End-of-Life Decisions in the Netherlands over 25 Years
N Engl J Med 2017; 377:492-494August 3, 2017DOI: 10.1056/NEJMc170563
To the Editor:
In the Netherlands, the much debated practice of physician assistance in dying has been legally regulated since 2002.1,2 Such assistance may include physician-assisted suicide or euthanasia, in which a physician administers lethal medication at the explicit request of a patient. Both types of assistance are allowed only for patients who are “suffering unbearably” without any prospect of relief.
We studied end-of-life decision-making practices in the Netherlands between 1990 and 2015. Every 5 years, physicians were asked to fill out a questionnaire for a nationwide stratified sample of recently deceased patients.3,4 Response rates varied from 74 to 78%, and numbers of patients varied from 5197 in 1990 to 7761 in
The percentage of patients in whom an end-of-life decision had preceded death increased from 39% in 1990 to 58% in 2015. In 1990, 1.7% of all deaths were the result of euthanasia; in 2015, the percentage was 4.5%. The rate of physician-assisted suicide varied between 0.1% and 0.2%, respectively. In 2015, physician assistance in dying was requested by 8.3% of all deceased persons. Ending of life without an explicit patient request decreased, from 0.8% in 1990 to 0.3% in 2015. The use of morphine to alleviate symptoms while taking into account possible hastening of death as a result increased from 19% of all deaths in 1990 to 36% in 2010 and 2015. Continuous deep sedation was provided in 8.2% of all patients in 2005 and in 18.3% in 2015; this practice involved the use of benzodiazepines, often combined with an opioid, in 83% and 95% of all cases, respectively.
Physician assistance in dying is performed mainly by general practitioners (in 93% of cases in 2015). However, we found some shifts in the circumstances in which such assistance was provided. In 2015, the percentage of patients who were older than 80 years of age was higher than in 1990 (35% vs. 22%), as was the percentage of patients who had an estimated life expectancy of more than a month (27% vs. 16%). In 2015, physicians who responded to a survey (with more than one possible option) indicated that 92% of the patients who received physician assistance in dying had a serious somatic disease; 14% had an accumulation of health problems related to old age, and a small minority had early-stage dementia (3%) or psychiatric problems (3%).
The use of potentially life-shortening medication and continuous deep sedation to relieve end-of-life suffering has become common practice in the Netherlands. The frequency of physician assistance in dying is similar to the rate that was recently reported in Belgium, which is one of the few countries in which physician assistance in dying is also allowed.5 About half of all requests for physician assistance in dying were granted in 2015. Such assistance is provided predominantly to patients with severe disease but increasingly involves older patients and those with a life expectancy of more than a month.
Agnes van der Heide, M.D., Ph.D.
Erasmus MC, Rotterdam, the Netherlands
Johannes J.M. van Delden, M.D., Ph.D.
University Medical Center Utrecht, Utrecht, the Netherlands
Bregje D. Onwuteaka-Philipsen, Ph.D.
VU University Medical Center, Amsterdam, the Netherlands