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Changes in medical end-of-life practices during the legalization process of euthanasia in Belgium

https://doi.org/10.1016/j.socscimed.2007.04.016Get rights and content

Abstract

Changes in medical practices during transitions in regulating healthcare are rarely investigated. In this study, we investigated changes in medical end-of-life decisions with a possible or certain life-shortening effect (ELDs) that occurred during the legalization process of euthanasia in Belgium. We took representative random samples from deaths reported to registries in Flanders, Belgium in 1998 (n=3999) at the beginning of the process and in 2001 (N=5005), at the end of the process. The reporting physicians received an anonymous mail questionnaire about possible ELDs preceding the death involved. We found no significant shifts in the epidemiology of diseases between 1998 and 2001. The overall incidence of ELDs did not change. The incidence decreased for euthanasia, administering life-ending drugs without patient's explicit request, and alleviation of pain and symptoms with life-shortening co-intention. Incidence increased for alleviation of pain and symptom without life-shortening intention, and remained stable for non-treatment decisions. All decisions in 2001 were more often discussed with patients, their relatives and nurses. In 2001, continuous deep sedation was reported in 8.3% of deaths. We can conclude that physicians’ end-of-life practices have substantially changed during the short but tumultuous legalization process of euthanasia in Belgium. Although follow-up research is needed to investigate the continuance of these changes, it is important for policy makers to keep in mind that social factors related to transitions in healthcare regulation may play an important role in the physicians’ actual behaviour.

Introduction

In several countries, regulation of physician-assisted suicide and the role of medical care in the process of death and dying are increasingly discussed (Charatan, 2006; Doyal & Doyal, 2001; Finlay, Wheatley, & Izdebski, 2005). However, until now, only the Netherlands and Belgium have formally legalized euthanasia, both in 2002 (Deliens & van der Wal, 2003). In the Netherlands, the legalization of euthanasia was the outcome of a social process, lasting about two decades (Griffiths, Weyers, & Blood, 1998), and with active involvement of the Parliament, the judicial system, healthcare professionals, patients’ lobbying groups, and ethicists (Weyers, 2001). The Dutch government also repeatedly commissioned researchers to investigate the incidence of euthanasia and other medical end-of-life decisions with a possible or certain life-shortening effect (ELDs) (van der Heide et al., 2003; van der Maas et al., 1996). In Belgium, the process of legalization of euthanasia, preceded by a debate in 1997 in the Belgian Council for Bioethics (Adams, 2001) was actually put on the political agenda in 1999, resulting in parliamentary hearings in the Senate in 2000 (Broeckaert, 2001). A vigorous debate followed in the media, and among healthcare professional organizations (Schotsmans & Broeckaert, 1999; Weber, 2001). On May 2002, the euthanasia law was already approved, allowing physicians to administer lethal drugs to adult patients under strict conditions of carefulness (Wet betreffende euthanasie 28 mei 2002, 2002). In contrast with the Netherlands, the legalization process in Belgium was thus finalized rather quickly, without broad professional consensus, and accompanied by an intensive political and social debate.

The aim of this paper is to investigate possible changes in medical end-of-life decisions with a possible or certain life-shortening effect (ELDs) occurring during such tumultuous transition period, and to look for possible explanations.

Section snippets

Study design

We compared two identical nationwide death certificate studies establishing the incidence and characteristics of ELDs in Flanders, Belgium, one conducted in 1998, before the real debate on the legalization of euthanasia started, and the other in 2001 at the end of the debate (Deliens et al., 2000; van der Heide et al., 2003). In both studies, we took a random sample (N=3999 in 1998 and N=5005 in 2001) of all deaths from the official death registries. Physicians who had signed a sampled death

Shifts in population mortality

In 1998 as well as in 2001, the annual mortality rate in Flanders was 0.9% for a stable population of six million inhabitants. The distribution of deaths’ characteristics (age, sex, educational level, cause of death) was very similar in both years. A quarter of all people died at home. Compared with 1998, somewhat less people in 2001 died in a hospital (56% versus 50%) and somewhat more in a nursing home (17% versus 21%) (not shown in table).

Incidence and characteristics of end-of-life decisions

The proportion of sudden deaths, non-sudden deaths

Discussion

We observed remarkable shifts within medical end-of-life practices between early 1998 when the legalization process of euthanasia in Belgium started and late 2001 just before the end of this process. First, in 2001 there was a substantial reduction in the incidence of euthanasia, the use of life-ending drugs without the patient's explicit request and the alleviation of suffering with the co-intention to hasten deaths, while the incidence increased for alleviation of suffering taking into

Acknowledgements

We would like to thank the Federal and Flemish Departments of Public Health for their cooperation in the data collection, and all the physicians who provided the study data in both years. We thank Greta Van Der Kelen and Jan Bernheim for their contribution in the study conception, data analysis and interpretation of the results. We thank Johan Vanoverloop for his statistical advice and Helen White for her linguistic help. The studies were supported by grants from the Fund for Scientific

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