Dutch Euthanasia Rates Steady After Legalization

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Since euthanasia and physician-assisted suicide were legalized by the Dutch in 2002, use of the practices has dropped slightly and now has stabilized, a new report finds.

That marks an abrupt turnaround from trends during the last 10 years, say the authors of a study in the May 10 New England Journal of Medicine.

In the United States, physician-assisted suicide is legal only in the state of Oregon, while euthanasia is not legal in any state.

“One lesson is there’s not a big slippery slope in this area, that the practice will be used relatively infrequently and that it’s generally a good thing to have an open conversation,” said Dr. Timothy Quill, director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center in Rochester, N.Y. He also wrote a related perspective article in the journal.

Dr. Nancy W. Dickey, president of the Texas A&M Health Science Center and vice chancellor for health affairs for the Texas A&M System, agreed. “Neither Oregon nor the Netherlands appear to have started down a slippery slope,” she said. “Also, physicians have become better equipped to offer a wide variety of palliative care, leading them to become more effective at it and very rarely having to resort to assisted death,” she said.

In the Netherlands, euthanasia is defined as death resulting from medication administered by a physician with the intention of hastening death at the request of the patient. In assisted suicide, the patient hastens death by giving him or herself medication prescribed by a physician.

Although neither procedure was legal in the Netherlands in the early 1990s, physicians were generally not prosecuted if they had adhered to certain requirements.

“The passing of the law was a formalization of a practice that the Netherlands freely admitted occurred on a less-than-rare basis,” Dickey said.

In 1990, the reporting rate for euthanasia and physician-assisted suicide was 18 percent. An official reporting procedure was established in 1993, after which the reporting rate climbed to almost 41 percent.

“An important goal of the euthanasia law in the Netherlands is to achieve public control of this practice,” said study co-author Bregje Onwuteaka-Philipsen, associate professor at the VU University Medical Center in Amsterdam, EMGO Institute/Department of Public and Occupational Health. “The increase in the reporting of euthanasia and physician-assisted suicide to the review committees, from 18 percent in 1990, through 41 percent in 1995 and 54 percent in 2001 to 80 percent in 2005, shows that that goal of the law is met.”

According to Onwuteaka-Philipsen, approximately 8,400 people per year explicitly request euthanasia or physician-assisted suicide, at which point physicians must determine whether or not to grant the request according to legal criteria. This results in approximately 2,300 cases of euthanasia and 100 cases of physician-assisted suicide per year which, together, make up 1.8 percent of all deaths in the Netherlands.

For this study, researchers mailed questionnaires to doctors who had attended 6,860 deaths. More than three-quarters (77.8 percent) of physicians responded.

In 2005, 1.7 percent of all deaths in the Netherlands were the result of euthanasia and 0.1 percent were the result of physician-assisted suicide. This a substantial decrease from 2001, when 2.6 percent of all deaths resulted from euthanasia and 0.2 percent from assisted suicide.

“The euthanasia law did not coincide with an increase of the practice,” noted Onwuteaka-Philipsen.

In 2005, 0.4 percent of all deaths were the result of the ending of life without an explicit request by the patient.

In 7.1 percent of all deaths in 2005, continuous deep sedation was used in conjunction with a possible hastening of death. This was an increase from 5.6 percent in 2001.

Why the decrease in overall euthanasia and physician-assisted suicide?

“We have three likely explanations,” Onwuteaka-Philipsen said. “The first one is a demographic one. The percentages of deaths of people of 80 years and older was higher in 2005 than in 2001. Since euthanasia and assisted suicide relatively infrequently occur in this age group, this explains a small part of the decrease.”

Other explanations include improvement in palliative care as well as changing opinions and knowledge as to the effects of opioids.

“There has been increasing evidence that the potentially life-shortening effects of opioids are often overestimated, making physicians less inclined to attribute life-shortening effects to opioids,” Onwuteaka-Philipsen said.

According to the perspective piece, the palliative care movement has grown similarly robust in the United States, albeit with some disparities.

“Clearly, we’re moving in a direction of widespread acceptance and growth of palliative care as the standard of care for people who are dying,” Quill said. “In the last 10 years, there is a wider acceptance, but there’s still going to be some tough cases, and we will have to figure out ways to respond to those cases.”

And disparities remain, Dickey added.

“We have made substantial progress [in end-of-life care], but we probably do not pay it enough attention in this country,” she said. “One of the most troubling statements in the perspective paper was that this is still largely limited to people who are white, relatively educated, insured and enrolled in hospice. I can think of few disparities that are more troubling to my soul than the thought that we give less-than-satisfactory end-of-life care to the poor, to the less well-educated, to the newest immigrants. We’re not there yet.”
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