Abstract
ContextExisting empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K. ObjectivesThis study compares characteristics of continuous deep sedation to explain these varying frequencies. MethodsIn Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007–2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended. ResultsThe total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country. ConclusionDifferences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients’ characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.
Highlights
Dying with dignity and without pain are characteristics of what people consider to be a ‘‘good death.’’1e5 palliative medicine has made improvements in controlling symptoms at the end of life, some terminally ill patients still experience ‘‘refractory symptoms,’’ uncontrollable and unresponsive to conventional therapies and optimal palliative care.6e8 As an option of last resort, palliative sedation, that is, reducing the patient’s consciousness and the awareness of suffering, may be used.[9,10] Palliative sedation can vary from mild to deep sedation and can be used intermittently or continuously
Continuous deep sedation until death can be considered an extreme form of palliative sedation; it has been described by some as a form of ‘‘slow euthanasia.’’11
Our analysis reveals differences in the frequency of continuous deep sedation according to place of death: sedation was less often performed in Dutch hospitals compared with Flanders and the U.K. and more often at home in the U.K. compared with Flanders and NL
Summary
Dying with dignity and without pain are characteristics of what people consider to be a ‘‘good death.’’1e5 palliative medicine has made improvements in controlling symptoms at the end of life, some terminally ill patients still experience ‘‘refractory symptoms,’’ uncontrollable and unresponsive to conventional therapies and optimal palliative care.6e8 As an option of last resort, palliative sedation, that is, reducing the patient’s consciousness and the awareness of suffering, may be used.[9,10] Palliative sedation can vary from mild to deep sedation and can be used intermittently or continuously. There appears to be significant and substantial variation in the prevalence of continuous deep sedation between countries and over the years. A study across six European countries in 2001e2002 reported a prevalence ranging from 3% (Denmark) to 9% (Italy) of all deaths. In Flanders, Belgium (BE), its incidence was estimated to be 8% and in The Netherlands (NL) 6%.10. More recent studies with comparable designs showed an increase in the incidence of sedation. In Flanders, BE in 2007, its incidence was estimated to be 15% of all deaths.[12] In NL in 2005, this was 8%.13. In the U.K. in 2008, its prevalence was 17% of all deaths.[14] Further details of the methods used in these studies are given in the section below
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