Comparison of the Expression and Granting of Requests for Euthanasia in Belgium in 2007 vs 2013

Belgium legalized euthanasia in 2002.¹ Between 2007 and 2013, the prevalence of euthanasia in Flanders, the Dutch-speaking part of Belgium, increased from 1.9% to 4.6% of all deaths.² Here we describe the shifts (overall and in specific groups of patients) in the expression and granting of euthanasia requests during this period and the reasons that physicians granted or denied these requests.

Approval was obtained from the Ethical Review Board of the University Hospital of the Vrije Universiteit Brussel, the Belgian Privacy Commission, and the Belgian National Disciplinary Board of Physicians. Patients were deceased, so no consent could be obtained. Physicians' participation was regarded as implicit consent.

We conducted a nationwide postal questionnaire survey in 2013 that was identical to a survey conducted in 2007 of physicians who certified a random sample of 6871 deaths that occurred from January 1 through June 30, 2013, in Flanders; details of the study design have been published elsewhere.² The survey was conducted from March 1 through December 31, 2013. Data analysis was conducted from March 1 through March 31, 2015. The questionnaire asked whether physicians had administered drugs with the intention of hastening death at the explicit request of the patient (euthanasia), whether the patient had formed a euthanasia request that was not granted, and the most important reasons for granting or not granting the request. The physicians could choose several reasons.

Questionnaires were returned for 3751 of the 6871 deaths (55%). For 683 deaths, we determined that a response was impossible because of issues with access to the patient’s medical records or patient identification. Therefore, the response rate was 60.6% (3751 of 6188 eligible cases) compared with 58.4% (3623 of 6202 eligible cases) in 2007.

The prevalence of euthanasia increased in all patient groups and in all health care settings (Table 1). There were significant increases in the number of requests (from 3.4% to 5.9%; P < .001) and the proportion of requests granted (from 55.4% to 76.7%; P < .001). The most pronounced increases in the frequency of requests were in those who were 80 years or older (2.0% to 4.6%; P < .001), those with a college or university education (4.5% to 12.9%; P = .008), or those with a diagnosis of cardiovascular disease (0.8% to 3.0%; P < .001). The largest increases in the rates of granting requests were among women (45.7% to 76.4%; P < .001) and those who were 80 years or older (38.1% to 75.4%; P < .001), had less education (35.1% to 69.5%; P < .001), and died in nursing homes (22.9% to 68.2%; P < .001).

In 2013, physicians reported that the most important reasons for granting a euthanasia request were the patient’s request (88.3%; 95% CI, 82.5%-92.4%), physical and/or mental suffering (87.1%; 95% CI, 81.7%-91.1%), and the lack of prospects for improvement of their condition (77.7%; 95% CI, 71.6%-82.8%) (Table 2). The most important reasons for not granting the request were that the patient died before the decision (58.5%; 95% CI, 44.8%-71.0%), the request was revoked (17.9%; 95% CI, 9.9%-30.2%), and legal criteria were not met (19.6%; 95% CI, 10.8%-33.0%).

The percentage of cases in which the physician reported denying the request for reasons external to the patient (restrictive institutional policy, personal objections, or fear of legal consequences) decreased from 23.4% in 2007 to 2.0% in 2013 (P = .003).

Previous research³ has suggested that the euthanasia law in Belgium created a context of increased openness about end-of-life care and decision making in which patients could more freely discuss their wishes. Between 2007 and 2013, there were substantial increases in the proportion of euthanasia requests across various patient groups in Flanders, including groups whose requests were formerly less prevalent. These increases reflect continuing attitudinal and cultural shifts; values of autonomy and self-determination have become more prominent, and acceptance of euthanasia continues to increase in the population at large.⁴ In our opinion, physicians, as part of the overall society, share this overarching perspective, which may in part explain their greater willingness to grant euthanasia requests. Additional reasons are growing familiarity with the practice, reassurance of nonprosecution when legal criteria are met, and the diminished reluctance of some health care institutions to allow euthanasia. Moreover, euthanasia is perceived as part of the palliative care continuum, as formally expressed in a position statement from the Federation of Palliative Care Flanders.⁵ Although the prevalence of euthanasia remains highest in patients with cancer, those with a college or university education, and those who die before 80 years of age, there are increasing numbers of requests and granted requests in patients with diseases other than cancer, those who die after 80 years of age, and those who reside in nursing homes.

Corresponding Author: Sigrid Dierickx, MSc, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium (sigrid.dierickx@vub.ac.be).

Published Online: August 10, 2015. doi:10.1001/jamainternmed.2015.3982.

Author Contributions: Ms Dierickx had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Cohen and Chambaere contributed equally as last author.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Dierickx, Cohen, Chambaere.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Dierickx, Chambaere.

Obtained funding: Deliens, Cohen.

Administrative, technical, or material support: Deliens.

Study supervision: Deliens, Cohen, Chambaere.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by Strategic Basic Research (Strategisch Basis Onderzoek) grant 100036 from the Agency for Innovation by Science and Technology (Agentschap voor Innovatie door Wetenschap en Technologie).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: This study is part of the Flanders Study to Improve End-of-Life Care and Evaluation Tools (FLIECE) project, a collaboration between the Vrije Universiteit Brussel, Ghent University, and the Katholieke Universiteit Leuven in Belgium, and VU University Medical Centre Amsterdam in the Netherlands. Kenneth Chambaere and Joachim Cohen are Postdoctoral Fellows of the Research Foundation Flanders.

Additional Contributions: The Flemish Agency for Care and Health; Jef Deyaert, MSc, and Lenzo Robijn, MSc, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University; Brecht Haex, MSc, Agency for Care and Health; and Wim De Brock, LLM, an independent attorney, contributed to the data collection. The Belgian Medical Disciplinary Board recommended the study to the investigators. Jane Ruthven, PhD, End-of-Life Care Research Group, provided critical and language review of the manuscript. We are also deeply indebted to the thousands of Flemish physicians participating in the survey. Messrs Haex and De Brock and Ms Ruthven received financial compensation for their contributions.