Physician Reports of Terminal Sedation without Hydration or Nutrition for Patients Nearing Death in the Netherlands

  1. Judith A.C. Rietjens, MSc;
  2. Agnes van der Heide, MD, PhD;
  3. Astrid M. Vrakking, MSc;
  4. Bregje D. Onwuteaka-Philipsen, PhD;
  5. Paul J. van der Maas, MD, PhD; and
  6. Gerrit van der Wal, MD, PhD
  1. From Erasmus MC, Rotterdam, and Vrije Universiteit Medical Center, Amsterdam, the Netherlands.

    Abstract

    Background: Terminal sedation in patients nearing death is an important issue related to end-of-life care.

    Objective: To describe the practice of terminal sedation in the Netherlands.

    Design: Face-to-face interviews.

    Setting: The Netherlands.

    Participants: Nationwide stratified sample of 482 physicians; 410 responded and 211 of these reported characteristics of their most recent terminal sedation case.

    Measurements: Physician reports of frequency of terminal sedation (defined as the administration of drugs to keep the patient in deep sedation or coma until death, without giving artificial nutrition or hydration), characteristics of the decision-making process, drugs used, the estimated life-shortening effect, and frequency of euthanasia discussions.

    Results: Of respondents, 52% (95% CI, 48% to 57%) had ever used terminal sedation. Of the 211 most recent cases, physicians used terminal sedation to alleviate severe pain in 51% of patients (CI, 44% to 58%), agitation in 38% (CI, 32% to 45%), and dyspnea in 38% (CI, 32% to 45%). Physicians reported discussing with patients the decision to use deep sedation in 59% of the 211 most recent cases (CI, 52% to 66%) and the decision to forgo artificial nutrition or hydration in 34% (CI, 28% to 41%). Hastening death was partly the intention of the physician in 47% (CI, 41% to 54%) of cases and the explicit intention in 17% (CI, 13% to 22%) of cases.

    Limitations: The generalizability of physician reports about their most recent cases to all terminal sedation cases is uncertain. In addition, the findings are subject to recall bias and may not apply to other geographic settings.

    Conclusions: Terminal sedation precedes a substantial number of deaths in the Netherlands. In about two thirds of most recently reported cases, physicians indicated that in addition to alleviating symptoms, they intended to hasten death.

    Article and Author Information

    • Acknowledgments: The authors thank the members of the Steering Committee for their continuous support throughout the study; the physicians who provided the study data; the interviewers; Caspar W.N. Looman for his statistical support and advice; Karen L. Gribling for translation advice; and the chairman of the Royal Dutch Medical Association and the Chief Inspector for Health Care for their support for the study.

    • Grant Support: By a grant from the Ministry of Health and the Ministry of Justice.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Judith Rietjens, MSc, Department of Public Health, Erasmus MC, PO Box 1738, 3000 DR Rotterdam, the Netherlands; e-mail, j.rietjens{at}erasmusmc.nl.

    • Current Author Addresses: Drs. Rietjens, van der Heide, Vrakking, and van der Maas: Department of Public Health, Erasmus MC, PO Box 1738, 3000 DR Rotterdam, the Netherlands.

    • Drs. Onwuteaka-Philipsen and van der Wal: Department of Social Medicine, Vrije Universiteit Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.

    • Author Contributions: Conception and design: J.A.C. Rietjens, A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. van der Maas, G. van der Wal.

    • Analysis and interpretation of the data: J.A.C. Rietjens, A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. van der Maas, G. van der Wal.

    • Drafting of the article: J.A.C. Rietjens, A. van der Heide.

    • Critical revision of the article for important intellectual content: J.A.C. Rietjens, A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. van der Maas, G. van der Wal.

    • Final approval of the article: J.A.C. Rietjens, A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. van der Maas, G. van der Wal.

    • Statistical expertise: J.A.C. Rietjens, A. van der Heide.

    • Obtaining of funding: A. van der Heide, B.D. Onwuteaka-Philipsen, P.J. van der Maas, G. van der Wal.

    • Administrative, technical, or logistic support: J.A.C. Rietjens.

    • Collection and assembly of data: J.A.C. Rietjens.

    Responses to this article

    • IN RESPONSE-
      • Judith A.C. Rietjens and
      • Agnes van der Heide and Gerrit van der Wal.
      Ann Intern Med published online October 26, 2009
    • The Slope is Really Slippery
      • shimon m glick
      Ann Intern Med published online October 26, 2009
    • Two faces of Terminal Sedation in The Netherlands
      • Zbigniew Zylicz
      Ann Intern Med published online October 26, 2009

    Summary for Patients

    • Summaries for Patients:Doctors' Reports of Terminal Sedation without Hydration or Nutrition for Patients Nearing Death in the Netherlands Ann Intern Med August 3, 2004 141:I-22
    « Previous | Next Article »Table of Contents

    This Article

    1. Ann Intern Med August 3, 2004 vol. 141 no. 3 178-185
    1. » Abstract
    2. Full Text
    3. Full Text (PDF)
      1. Summary for Patients
    5. Appendix Figure

    Current Issue

    1. November 3, 2009, 151 (9)
    1. Alert me to current issues