Physician-Aided Death Decreases after It's Legalized in Holland

ROTTERDAM, The Netherlands, May 10 -- Euthanasia and physician-assisted suicide decreased here after these practices were legalized in 2002, researchers reported.

At the same time, there was an increase in the use of continuous deep sedation near the end of life, Agnes van der Heide, M.D., Ph.D., of Erasmus Medical Center, and colleagues, said in the May 10 issue of the New England Journal of Medicine.

The researchers studied death certificates for all 43,959 deaths in the Netherlands from August through November of 2005, paralleling studies that had been done of end-of-life practices in 1990, 1995, and 2001.

Those earlier studies had shown an increasing rate of euthanasia and physician-assisted suicide, both of which were illegal at the time, although they were tolerated.

The investigators mailed questionnaires to physicians who attended the 6,860 deaths that were identified as possibly involving physician assistance in death.

A nearly 80% response rate showed that 1.7% of all the deaths in the Netherlands for that time period were the result of euthanasia and 0.1% were from physician-assisted suicide.

These percentages were significantly lower than those in 2001, when 2.6% of all deaths resulted from euthanasia and 0.2% from assisted suicide.

When looking at medication use to possibly hasten death, the researchers found that continuous deep sedation had been used in 7.1% of all deaths. That was a significant increase from 5.6% in 2001.

In 73.9% of all cases of euthanasia or assisted suicide, life was ended with the use of neuromuscular relaxants or barbiturates. Opioids were used in only 16.2% of cases, a significant decrease from 21.6% in 2001.

Physicians' attitudes about using opioids for euthanasia and their understanding of the effects of the drugs may have contributed to a decrease in the frequency of their use, the investigators speculated.

Although physician assistance in dying is regulated in some other countries, Holland is the first where large-scale research has provided insight into how these practices are used, Dr. van der Heide said.

In the Netherlands, euthanasia is defined as death resulting from medication administered by a physician with the explicit intention of hastening death at the request of the patient.

In assisted suicide, the patient self-administers medication prescribed by a physician.

The researchers also looked at another practice that possibly hastened death-ending a life without the explicit request of the patient. Less than 1% of deaths occurred in such a situation, virtually unchanged from 2001 numbers, the researchers noted. When it did occur, 60% of the patients had made a request for physician intervention at some earlier point, compared with 26.5% in 2001.

Other reasons physicians gave for not discussing the decision with a patient include situations in which the patient was unconscious or too young to make a decision. In such cases, 80.9% of the decisions had been discussed with a relative, and in 65%, the physicians had discussed the decision with colleagues.

The researchers' findings represent a significant reversal of the trends in end-of-life decisions found from 1990 to 2001, before enactment of the 2002 Euthanasia Act, Dr. van der Heide said.

Discounting the aging of the population as a factor, the researchers suggested that Dutch physicians consider high-quality end-of-life care as an alternative to euthanasia or assisted suicide, at least in some cases. Deep continuous sedation was the preferred method, especially for patients younger than 80, male cancer patients, and those attended by general practitioners.

Summing up, the investigators said that the high response rate of the study, the fact that both the study design and its questions were constant over the years, the endorsement by authoritative medical bodies, and the guarantee of anonymity of patients and physicians all strengthen the reliability and validity of these results.