Elsevier

The Lancet

Volume 380, Issue 9845, 8–14 September 2012, Pages 908-915
The Lancet

Articles
Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey

https://doi.org/10.1016/S0140-6736(12)61034-4Get rights and content

Summary

Background

In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency. We assessed frequency and characteristics of euthanasia, physician-assisted suicide, and other end-of-life practices in 2010, and assessed trends since 1990.

Methods

In 1990, 1995, 2001, 2005, and 2010 we did nationwide studies of a stratified sample from the death registry of Statistics Netherlands, to which all deaths and causes were reported. We mailed questionnaires to physicians attending these deaths (2010: n=8496 deaths). All cases were weighted to adjust for the stratification procedure and for differences in response rates in relation to the age, sex, marital status, region of residence, and cause and place of death.

Findings

In 2010, of all deaths in the Netherlands, 2·8% (95% CI 2·5–3·2; 475 of 6861) were the result of euthanasia. This rate is higher than the 1·7% (1·5–1·8; 294 of 9965) in 2005, but comparable with those in 2001 and 1995. Distribution of sex, age, and diagnosis was stable between 1990 and 2010. In 2010, 77% (3136 of 4050) of all cases of euthanasia or physician-assisted suicide were reported to a review committee (80% [1933 of 2425] in 2005). Ending of life without an explicit patient request in 2010 occurred less often (0·2%; 95% CI 0·1–0·3; 13 of 6861) than in 2005, 2001, 1995, and 1990 (0·8%; 0·6–1·1; 45 of 5197). Continuous deep sedation until death occurred more frequently in 2010 (12·3% [11·6–13·1; 789 of 6861]) than in 2005 (8·2% [7·8–8·6; 521 of 9965]). Of all deaths in 2010, 0·4% (0·3–0·6; 18 of 6861) were the result of the patient's decision to stop eating and drinking to end life; in half of these cases the patient had made a euthanasia request that was not granted.

Interpretation

Our study provides insight in consequences of regulating euthanasia and physician-assisted suicide within the broader context of end-of-life practices. In the Netherlands the euthanasia law resulted in a relatively transparent practice. Although translating these results to other countries is not straightforward, they can inform the debate on legalisation of assisted dying in other countries.

Funding

The Netherlands Organization for Research and Development (ZonMw).

Introduction

At the end of life, many patients need comfort-oriented care. Such care might include end-of-life decision making (eg, on forgoing burdensome treatment or intensifying alleviation of pain or other symptoms). During this period, people can even develop a death wish, when suffering becomes overwhelming.1, 2 Patients might then ask their physician to end their life. In most countries physicians are not allowed to grant such a request, but there is much debate on this issue.3, 4, 5, 6 Concerns expressed include the fear of an expanding practice of euthanasia (eg, among vulnerable groups such as older people or incompetent patients). It is not known to what extent refused requests for euthanasia result in patients ending their own life.

Since 2002, the Netherlands has been one of the few countries where euthanasia and physician-assisted suicide are, under strict conditions, regulated by law. Comparable laws exist in Belgium and Luxembourg; Oregon, Montana, Washington (USA), and Switzerland have legally regulated assistance in suicide.7, 8 In the Netherlands, euthanasia is defined as the administering of lethal drugs by a physician with the explicit intention to end a patient's life on the patient's explicit request. In physician-assisted suicide the patient self-administers medication that was prescribed intentionally by a physician. In the Netherlands, the enactment of the euthanasia law was preceded by several decades of debate among medical practitioners, lawyers, ethicists, politicians, and the general public in which a reporting procedure was developed.7 This debate has been informed by nationwide studies on end-of-life decision making that were done in 1990, before the first reporting procedure, 1995, 2001, and 2005.9, 10, 11, 12, 13 These studies have allowed monitoring of the practice of end-of-life decision making in relation to development of the regulatory system. In 2005, 3 years after enactment of the euthanasia law, the euthanasia rate had decreased significantly, from 2·6% of all deaths in 2001, to 1·7% in 2005, which was a reversal of the trend from 1990 to 2001. Ending of life without an explicit request of the patient had decreased, albeit not significantly (0·7% in 2001 and 0·4% in 2005).9 In 2010, 8 years after enactment of the euthanasia law, we investigated how end-of-life decision making practices have further developed.

Section snippets

Study design

In 2010, we undertook a nationwide death-certificate study that was largely similar to earlier studies done in 1990, 1995, 2001, and 2005.9, 10, 11, 12, 13 We drew a random sample from the central death registry of Statistics Netherlands, to which all deaths and causes were reported. The period studied was Aug 1, through Nov 1, in all studied years. All deaths that occurred in that period were assigned to one of five strata. When the cause of death clearly precluded end-of-life decision making

Results

Of the 8496 questionnaires that were mailed, 6263 were returned and eligible for analysis (response rate 74%). Response rates in the different strata ranged between 64% and 84%, with response being higher in strata in which the likelihood of an end-of-life decision was higher. Response rates in 1990, 1995, 2001, and 2005 were comparable (range 74% to 78%). The frequency of euthanasia increased between 2005 and 2010 (table 1). The frequency of physician-assisted suicide remained low over the

Discussion

After the modest decrease in euthanasia frequency 3 years after enactment of the euthanasia law, we saw an increase 8 years after the enactment. A rise in the number of patients requesting euthanasia explains this increase partly. While more than half of these requests were not granted, physicians granted requests more often in 2010 than in 2005. As no differences occurred in patient characteristics of cases of euthanasia and physician-assisted suicide, the increase seems not to be due to

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