Response to Finucane.

Abstract

To the Editor: We wish to thank Dr. Finucane for his interest in our study on the practice of continuous sedation until death (CSD) in nursing homes in Flanders.1, 2 We would like to take the opportunity to respond to his comments and concerns. We share Dr. Finucane's view that the finding that approximately one-quarter of competent individuals undergoing CSD were not actively involved in the decision-making process is ethically troublesome. Does this imply negligence or a paternalistic approach of the nursing home staff or rather a passive attitude of the individual? We were not surprised to find that most individuals undergoing CSD were women. The general population of nursing home residents in Flanders is indeed predominantly female. A previous nationwide study in nursing homes in Flanders provided a clear picture of the general population of nursing home residents by collecting data on all residents who had died during a 2-month period.3 A comparison of our results with data from that study revealed no significant differences regarding sex.1 Regarding the combination of CSD and withholding artificial nutrition and hydration, we would like to stress that most individuals in our study no longer had sufficient oral intake of food and fluids before the administration of CSD. Hence, we do not believe that the lives of all sedated individuals were ended through the withholding of artificial nutrition. Nevertheless, we share Dr. Finucane's concerns on the use of CSD to end an individual's life. We conducted a similar survey among the coordinating and advisory physicians of all nursing homes in Flanders4 in which we collected data on the physician's intention when administering CSD. In 62.2% of the studied cases, the attending physician reported that CSD was not used to hasten death. In the remaining cases, the physician reported a partial (32.7%) or explicit (5.1%) intention to hasten death. Moreover, our findings strongly suggest that CSD is sometimes being used as a substitute for euthanasia, which is a legally accepted practice in Belgium (provided that all the formal requirements are fulfilled). In approximately one-fifth of the cases in which CSD was used to hasten death, the individual requested euthanasia, although this request was frequently declined to avoid the legal euthanasia procedure or to comply with local nursing home policy. In conclusion, we think that the distinction between CSD and physician-assisted death (euthanasia) is often blurred in clinical practice. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Sam Rys and Johan Bilsen wrote this response. Sponsor's Role: N/A.