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Open Access Highly Accessed Research article

Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium

Koen Meeussen1*, Lieve Van den Block12, Nathalie Bossuyt3, Michael Echteld4, Johan Bilsen15 and Luc Deliens14

Author Affiliations

1 End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium

2 Department of General Practice, Vrije Universiteit Brussel, Brussels, Belgium

3 Scientific Institute of Public Health, Unit of Epidemiology, Brussels, Belgium

4 VU University Medical Centre, Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Centre for Palliative Care, Amsterdam, the Netherlands

5 Department of Public health, Vrije Universiteit Brussel, Brussels, Belgium

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BMC Public Health 2010, 10:186  doi:10.1186/1471-2458-10-186

Published: 9 April 2010

Abstract

Background

Although the incidence of the use of life-ending drugs without explicit patient request has been estimated in several studies, in-depth empirical research on this controversial practice is nonexistent. Based on face-to-face interviews with the clinicians involved in cases where patients died following such a decision in general practice in Belgium, we investigated the clinical characteristics of the patients, the decision-making process, and the way the practice was conducted.

Methods

Mortality follow-back study in 2005-2006 using the nationwide Sentinel Network of General Practitioners, a surveillance instrument representative of all GPs in Belgium. Standardised face-to-face interviews were conducted with all GPs who reported a non-sudden death in their practice, at home or in a care home, which was preceded by the use of a drug prescribed, supplied or administered by a physican without an explicit patient request.

Results

Of the 2690 deaths registered by the GPs, 17 were eligible to be included in the study. Thirteen interviews were conducted. GPs indicated that at the time of the decision all patients were without prospect of improvement, with persistent and unbearable suffering to a (very) high degree in nine cases. Twelve patients were judged to lack the competence to make decisions. GPs were unaware of their patient's end-of-life wishes in nine cases, but always discussed the practice with other caregivers and/or the patient's relatives. All but one patient received opioids to hasten death. All GPs believed that end-of-life quality had been "improved considerably".

Conclusions

The practice of using life-ending drugs without explicit patient request in general practice in Belgium mainly involves non-competent patients experiencing persistent and unbearable suffering whose end-of-life wishes can no longer be ascertained. GPs do not act as isolated decision-makers and they believe they act in the best interests of the patient. Advance care planning could help to inform GPs about patients' wishes prior to their loss of competence.