Forgoing treatment at the end of life in 6 European countries


Forgoing treatment at the end of life in 6 European countries


Bosshard G; Nilstun T; Bilsen J; Norup M; Miccinesi G; van Delden JJ; Faisst K; van der Heide A


Archives Of Internal Medicine




statistics & numerical data Male Middle Aged Physician's Practice Patterns; statistics & numerical data Physician-Patient Relations Questionnaires Refusal to Treat; 80 and over Cause of Death/trends Child Child; Adolescent Adult Aged Aged; Attitudes; Non-U.S. Gov't Retrospective StudiesTerminally Ill Treatment Refusal/statistics & numerical data; PedPal Lit; Practice Humans Infant Life Support Care; Preschool Comparative StudyDecision Making Europe/epidemiology Female Health Knowledge; statistics & numerical data Registries; statistics & numerical data Research Support


Background: Modern medicine provides unprecedentedopportunities in diagnostics and treatment. However,in some situations at the end of a patient’s life, manyphysicians refrain from using all possible measures to prolonglife. We studied the incidence of different types oftreatment withheld or withdrawn in 6 European countriesand analyzed the main background characteristics.Methods: Between June 2001 and February 2002,samples were obtained from deaths reported to registriesin Belgium, Denmark, Italy, the Netherlands, Sweden,and Switzerland. The reporting physician was thensent a questionnaire about the medical decision-makingprocess that preceded the patient’s death.Results: The incidence of nontreatment decisions,whether or not combined with other end-of-life decisions,varied widely from 6% of all deaths studied in Italyto 41% in Switzerland. Most frequently forgone in everycountry were hydration or nutrition and medication, togetherrepresenting between 62% (Belgium) and 71%(Italy) of all treatments withheld or withdrawn. Forgoingtreatment estimated to prolong life for more than 1month was more common in the Netherlands (10%), Belgium(9%), and Switzerland (8%) than in Denmark (5%),Italy (3%), and Sweden (2%). Relevant determinants oftreatment being withheld rather than withdrawn wereolder age (odds ratio [OR], 1.53; 95% confidence interval[CI], 1.31-1.79), death outside the hospital (death inhospital: OR, 0.80; 95% CI, 0.68-0.93), and greater lifeshorteningeffect (OR, 1.75; 95% CI, 1.27-2.39).Conclusions: In all of the participating countries, lifeprolongingtreatment is withheld or withdrawn at the endof life. Frequencies vary greatly among countries. Lowtechnologyinterventions, such as medication or hydrationor nutrition, are most frequently forgone. In olderpatients and outside the hospital, physicians prefer notto initiate life-prolonging treatment at all rather than stopit later.


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Bosshard G; Nilstun T; Bilsen J; Norup M; Miccinesi G; van Delden JJ; Faisst K; van der Heide A, “Forgoing treatment at the end of life in 6 European countries,” Pediatric Palliative Care Library, accessed September 26, 2023,