Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium

N Engl J Med 2015; 372:1179-1181March 19, 2015DOI: 10.1056/NEJMc1414527

To the Editor:

In Belgium, where euthanasia was legalized in 2002, large-scale repeat surveys have monitored the evolution of medical end-of-life practices since 1998, with subsequent surveys conducted in 2001 and 20071,2 and the latest in 2013.

As was done in previous surveys,2 we sent questionnaires to 6188 physicians certifying death certificates from the first half of 2013 in Flanders, the Dutch-speaking half of Belgium, with approximately 6 million inhabitants and 58,000 deaths annually (see the Supplementary Appendix, available with the full text of this letter at NEJM.org). The response rate was 60.6%. The response sample was weighted to be representative of all the deaths that occurred in the first half of 2013.

After a large increase between 2001 and 2007, the total percentage of deaths preceded by one or more possibly life-shortening end-of-life practices remained stable at 47.8% in 2013 (Table 1TABLE 1Prevalence of Euthanasia and Other End-of-Life Practices in Flanders, Belgium, in 1998, 2001, 2007, and 2013.). The intensified alleviation of pain and other symptoms with the use of drugs, with possible shortening of life taken into account (24.2% of deaths), and the withholding or withdrawing of life-prolonging treatment (17.2%) remained the most prevalent end-of-life practices.

The rate of euthanasia increased significantly between 2007 and 2013, from 1.9 to 4.6% of deaths. The overall increase relates to increases in both the number of requests (from 3.5 to 6.0% of deaths) and the proportion of requests granted (from 56.3 to 76.8% of requests made).

After a decrease from 3.2% in 1998 to 1.8% in 2007, the rate of hastening death without an explicit request from the patient remained stable at 1.7% in 2013. After an increase from 8.2% in 2001 to 14.5% in 2007, the rate of use of continuous deep sedation until death decreased to 12.0% in 2013.

As compared with practices in 2007, decision making in euthanasia and physician-assisted suicide in 2013 more often included an oral and written request from the patient and consultation with another physician, both of which are requirements of the euthanasia law3 (Table S1 in theSupplementary Appendix). Palliative care services were involved in 73.7% of cases in 2013. These results suggest a stricter assessment of legal eligibility criteria in 2013 than in 2007. Decision making in other end-of-life practices also increasingly included patient and family input (data not shown).

We found an increased demand for euthanasia in Belgium between 2007 and 2013, as well as growing willingness among physicians to meet those requests, mostly after the involvement of palliative care services. 

Kenneth Chambaere, Ph.D.
Vrije Universiteit Brussel, Brussels, Belgium
kenneth.chambaere@vub.ac.be

Robert Vander Stichele, M.D., Ph.D.
Ghent University Hospital, Ghent, Belgium

Freddy Mortier, Ph.D.
Ghent University, Ghent, Belgium

Joachim Cohen, Ph.D.
Luc Deliens, Ph.D.
Vrije Universiteit Brussel, Brussels, Belgium

Supported by a grant (100036) from Agentschap voor Innovatie door Wetenschap en Technologie, the Flemish government agency for Innovation by Science and Technology.

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

Drs. Cohen and Deliens contributed equally to this letter.

This letter was published on March 17, 2015, at NEJM.org.

This finding indicates that, after 11 years of experience, euthanasia is increasingly considered as a valid option at the end of life in Belgium. For the first time, the rate of euthanasia in the Flanders area of Belgium is significantly higher than that in the Netherlands (2.8% in 2010).4