Open Access Highly Accessed Open Badges Research article

The use of opioids at the end of life: the knowledge level of Dutch physicians as a potential barrier to effective pain management

Mette L Rurup12, Christiaan A Rhodius23, Sander D Borgsteede45, Manon SA Boddaert23, Astrid GM Keijser1, H Roeline W Pasman12 and Bregje D Onwuteaka-Philipsen12*

Author Affiliations

1 VU University Medical Center, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Amsterdam, The Netherlands

2 VU University Medical Center, Palliative Care Center of Expertise, Amsterdam, The Netherlands

3 VU University Medical Center, Department of Medical Oncology, Palliative Care Consultation team, Amsterdam, The Netherlands

4 VU University Medical Center, Department of Clinical Pharmacology and Pharmacy, Amsterdam, The Netherlands

5 Department of Clinical Pharmacy, Academic Medical Center, Amsterdam, The Netherlands

For all author emails, please log on.

BMC Palliative Care 2010, 9:23  doi:10.1186/1472-684X-9-23

Published: 12 November 2010



Pain is still one of the most frequently occurring symptoms at the end of life, although it can be treated satisfactorily in most cases if the physician has adequate knowledge. In the Netherlands, almost 60% of the patients with non-acute illnesses die at home where end of life care is coordinated by the general practitioner (GP); about 30% die in hospitals (cared for by clinical specialists), and about 10% in nursing homes (cared for by elderly care physicians).

The research question of this study is: what is the level of knowledge of Dutch physicians concerning pain management and the use of opioids at the end of life?


A written questionnaire was sent to a random sample of physicians of specialties most often involved in end of life care in the Netherlands. The questionnaire was completed by 406 physicians, response rate 41%.


Almost all physicians were aware of the most basal knowledge about opioids, e.g. that it is important for treatment purposes to distinguish nociceptive from neuropathic pain (97%). Approximately half of the physicians (46%) did not know that decreased renal function raises plasma concentration of morphine(-metabolites) and 34% of the clinical specialists erroneously thought opioids are the favoured drug for palliative sedation.

Although 91% knew that opioids titrated against pain do not shorten life, 10% sometimes or often gave higher dosages than needed with the explicit aim to hasten death. About half felt sometimes or often pressured by relatives to hasten death by increasing opioiddosage.

The large majority (83%) of physicians was interested in additional education about subjects related to the end of life, the most popular subject was opioid rotation (46%).


Although the basic knowledge of physicians was adequate, there seemed to be a lack of knowledge in several areas, which can be a barrier for good pain management at the end of life. From this study four areas emerge, in which it seems likely that an improvement can improve the quality of pain management at the end of life for many patients in the Netherlands: 1)palliative sedation; 2)expected effect of opioids on survival; and 3) opioid rotation.