Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2



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Competing interests

Non-financial competing interests: Wim Distelmans is chair of the LEIF forum. He collaborated to the research but did not have any influence on the choice of data being presented or the interpretations the other authors choose to give to the findings.


Authors’ contributions

JC, YVW, TS, JB, and LD designed the study. JC and LD obtained funding. JC, YVW, and TS were responsible for data acquisition and the data analyses. All authors contributed to the interpretation of data. JC and YVW drafted the manuscript and all authors critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.


Acknowledgements

This study is part of the ‘Monitoring Quality of End-of-Life Care (MELC) Study’, a collaboration between the Vrije Universiteit Brussel, Ghent University, Antwerp University, the Scientific Institute of Public Health, Belgium, and VU University Medical Centre Amsterdam, the Netherlands.

We would like to thank all physicians participating in this study, as well as lawyer Wim De Brock and his secretary Jessica for helping with the mailing procedure and hence, guaranteeing the anonymity of the survey. We also thank Jane Ruthven for proofreading the paper.

Joachim Cohen is a postdoctoral research fellow of the Research Foundation Flanders.



Funding: This work was supported by a grant from the Institute for the Promotion of Innovation by Science and Technology in Flanders (Instituut voor de aanmoediging van Innovatie door Wetenschap en Technologie in Vlaanderen) (SBO IWT nr. 050158) and a grant from the Research Council of the Vrije Universiteit Brussel (OZR 1911).

The funding bodies of the study did not have any role in the design, in the collection, analysis, and interpretation of data.


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2. Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen B, Mortier F, Deliens L: Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. Canadian Medical Association Journal 2010, 182:895-901.

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4. Smets T, Bilsen J, Cohen J, Rurup M, Mortier F, Deliens L: Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. British Medical Journal 2010, 341.

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8. Distelmans W: Een Waardig Levenseinde. Amsterdam/Antwerpen: Houtekiet; 2010.

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10. Lloyd-Williams M, MacLeod RD: A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Med Teach 2004, 26:683-690.

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13. Löfmark R, Mortier F, Nilstun T, Bosshard G, Cartwright C, Van Der Heide A, Norup M, Simonato L, Onwuteaka-Philipsen B, Consortium E: Palliative care training: a survey of physicians in Australia and Europe. J Palliat Care 2006, 22:105-110.

14. Buss MK, Lessen DS, Sullivan AM, Von Roenn J, Arnold RM, Block SD: A study of oncology fellows' training in end-of-life care. J Support Oncol 2007, 5:237-242.

15. Van Wesemael Y, Cohen J, Bilsen J, Smets T, Onwuteaka-Philipsen B, Deliens L: Process and Outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey. Journal of Pain and Symptom Management 2011, 42:721-733.

16. Dillman D: The design and administration of mail surveys. Annu Rev Sociol 1991, 17:225-249.

17. Smets T, Cohen J, Bilsen J, Van Wesemael Y, Rurup M, Deliens L: Attitudes and Experiences of Belgian Physicians Regarding Euthanasia Practice and the Euthanasia Law. Journal of Pain and Symptom Management 2011, 41:580-593.

18. Onwuteaka-Philipsen B, Gevers JKM, van der Heide A, van Delden JJM, Pasman HRW, Rietjens JAC, Rurup ML, Buiting HM, Hanssen-de Wolf JE, Janssen AGJM, van der Maas PJ: Evaluation of Law Termination of Life on Request and Assisted Suicide (in Dutch) [Evaluatie Wet toetsing levensbeeindiging op verzoek en hulp bij zelfdoding]. In Programma evaluatie regelgeving (ZonMw ed. Den Haag: ZonMw; 2007.

19. Onwuteaka-Philipsen BD, van der Wal G: A protocol for consultation of another physician in cases of euthanasia and assisted suicide. J Med Ethics 2001, 27:331-337.

20. Cohen J, Van Wesemael Y, Smets T, Bilsen J, Deliens L: Cultural differences affecting euthanasia practice in Belgium: One law but different attitudes and practices in Flanders and Wallonia. Social Science & Medicine 2012, 75:845-853.

21. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G: Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Arch Intern Med 2005, 165:1698-1704.

22. Smets T, Bilsen J, Van Den Block L, Cohen J, Van Casteren V, Deliens L: Euthanasia in patients dying at home in Belgium: interview study on adherence to legal safeguards. British Journal of General Practice 2010, 60:268-274.

23. Billings JA, Block S: Palliative care in undergraduate medical education. Status report and future directions. JAMA 1997, 278:733-738.

24. Paice E, Heard S, Moss F: How important are role models in making good doctors? BMJ 2002, 325:707-710.

25. Meier D, Isaacs S, Hughes R: Palliative Care: Transforming the Care of Serious Illness. Princeton: John Wiley and Sons; 2009.

26. Hayes RP, Stoudemire AS, Kinlaw K, Dell ML, Loomis A: Changing attitudes about end-of-life decision making of medical students during third-year clinical clerkships. Psychosomatics 1999, 40:205-211.

27. Wear D: "Face-to-face with It": medical students' narratives about their end-of-life education. Acad Med 2002, 77:271-277.

28. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G: Quality of consultation and the project 'Support and Consultation on Euthanasia in the Netherlands' (SCEN). Health Policy 2007, 80:97-106.


1. Law concerning euthanasia May 28 2002 [in Dutch] L. Wet betreffende euthanasie, 28 mei 2002. 2002.

2. Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ. 2010;182(9):895-901.

3. Van Wesemael Y, Cohen J, Onwuteaka-Philipsen B, Bilsen J, Deliens L. Establishing specialized health services for professional consultation in euthanasia: experiences in the Netherlands and Belgium. BMC Health Services Research. 2009 ;9(220):

4. Van Wesemael Y, Cohen J, Onwuteaka-Philipsen BD, Bilsen J, Distelmans W, Deliens L. Role and involvement of life end information forum physicians in euthanasia and other end-of-life care decisions in Flanders, Belgium. Health services research. 2009 Dec ;44(6):2180-92.

5. Distelmans W. Een Waardig Levenseinde. Zesde geactualiseerde druk. Houtekiet; 2010.

6. Lloyd-Williams M, MacLeod RDM. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Medical teacher. 2004 ;26(8):683-90.

7. Hesselink BAM, Pasman HRW, Wal G van der, Soethout MBM, Onwuteaka-Philipsen BD. Education on end-of-life care in the medical curriculum: students’ opinions and knowledge. Journal of Palliative Medicine. 2010 ;13(4):381-387.

8. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. Journal of general internal medicine. 2003 Sep ;18(9):685-95.

9. Lofmark R, Mortier F, Nilstun T, Bosshard G, Cartwright C, Van der Heide A, et al. Palliative Care Training: a Survey of Physicians in Australia and Europe. Journal of Palliative Care. 2006 ;22 105-110.

10. Buss MK, Lessen DS, Sullivan AM, Von Roenn J, Arnold RM, Block SD. A study of oncology fellows’ training in end-of-life care. The journal of supportive oncology. 2007 ;5(5):237-42.

11. Van Wesemael Y, Cohen J, Bilsen J, Smets T, Onwuteaka-Philipsen B, Deliens L. Process and outcomes of euthanasia requests in Belgium under the euthanasia act: a nationwide survey. Journal of Pain and Symptom Management. 2011, 42(5):721-33.

12. Dillman DA. The design and administration of mail surveys. Annu Rev Sociol. 1991 ;17225-249.

13. Smets T, Cohen J, Bilsen J, Van Wesemael Y, Rurup ML, Deliens L. Attitudes and experiences of belgian physicians regarding euthanasia practice and the euthanasia law. Journal of pain and symptom management. 2011 ;41(3):580-93.

14. Onwuteaka-Philipsen B, Gevers J, Heide A van der, Delden J van, Pasman R, Rietjens J, et al. Evaluation of Law Termination of Life on Request and Assisted Suicide (in Dutch) [Evaluatie Wet toetsing levensbeeindiging op verzoek en hulp bij zelfdoding]. Den Haag: Zon/Mw; 2007.

15. Onwuteaka-philipsen BD, van der Wal G. A protocol for consultation of another physician in cases of euthanasia and assisted. Journal of Medical Ethics. 2001;27(5):331-337.

16. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Archives of Internal Medicine. 2005 ;165(15):1698-1704.

17. Smets T, Bilsen J, Van den Block L, Cohen J, Van Casteren V, Deliens L. Euthanasia in patients dying at home in Belgium: interview study on adherence to legal safeguards. The British Journal of General Practice : the Journal of the Royal College of General Practitioners. 2010 ;60(573):e163-70.

18. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA : the Journal of the American Medical Association. 1997 ;278(9):733-738.

19. Paice E. How important are role models in making good doctors? BMJ. 2002 ;325(7366):707-710.

20. Meier DE, Isaacs SL, Hughes R. Palliative Care: Transforming the Care of Serious Illness. John Wiley and Sons; 2009.

21. Hayes RP, Stoudemire AS, Kinlaw K, Dell ML, Loomis A. Changing Attitudes About End-of-Life Decision Making of Medical Students During Third-Year Clinical Clerkships. Psychosomatics. 1999 ;40(3):205-211.

22. Wear D. “Face-to-face with It”: medical students’ narratives about their end-of-life education. Academic Medicine : Journal of the Association of American Medical Colleges. 2002 ;77(4):271-277.Box Table 1: quality criteria as outlined by the Dutch consultation protocol



The consultant

- was not a colleague of the attending physician

- was not a co-attending physician

- did not know the patient

- talked to/examined the patient

- considered the request*

- talked about possible alternatives†

- made a written report

* This criterion was not questioned in the Belgian survey because it is too vague and not a task stipulatedrequirement in de Belgian euthanasia law.

†This criterion was not questioned in the Belgian survey because it is not a requirement for the second physician in the Belgian law on euthanasia.


Table 12: number of consultations with a second physician (LEIF and not LEIF) since the euthanasia law, according to physician’s characteristics (n=244)





Number of physicians who consulted with a second physician after receiving request in FL and BXL (and % of total physicians in FL and BXL)*
Total N= 170 (69.7%)

p-value†

LEIF physician N=51 (30.0%)

Not LEIF physician or not known

N=119 (70.0%)




p-value

LEIF vs not LEIF‡



Specialty
















General practitioners

118 (69.4)

0.764

42 (35.6)

76 (64.4)

0.010

Specialist

51 (30.2)




9 (15.7)

43 (84.3)






















Physician’s age
















Younger than 36

17 (10.1)

0.656

5 (29.4)

12 (70.6)

1.000

36-50 years

74 (44.0)

0.022

14 (18.9)

60 (81.1)

0.017

51-60 years

58 (34.5)

0.149

22 (37.9)

36 (62.1)

0.153

Older than 60

19 (11.3)

0.526

9 (47.4)

10 (52.6)

0.114



















Number of terminal patients cared for in 1 year
















0 patients

12 (7.2)

0.202

6 (50.0)

6 (50.0)

0.102

1 to 10 patients

114 (74.5)

0.255

35 (30.7)

79 (69.3)

1.000

more than 10 patients

27 (17.6)

0.850

6 (22.2)

21 (77.8)

0.360



















Religiosity
















Not religious

57 (33.5)

0.176

19 (33.3)

38 (66.7)

0.595

Religious

113 (66.5)




32 (28.3)

81 (71.7)






















Training in palliative care or member of palliative team
















Yes

115 (67.6)

0.243

38 (33.0)

77 (67.0)

0.283

No

55 (32.4)




13 (23.6)

42 (76.4)






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