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Previous Volume 361:1119-1121 September 10, 2009 Number 11 Next

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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 1). 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.

View this table: [in this window] [in a new window]   Table 1. Frequency of Medical End-of-Life Practices in Flanders, Belgium, in 1998, 2001, and 2007.

 
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{at}vub.ac.be

Bregje D. Onwuteaka-Philipsen, Ph.D.
VU University Medical Center
Amsterdam, the Netherlands

Freddy Mortier, Ph.D.
Ghent University
Ghent, Belgium

Luc Deliens, Ph.D.
Vrije Universiteit Brussel
Brussels, Belgium

Supported by a grant from the Institute for the Promotion of Innovation by Science and Technology in Flanders.

References

1. Quill TE. Physician assisted death in vulnerable populations. BMJ 2007;335:625-626. [Free Full Text]
2. Deliens L, Mortier F, Bilsen J, et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 2000;356:1806-1811. [CrossRef][Web of Science][Medline]
3. van der Heide A, Deliens L, Faisst K, et al. End-of-life decision-making in six European countries: descriptive study. Lancet 2003;362:345-350. [CrossRef][Web of Science][Medline]
4. Chambaere K, Bilsen J, Cohen J, et al. A post-mortem survey on end-of-life decisions using a representative sample of death certificates in Flanders, Belgium: research protocol. BMC Public Health 2008;8:299-299. [CrossRef][Medline]
5. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, et al. End-of-life practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007;356:1957-1965. [Free Full Text]

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