In Belgium, where euthanasia was legalized in 2002, we conducted a follow-up study in 2007 to two largescale nationwide surveys on medical end-of-life practices that had been conducted in 1998 and 2001. 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.
In the linked study (doi:10.1136/bmj.b2772), Van den Block and colleagues report a national mortality follow-back study of end of life care in Belgium conducted during 2005 and 2006. The findings are a valuable contribution to understanding the context of dying in Belgium. They detail the frequency of team based palliative care; involvement of generalists; use of intensive alleviation of symptoms, which can extend to palliative sedation (termed continuous deep sedation); and the incidence of euthanasia and physician assisted suicide. However, the authors’ interpretation of the data and the conclusions they reach raise questions. Their conclusion that life shortening decisions, including euthanasia and physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care, misrepresents the frequencies they report and is tangential to the main findings.
This study investigates the use of CDS in the United Kingdom. In total, 18.7% (17.3–20.1) of the doctors attending a dying patient reported the use of CDS. CDS was more likely when patients were younger or were dying of cancer. Specialists in care of the elderly were least likely to report the use of CDS; doctors in other hospital specialties were most likely to report its use. CDS was associated with a higher rate of requests from patients or relatives for a hastened death and with a greater incidence of other end-of-life decisions containing some intent to end life by the doctor. Doctors supporting legalization of euthanasia or physician-assisted suicide, or who were nonreligious, were more likely to report using CDS. There was palliative care team involvement in half of all CDS cases, and prescription of opioids alone for sedation occurred in one-fifth of the cases but was not reported by specialists in palliative care.
The book strives for as complete and dispassionate a description of the situation as possible and covers in detail: the substantive law applicable to euthanasia, physician-assisted suicide, withholding and withdrawing treatment, use of pain relief in potentially lethal doses, terminal sedation, and termination of life without a request (in particular in the case of newborn babies); the process of legal development that has led to the current state of the law; the system of legal control and its operation in practice; and, the results of empirical research concerning actual medical practice.
Rurik Löfmark, Tore Nilstun, Colleen Cartwright, Susanne Fische, Agnes van der Heide, Freddy Mortier, Michael Norup, Lorenzo Simonato and Bregje D Onwuteaka-Philipsen for the EURELD Consortium
But there is evidence that some clinicians may already be using continuous deep sedation (CDS), as a form of "slow euthanasia". Research suggests use of CDS in Britain is particularly high - accounting for about one in six of all deaths.
Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.
Terminal sedation is the procedure whereby a patient is placed into a deep sleep with the expectation that this will be maintained until he or she dies. Artificial administration of food and fluid is often withdrawn at the same time. This leads to a marked decline in the patient’s consciousness up till death, and may also shorten his or her life. It is important that fundamental values and norms are not violated during this process, and that the patient continues to be treated with due care. This report indicates that opportunities for monitoring and encouraging this process will increase if terminal sedation administered on sound medical grounds is regulated by the medical profession itself on the basis of its own standards. This means that if terminal sedation has a life-shortening effect, then the physician’s ‘intention’ when taking this action is no longer a decisive factor in deciding whether or not the physician has (criminally) ended the patient’s life.