Euthanasia and other end-of-life decisions after implementation of the law on euthanasia in Belgium

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Euthanasia and other end-of-life decisions after implementation of the law on euthanasia in Belgium

Prof dr Luc Deliens Prof essor of Public H ealth and Palliative C are Head of End-of-Life Care Research Group, Brussels

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Questions addressed

How was the law on euthanasia implemented in Belgiu

m? (“reported case”)

How did the incidence of end-of-life decisions develope since the implementation of th

e law on euthanasia in 2002?

How does medical end-of-life decision- making vary according to language community (Dutch vs French) in Belgium? How does medical end-of-life decision- making vary according to palliative care and end-of-life care?

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ELDs = end-of-life decisions with a possible or certain life-shortening effect – Non-treatment decision : forgoing a possibly life-prolonging treatment • With the explicit intention of hastening death – Intensifying symptom alleviation using possibly life-shortening drugs (opioids) • Co-intended to hasten death – Administering, supplying, or prescribing lethal drugs with explicit life-shortening intention ^•

E uthanasia / Physician-assisted suicide • Life-ending without explicit patient request

e Research Group

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administering sedatives (barbiturates or benzodiazepines) to keep the patient in deep sedation or coma continuously until death: ^•

w ith administration of artificial food and fluid • W ithout administration of artificial food and fluid Life-shortening effect unclear in literature “slow euthanasia”

ELDs = end-of-life decisions with a possible or certain life-shortening effect

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Questions addressed 1.

How was the law on euthanasia implemented in Belgium?

• H ow many cases of euthanasia have been reported by physicians to the Federal Control and Evaluation Committee between 2002 and 2008 ?

e Research Group

Smets T, Bilsen J, Cohen J, Rurup ML, Deliens L. Legal euthanasia in Belgium: Characteristics of all reported euthanasia cases.Medical Care2010 Feb;48(2):187-92.

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24

235 347 388 428 495

705 2002 2003 2004 2005 2006 2007 2008

Tota l num be r of re p o rt e d cases R e p o rt e d cases in Du tc h R e p o rt e d cases in F ren ch

reported euthanasia cases (N= 2622)

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Ag e p a ti e n t 2 3 10

26 38

53 50

18 0% 20% 40% 60% 80% 100%

All deats in population

Reported cases of euthanasia

18- 39 year 40- 59 year 60- 79 year > 79 year

reported euthanasia cases

e Research Group

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D iag n o si s p a ti en t 24

83 76

17 0% 20% 40% 60% 80% 100%

aths in ation

ases of a

Can cer N on- ca nc er

reported euthanasia cases

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P lace o f d eat h 22

4 3

2 52

52 22

42 0% 20% 40% 60% 80% 100%

All deaths in population

Reported cases of euthanasia

Ho sp it al Ho me C ar e hom e Ot h er

reported euthanasia cases

e Research Group

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T erminally ill patients: 93% (N=1790) N on-terminally ill patients: 7% (N=126)

reported euthanasia cases

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D ia gnos is pa ti e n t 9 2 9 5

30 88% 38% 5 0 10 20 30 40 50 60 70 80 90 100 Te rm ina lly ill N on- te rm ina lly ill

Can ce r N eur om us cu la r d isease Card io vascu lar d isease Ot h er

reported euthanasia cases

e Research Group

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reported euthanasia cases

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Consultation services • Life End Information Forum in Flanders (since 2003)

• S upport and Consultation for Euthanasia in the Netherlands (since 1997) Æ

Provide trained independent physicians for consultation in cases of a euthanasia request

Æ

Qualitative consultations in which the legally defined due care criteria are checked

e Research Group

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Questions addressed

How was the law on euthanasia implemented in Belgiu

m?

How did the incidence of end-of-life decisions develope since the implementation of th

e law on euthanasia in 2002? death certificates ( 3,623 cases in 2007 )

Chambaere K, Deliens L et al. Continuous deep sedation until death in Belgium. Archives of Internal Medicine2010 Mar 8;170(5):490-3 Bilsen J, Deliens L et al. Medical end-of-life practices under the euthanasia law in Belgium. New Engl J Med. 2009 sep; 361(11):1119-21 Chambaere K, Deliens L et al. A post-mortem survey on end-of-life decisions using a representative sample of death certificates inFlanders, Belgium: research protocol. BMC Public Health2008 Aug;8:299

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Research method • R epresentative sample of official Flemish death certificates in 1998 and 2007 • Q uestionnaire sent to physicians • A nonymity guaranteed • 6927 cases in 2007 (12% of all deaths) • R esponse rate 58% • M ethod and questionnaire identical to past study in 1998 (response 48%)

e Research Group

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1998 N=1,925 2007 N=3,623 33.3 31.9 27.4 20.3 39.3 47.8 4.4 3.8 E uthanasia 1.1 1.9 P hysician-assisted suicide 0.12 0.07 Life-ending without request 3.2 1.8 18.4 26.7 16.4 17.4 8.2* 14.5

Bilsen J, Deliens L et al. Medical end-of-life practices under the euthanasia law in Belgium. New Engl J Med. 2009 sep; 361(11):1119-21

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Euthanasia cases (%) 1998 2007 Male 1.0 2.4 Female 1.5 1.5 1-64 years 2.4 4.2 65-79 years 1.0 2.6 80+ years 0.9 0.8 Cancer 2.1 5.7 Non-cancer 0.9 0.5 At home 2.6 4.2 In hospital 1.0 1.7 In care home 0.6 0.3

e Research Group Bilsen J, Deliens L et al. Medical end-of-life practices under the euthanasia law in Belgium. New Engl J Med. 2009 sep; 361(11):1119-21

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Life-ending without request (%) 1998 2007 Male 3.4 1.7 Female 3.0 1.9 1-64 years 4.2 0.8 65-79 years 3.8 2.2 80+ years 2.2 1.9 Cancer 5.9 2.1 Non-cancer 2.2 1.7 At home 3.6 1.4 In hospital 3.0 2.4 In care home 3.0 1.0

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Euthanasia

e Research Group

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Life-ending without request

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Questions addressed 1.

How was the law on euthanasia implemented in Belgiu

m? 2.

How did the incidence of end-of-life decisions develope since the implementation of th

e law on euthanasia in 2002? 3.

How does medical end-of-life decision- making vary according to language community (Dutch vs French) in Belgium?

e Research Group

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Dutch vs French-speaking communities in Belgium

ate 82% (Dutch) - 18% (French) • N on-explicable on the basis of population size : 60% - 4 0% • In home care : 92% - 8 %

Do the two language communities of Belgium differ in incidence and types of medical end-of-life decisions? If so, how?

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OR 1.4 50 41 0 10 20 30 40 50 60 Du tc h F re nc h

% patient s

Dutch-speaking and French- speaking communities End-of-life decisions with possible or certain life-shortening effect among non-sudden deaths

e Research Group

Van den Block L, Deliens L et al. Euthanasia and other end-of-life decisions: a mortality follow-back study comparing medical practice in the two cultural communities of Belgium. BMC Public Health2009 Mar 9;9:79.

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15 11 0 5 10 15

20

25 30 Dut ch F re nc h

% patient s

co-intended or with the explicit intention among non-sudden deaths OR 1.4

Dutch-speaking and French- speaking communities

Van den Block L, Deliens L et al. Euthanasia and other end-of-life decisions: a mortality follow-back study comparing medical practice in the two cultural communities of Belgium. BMC Public Health2009 Mar 9;9:79.

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1, 6 1, 7

29, 3 17, 6 0, 9 1 ,4

25, 1 14 0 5 10 15 20 25 30 _{% pa} _tie _nts OR N S

Du tc h Fr e n ch

Dutch-speaking and French- speaking communities

Van den Block L et al. Euthanasia and other end-of-life decisions: a mortality follow-back study comparing medical practice in the two cultural communities of Belgium. BMC Public Health2009 Mar 9;9:79. e Research Group

End-of-life decisions among non-sudden deaths

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9. 2

15. 1 8. 2 3. 6 5. 9 4. 6 0 5 10 15

20

25 30 Du tc h F re nc h

% p atie nts

to ta l wit h out fo o d /fl u id w ith fo o d /fl u id

deep sedation among non-sudden deaths

Dutch-speaking and French- speaking communities

Van den Block L et al. Euthanasia and other end-of-life decisions: a mortality follow-back study comparing medical practice in the two cultural communities of Belgium. BMC Public Health2009 Mar 9;9:79.

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Questions addressed 1.

How was the law on euthanasia implemented in Belgiu

m? 2.

How did the incidence of end-of-life decisions develope since the implementation of th

e law on euthanasia in 2002? 3.

How does medical end-of-life decision- making vary according to language community (Dutch vs French) in Belgium?

4. How does medical end-of-life decision- making vary according to palliative care and end-of-life care?

e Research Group

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End-of-life decisions and end-of-life care T o what extent are medical end-of-life decisions part of palliative care provision? T he WHO states that “ palliative care

intends neither to hasten nor to postpone death

” E thics Taskforce of the European Association of Palliative Care states that “euthanasia is not part of the responsibility of palliative care

”

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End-of-life decisions according to place of death

3 0

0,8

3,2 2,2 1,8 0,6

3,2

5,2 2

3,7

6

0 1 2 3 4 5 6 7

8 9 10

% patients dying following a decision per sett

ing

p lace o f d eat h

euthanasia / PAS life-ending without expl request sedation without food/fluid Van den Block L, et al. How are euthanasia and other medical end-of-life decisions related to the care provided in the final three months of life? Brit Med J 2009 Jul;339:b2772 e Research Group

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End-of-life decisions and multidisciplinary palliative care

1.41.9

9. 8

14. 1

2 0.9

6.1 2.3

0 2 4 6

8 10

12

14 16 no ye s u s e o f s p e c ia lis t m u lt id is c ip lin a ry p a llia ti v e c a re

% p ati ents wh ere d ecisi on

eut hanas ia / P A S lif e- endi ng w ithout ex pl r e ques t sedat ion w ith out food/ flui d e xp lic it lif e -e n d in g

Van den Block L, et al. How are euthanasia and other medical end-of-life decisions related to the care provided in the final three months of life? Brit Med J 2009 Jul;339:b2772

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0. 2

1. 9

3. 8 0 1 2 3 4 5 6 7 8 9 10 to a ( ve ry ) sm all ex tent av er aged to a ( ver y) lar ge ex te nt s p ir it u a l o r e x is te n tia l c a re

% p ati ents wh ere d ecisi

on

eut hanas ia / P A S

End-of-life decisions and spiritual/existential care

Van den Block L, et al. How are euthanasia and other medical end-of-life decisions related to the care provided in the final three months of life? Brit Med J 2009 Jul;339:b2772 e Research Group

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Conclusion uthanasia most often performed in o significant changes in characteristics

Conclusions on “reported” euthanasia cases

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Conclusion Conclusions on incidence “trends”

e Research Group

• E nactment of the law was followed by an increase in all types of medical end-of- life decisions, except for life ending without request • N o shift towards the use of life-e nding drugs in vulnerable patient groups • S ubstantial increase in terminal sedation

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Conclusion Conclusions on Dutch-speaking vs French- speaking communities E uthanasia occurs less among French speaking people (but not significantly) T erminal sedation occurs more often among French speaking people M oreover, French speaking doctors report less often than Flemish doctors

to the Federal Control and Evaluation Committee on Euthanasia

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Conclusion Conclusions concerning “palliative care”

e Research Group

• Life shortening and palliative care do not have to oppose each other ; t h ey commonly coexist • E uthanasia and other end-of-life decisions

that shorten life are NOT related to a lower use of palliative care in Belgium

• E uthanasia occurs often within the context of multidisciplinary palliative care

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Euthanasia and other end-of-life decisions after implementation of the law on euthanasia in Belgium