Abstract
BackgroundEducational attainment has been shown to influence access to and quality of health care. However, the influence of educational attainment on decision-making at the end of life with possible or certain life-shortening effect (ELDs ie intensified pain and symptom alleviation, non-treatment decisions, euthanasia/physician-assisted suicide, and life-ending acts without explicit request) is scarcely studied. This paper examines differences between educational groups pertaining to prevalence of ELDs, the decision-making process and end-of-life treatment characteristics.MethodWe performed a retrospective survey among physicians certifying a large representative sample of Belgian deaths in 2007. Differences between educational groups were adjusted for relevant confounders (age, sex, cause of death and marital status).ResultsIntensified pain and symptom alleviation and non-treatment decisions are more likely to occur in higher educated than in lower educated patients. These decisions were less likely to be discussed with either patient or family, or with colleague physicians, in lower educated patients. A positive association between education and prevalence of euthanasia/assisted suicide (acts as well as requests) disappeared when adjusting for cause of death. No differences between educational groups were found in the treatment goal in the last week, but higher educated patients were more likely to receive opioids in the last day of life.ConclusionThere are some important differences and possible inequities between educational groups in end-of-life decision-making in Belgium. Future research should investigate whether the found differences reflect differences in knowledge of and adherence to patient preferences, and indicate a discrepancy in quality of the end of life.
Highlights
Educational attainment has been shown to influence access to and quality of health care
No differences between educational groups were found in the treatment goal in the last week, but higher educated patients were more likely to receive opioids in the last day of life
Patients with no or primary education are more often old, female, widowed, dying from cardiovascular or respiratory disease and in a care home than the higher educated. These differences between educational groups indicate the need for a controlling for these confounders when comparing both groups for end-of-life decisionmaking
Summary
Educational attainment has been shown to influence access to and quality of health care. The influence of educational attainment on decision-making at the end of life with possible or certain life-shortening effect (ELDs ie intensified pain and symptom alleviation, non-treatment decisions, euthanasia/physician-assisted suicide, and life-ending acts without explicit request) is scarcely studied. Occupation, income and education –indicators of overall socio-economic status – are thought to influence both the patient’s inclination to seek proper preventive and treatment care and how the health care system treats its patients [3,4]. This is contradictory to the widely held. Do these laws achieve equality – ic between educational groups – in end-of-life care?
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