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Forgoing Treatment at the End of Life in 6 European Countries
Georg Bosshard, MD, MAE;
Tore Nilstun, PhD;
Johan Bilsen, RN, MSc;
Michael Norup, MD, PhD;
Guido Miccinesi, MD;
Johannes J. M. van Delden, MD, PhD;
Karin Faisst, MD, MPH, MAE;
Agnes van der Heide, MD, PhD; for the European End-of-Life (EURELD) Consortium
Arch Intern Med. 2005;165:401-407.
Background Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.
Methods Between June 2001 and February 2002, samples were obtained from deaths reported to registries in Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. The reporting physician was then sent a questionnaire about the medical decision-making process that preceded the patient’s death.
Results The incidence of nontreatment decisions, whether or not combined with other end-of-life decisions, varied widely from 6% of all deaths studied in Italy to 41% in Switzerland. Most frequently forgone in every country were hydration or nutrition and medication, together representing between 62% (Belgium) and 71% (Italy) of all treatments withheld or withdrawn. Forgoing treatment estimated to prolong life for more than 1 month was more common in the Netherlands (10%), Belgium (9%), and Switzerland (8%) than in Denmark (5%), Italy (3%), and Sweden (2%). Relevant determinants of treatment being withheld rather than withdrawn were older age (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.31-1.79), death outside the hospital (death in hospital: OR, 0.80; 95% CI, 0.68-0.93), and greater life-shortening effect (OR, 1.75; 95% CI, 1.27-2.39).
Conclusions In all of the participating countries, life-prolonging treatment is withheld or withdrawn at the end of life. Frequencies vary greatly among countries. Low-technology interventions, such as medication or hydration or nutrition, are most frequently forgone. In older patients and outside the hospital, physicians prefer not to initiate life-prolonging treatment at all rather than stop it later.
Author Affiliations: Institute of Legal Medicine, University of Zurich, Zurich, Switzerland (Dr Bosshard); Department of Medical Ethics, Lund University, Lund, Sweden (Dr Nilstun); Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Brussels, Belgium (Mr Bilsen); Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Copenhagen, Denmark (Dr Norup); Center for Study and Prevention of Cancer, Florence, Italy (Dr Miccinesi); Julius Center for Health Sciences, University Medical Center, Utrecht, the Netherlands (Dr van Delden); University of Zurich, Institute of Social and Preventive Medicine, Zurich (Dr Faisst); and Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (Dr van der Heide).
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