevier

The Lancet

Volume 356, Issue 9244, 25 November 2000, Pages 1806-1811
The Lancet

Articles
End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey

https://doi.org/10.1016/S0140-6736(00)03233-5Get rights and content

Summary

Background

Our study is a repeat of the Dutch death-certificate study on end-of-life decisions (ELDs). The main objective was to estimate the frequency of euthanasia (the administration of lethal drugs with the explicit intention of shortening the patient's life at the patient's explicit request), physician-assisted suicide (PAS), and other ELDs in medical practice in Flanders, Belgium.

Methods

A 20% random sample of 3999 deaths was selected from all deaths recorded between Jan 1 and April 30, 1998. The physicians who signed the corresponding death certificates received one questionnaire by post per death.

Findings

The physicians' response rate was 1355 (52%). 1925 deaths were described. The results were corrected for non-response bias, and extrapolated to estimated annual rates after seasonal adjustment for death causes, and we estimate that 705 (1·3%, 95% Cl 1·0–1·6) deaths resulted from euthanasia or PAS. In 1796 (3·2%, 2·7–3·8) cases, lethal drugs were given without the explicit request of the patient. Alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect preceded death in 10 416 (18·5%, 17·3–19·7) cases and non-treatment decisions in 9218 (16·4%, 15·3–17·5) cases, of which 3261 (5·8%, 5·1–6·5) with the explicit intention of ending the patient's life.

Interpretation

ELDs are prominent in medical practice in Flanders. The frequency of deaths preceded by an ELD is similar to that in the Netherlands, but lower than that in Australia. However, in Flanders the rate of administration of lethal drugs to patients without their explicit request is similar to Australia, and significantly higher than that in the Netherlands.

Introduction

Belgium has no formal registration and authorisation procedure for end-of-life decisions (ELDs) in medical practice. Although euthanasia (the administration of drugs with the explicit intention to shorten the patient's life at the explicit request of the patient) is illegal in Belgium and treated as intentionally causing death under criminal law, prosecutions are exceptional. Legalisation of euthanasia is intensely discussed, both by the official Advisory Committee on Bioethics and the Belgian Parliament.1 In this country, the actual number of deaths by euthanasia, physician-assisted suicide (PAS), and other ELDs is not known.

This research was done in Flanders, the Dutch-speaking region of Belgium, where 60% of the population lives. In 1998, Flanders had about 5·9 million inhabitants and 56 354 deaths. There have been several attempts at establishing reliable ELD incidence estimates in various countries, with different methods. Some researchers chose to do interviews with a random sample of physicians.2, 3 The most reliable method, however, is the death-certificate method,4, 5 in which a random sample is taken from the official death register for a specific area and time, and physicians who sign the death certificate are questioned. A research project using this method was first done in the Netherlands in 1990 and repeated in 1995.4, 5 It attracted major international attention.6, 7, 8 Our study repeats one done in the Netherlands in Flanders, which has the same language, a similar culture and history, but a different legal approach towards euthanasia. Our data were obtained with a similar questionnaire and with an almost identical research design.

As in the Dutch study, three main categories of ELDs were assessed: first, the administration, prescription, or supply of drugs with the intention of shortening the patient's life (physician-assisted death); second, the alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect; and third, the withholding or withdrawal of potentially life-prolonging treatments (non-treatment decisions). The objective of this study is to estimate the frequency of these ELDs in Flanders, and to describe decision making processes and background characteristics of the patients and physicians involved.

Section snippets

Death-certificate study

All deaths in Flanders are reported to the Preventive and Social Health Care Division of the Ministry of Flanders by means of a detailed death certificate, signed by the reporting physician. Patients' names are not mentioned on death certificates. The department in charge of the cause-of-death statistics selected a stratified sample of deaths of persons aged 1 year or older (thus excluding infant mortality), which occurred between Jan 1 and April 30, 1998. The 20 362 death certificates in this

Results

A total of 3999 death certificates were selected (20% of stratified random sample) and questionnaires were sent to the 2585 physicians who signed them. Of the physicians, 30% (781) signed more than one sampled death certificate (62% [487] of the clinical specialists identified). The overall response rate of the physicians was 52% (1355). Because of the strict procedure for guaranteeing anonymity of participating physicians, some physicians could not be identified as GP or clinical specialist.

Discussion

We have shown that ELDs are common in medical practice in Flanders. The strict Belgian law has not prevented physicians from practising euthanasia and other ELDs, with ELDs explicitly intended to shorten life involved in about 10% of deaths.

Our results show the difficulties of obtaining reliable data on euthanasia and other end-of-life medical practices in a country with no formal registration and authorisation procedure for ELDs, and where criminal prosecution of (some) ELDs is a possibility.

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