Correspondence
Medical End-of-Life Practices under the Euthanasia Law in Belgium
N Engl J Med 2009; 361:1119-1121September 10, 2009
- Article
To the Editor:
The legalization of physician-assisted death for terminally ill patients is a controversial medical and societal issue.1 In Belgium, where euthanasia was legalized in 2002, we conducted a follow-up study in 2007 to two large-scale nationwide surveys on medical end-of-life practices that had been conducted in 19982 and 2001.3 This follow-up study enabled us to investigate differences in the frequency and characteristics of these practices before and after the enactment of the law.
We conducted the study with the use of data from death certificates in the Flemish-speaking part of Belgium, which has approximately 6 million inhabitants. A random sample of 6927 cases was drawn from all deaths that occurred from June 1, 2007, through November 30, 2007. The certifying physician in the case of each death was sent a five-page questionnaire about medical end-of-life practices that, according to their assessment, had a possible or certain life-shortening effect. The study protocol is described extensively elsewhere.4
The response rate was 58.4% (Table 1Table 1
Frequency of Medical End-of-Life Practices in Flanders, Belgium, in 1998, 2001, and 2007.). In 2007, 1.9% of all deaths in Flanders were the result of euthanasia (ending of life at the patient's explicit request), a rate that was higher than that in 1998 (1.1%) and 2001 (0.3%). In 1.8% of all deaths, lethal drugs were used without the patient's explicit request, a rate that was lower than that in 1998 (3.2%) but similar to that in 2001 (1.5%). The rate of intensified alleviation of pain increased from 18.4% in 1998 and 22.0% in 2001 to 26.7% in 2007, and the rate of withholding or withdrawing life-prolonging treatment increased from 14.6% in 2001 to 17.4% in 2007. In the case of 14.5% of all deaths, physicians reported using continuous and deep sedation until death, a rate that was substantially higher than that in 2001 (8.2%). Across the three studies, we found no shift in the characteristics of patients whose death was the result of euthanasia (mostly younger patients, patients with cancer, or patients dying at home) or in the characteristics of patients in whom lethal drugs were used without the patient's explicit request (mostly older, incompetent patients; patients with cardiovascular diseases or cancer; or patients dying in hospitals). The rate at which medical end-of-life practices were discussed between the physician and competent patients and their relatives was substantially higher in 2007 than in 1998 and was similar to the rate in 2001.The 2007 survey had the same robust design and asked the same key questions as did the previous surveys. We found that the enactment of the Belgian euthanasia law was followed by an increase in all types of medical end-of-life practices, with the exception of the use of lethal drugs without the patient's explicit request. No shift toward the use of life-ending drugs in vulnerable patient groups was observed. However, the substantial increase in the frequency of deep sedation demands more in-depth research. Different findings in a similar study in the Netherlands5 show that the influence of similar euthanasia laws on medical end-of-life practices seems to vary substantially according to country-specific factors.
Johan Bilsen, Ph.D.
Joachim Cohen, Ph.D.
Kenneth Chambaere, M.A.
Geert Pousset, M.A.
Vrije Universiteit Brussel, Brussels, Belgium
johan.bilsen@vub. ac. be Bregje D. Onwuteaka-Philipsen, Ph.D.
VU University Medical Center, Amsterdam, the NetherlandsFreddy Mortier, Ph.D.
Ghent University, Ghent, BelgiumLuc Deliens, Ph.D.
Vrije Universiteit Brussel, Brussels, BelgiumSupported by a grant from the Institute for the Promotion of Innovation by Science and Technology in Flanders.
5 References1
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Full Text | Web of Science | Medline
- Citing Articles (23)
Citing Articles
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Joachim Cohen, Yanna Van Wesemael, Tinne Smets, Johan Bilsen, Luc Deliens. (2012) Cultural differences affecting euthanasia practice in Belgium:one law but different attitudes and practices in Flanders and Wallonia. Social Science & Medicine
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Yanna Van Wesemael, Joachim Cohen, Johan Bilsen, Tinne Smets, Bregje Onwuteaka-Philipsen, Wim Distelmans, Luc Deliens. (2012) Implementation of a service for physicians’ consultation and information in euthanasia requests in Belgium. Health Policy 104:3, 272-278
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T. Smets, J. Cohen, J. Bilsen, Y. Van Wesemael, M. L. Rurup, L. Deliens. (2012) The labelling and reporting of euthanasia by Belgian physicians: a study of hypothetical cases. The European Journal of Public Health 22:1, 19-26
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, Koen Pardon, R. Deschepper, R. Vander Stichele, J. L. Bernheim, F. Mortier, N. Bossuyt, D. Schallier, P. Germonpré, D. Galdermans, W. Kerckhoven, L. Deliens. (2012) Changing preferences for information and participation in the last phase of life: a longitudinal study among newly diagnosed advanced lung cancer patients. Supportive Care in Cancer
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Kathleen Leemans, Lieve Van den Block, Johan Bilsen, Joachim Cohen, Nicole Boffin, Luc Deliens. (2012) Dying at home in Belgium: a descriptive GP interview study. BMC Family Practice 13:1, 4
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Yanna Van Wesemael, Joachim Cohen, Johan Bilsen, Tinne Smets, Bregje Onwuteaka-Philipsen, Luc Deliens. (2011) Process and Outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey. Journal of Pain and Symptom Management 42:5, 721-733
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Lorenz Imhof, Georg Bosshard, Susanne Fischer, Romy Mahrer-Imhof. (2011) Content of health status reports of people seeking assisted suicide: a qualitative analysis. Medicine, Health Care and Philosophy 14:3, 265-272
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Kasper Raus, Sigrid Sterckx, Freddy Mortier. (2011) Is Continuous Sedation at the End of Life an Ethically Preferable Alternative to Physician-Assisted Suicide?. The American Journal of Bioethics 11:6, 32-40
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Bert Broeckaert. (2011) Palliative Sedation, Physician-Assisted Suicide, and Euthanasia: “Same, Same but Different”?. The American Journal of Bioethics 11:6, 62-64
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Kris Vissers, Jeroen Hasselaar, Constans Verhagen. 2011. Sedation in Palliative Care and Its Impact on Nutrition. , 51-61.
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Els Inghelbrecht, Johan Bilsen, Freddy Mortier, Luc Deliens. (2011) Continuous Deep Sedation Until Death in Belgium: A Survey Among Nurses. Journal of Pain and Symptom Management 41:5, 870-879
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Tinne Smets, Joachim Cohen, Johan Bilsen, Yanna Van Wesemael, Mette L. Rurup, Luc Deliens. (2011) Attitudes and Experiences of Belgian Physicians Regarding Euthanasia Practice and the Euthanasia Law. Journal of Pain and Symptom Management 41:3, 580-593
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Biagio Solarino, Francesco Bruno, Giacomo Frati, Alessandro Dell’Erba, Paola Frati. (2011) A national survey of Italian physicians’ attitudes towards end-of-life decisions following the death of Eluana Englaro. Intensive Care Medicine 37:3, 542-549
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Edouard Ferrand, Eric Rondeau, François Lemaire, Marc Fischler. (2011) Requests for euthanasia and palliative care in France. The Lancet 377:9764, 467-468
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Geert Pousset, Johan Bilsen, Joachim Cohen, Freddy Mortier, Luc Deliens. (2011) Continuous Deep Sedation at the End of Life of Children in Flanders, Belgium. Journal of Pain and Symptom Management 41:2, 449-455
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Dirk Houttekier, Joachim Cohen, Lieve Van den Block, Nathalie Bossuyt, Luc Deliens. (2010) Involvement of Palliative Care Services Strongly Predicts Place of Death in Belgium. Journal of Palliative Medicine 13:12, 1461-1468
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Bernadette Dierckx de Casterlé, Yvonne Denier, Nele De Bal, Chris Gastmans. (2010) Nursing care for patients requesting euthanasia in general hospitals in Flanders, Belgium. Journal of Advanced Nursing 66:11, 2410-2420
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Bert Broeckaert, Joris Gielen, Trudie van Iersel, Stef Van den Branden. (2010) Euthanasia and Palliative Care in Belgium: The Attitudes of Flemish Palliative Care Nurses and Physicians Toward Euthanasia. AJOB Primary Research 1:3, 31-44
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Joachim Cohen, Kenneth Chambaere, Johan Bilsen, Dirk Houttekier, Freddy Mortier, Luc Deliens. (2010) Influence of the metropolitan environment on end-of-life decisions: A population-based study of end-of-life decision-making in the Brussels metropolitan region and non-metropolitan Flanders. Health & Place 16:5, 784-793
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Jan L. Bernheim, Arsène Mullie. (2010) Euthanasia and Palliative Care in Belgium: Legitimate Concerns and Unsubstantiated Grievances. Journal of Palliative Medicine 13:7, 798-799
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Clive Seale. (2010) Continuous Deep Sedation in Medical Practice: A Descriptive Study. Journal of Pain and Symptom Management 39:1, 44-53
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