The incidence and characteristics of end-of-life decisions by GPs in Belgium

Background. Medical end-of-life decisions (ELDs) have been discussed for several years in different countries, but little is known about the involvement of GPs in these ELDs. Objectives. The aim of the present study was to establish the incidence and characteristics of ELDs by GPs. Method. We selected 3999 deaths, a 20% random sample of all registered deaths during the first 4 months of 1998 in Flanders, Belgium, and mailed anonymous questionnaires to the attesting physicians. Here we focus exclusively on the 1647 deaths certified by GPs. Results. The GPs returned 1067 questionnaires (response rate of 64.8%). At least one ELD was made in 39.5% [95% confidence interval (CI) 37.8-41.2] of all primary care deaths. The incidence of euthanasia (including physician-assisted suicide) was 1.5% (95% CI 0.9-2.3) (incidence higher among more educated patients and at home), of administration of lethal drugs without the patient's explicit request 3.8% (95% CI 2.9-5.0) (higher among cancer patients), of alleviation of pain and symptoms with possibly life-shortening effect 18.6% (95% CI 17.0-20.2) (higher among cancer patients and married patients) and of non-treatment decisions 15.6% (95% CI 14.2-17.2) (higher among cancer patients and in nursing homes). The decision was not discussed with the patient in three out of four of the ELDs. A colleague was consulted in one in four ELD cases. Conclusion. ELDs are common in general practice in Flanders, Belgium, despite the restrictive law concerning euthanasia at the time of this study. The incidence of these ELDs varies with cause and place of death, the patient's education and the GP's religion and age. Requirements of prudent practice regarding ELDs are rather poorly met by GPs. Further international research and debate is needed to highlight the GPs' important role in end-of-life care.