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Differences in Performance of Euthanasia and Continuous Deep Sedation by French- and Dutch-Speaking Physicians in Brussels, Belgium

2010; Elsevier BV; Volume: 39; Issue: 2 Linguagem: Inglês

10.1016/j.jpainsymman.2009.10.001

1873-6513

Kenneth Chambaere, Johan Bilsen, Joachim Cohen, Evelien Raman, Luc Deliëns,

Grief, Bereavement, and Mental Health

Belgium consists of two large, geographically divided language communities: the Dutch-speaking community living in the northern region of Flanders and the French-speaking community living in the southern region of Wallonia. Both language communities are represented in the metropolitan Brussels-Capital Region. Its population of more than one million is culturally diverse, with a large proportion of foreign (non-Western) origin.1Ministry of the Brussels Capital Region, Directorate of Study and Regional Statistics IRIS, Brussels, Belgium2002Google Scholar Since 2002, a law legalizing euthanasia has been in effect in Belgium.2Law concerning euthanasia. Belgian official collection of the Laws.https://portal.health.fgov.be/pls/portal/docs/pageinternet_pg/homepage_menu/gezondheidzorg1_menu/overlegstructuren1_menu/commissies1_menu/euthanasia1_menu/publicaties105_hide/publicaties105_docs/loi_euthanasie.pdfGoogle Scholar Since then, speculation has arisen regarding differences between language communities in end-of-life practices with a possible or certain life-shortening effect. A report by the Belgian Federal Control and Evaluation Committee for Euthanasia revealed proportionally more euthanasia cases reported in the Dutch than in the French communities.3Federal Control and Evaluation Committee on Euthanasia https://portal.health.fgov.be/pls/portal/docs/page/internet_pg/homepage_menu/gezondheidzorg1_menu/overlegstructuren1_menu/commissies1_menu/euthanasia1_menu/publicaties105_hide/publicaties105_docs/g6635%20rapport%20euthanasie%20nl31-29%20oct_0.pdfGoogle Scholar It is not clear whether this reflects a difference in willingness to notify authorities about euthanasia cases or a difference in actual performance of euthanasia. A nationwide mortality follow-back study by means of a sentinel network of general practitioners found a tendency toward more euthanasia in Flanders but more continuous deep sedation in the Walloon region.4Van den Block L. Deschepper R. Bilsen J. et al.Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium.BMC Public Health. 2009; 9: 79Crossref PubMed Scopus (44) Google Scholar However, the question remained whether these differences reflect a cultural disparity between language communities rather than mere geographical differentiation. Examining differences in the occurrence of these and other end-of-life practices between language communities within the same geographical area of Brussels could more decisively inform us regarding these issues. In 2007, we performed a retrospective survey among the reporting physicians of a representative sample of death certificates in the Brussels-Capital Region. We sent questionnaires in French and Dutch to enable physicians to answer in their preferred language. Of 1,701 sampled eligible cases, we received 701 answers (response 41%), 552 from French-speaking physicians and 149 from Dutch-speaking physicians. The response sample was adjusted to be representative of all deaths in Brussels in 2007. Patients treated by French- and Dutch-speaking physicians did not differ significantly regarding age, sex, cause of death, living situation, or place of death. However, French-speaking physicians tended to have more non-Belgian patients (11.3% vs. 6.0%, P=0.055), which is not surprising, considering that most of the Brussels-Capital Region's inhabitants of foreign origin speak French as a second language rather than Dutch. French- and Dutch-speaking physicians did not differ in rates of intensification of pain and symptom alleviation, nontreatment decisions, or life-ending drug use without explicit patient request, whereas there was a higher rate of euthanasia by Dutch-speaking physicians (2.7% vs. 0.7%, P=0.069). Continuous deep sedation until death was performed more often by French-speaking physicians (15.8% vs. 9.3%, P=0.049). We observed a higher prevalence of sedation with a life-shortening intention by French-speaking physicians than by Dutch-speaking physicians (2.4% vs. 0.7%, P=0.332), though not significantly (Table 1). Additional analysis showed no influence of patient characteristics on these results (data not shown).Table 1End-of-Life Practices According to Physicians' Preferred LanguageLanguageEnd-of-life practicesFrench (n=552)Dutch (n=149)P-valueaCalculated with Fisher's exact test (two-sided).No end-of-life practice62.059.6End-of-life practice performed38.040.40.637 Intensified alleviation of pain and symptoms20.121.30.733 Nontreatment decision13.111.30.679 Use of life-ending drugs without explicit patient request4.24.60.821 Euthanasia0.72.70.069Continuous deep sedation performedbContinuous deep sedation can be performed in combination with other end-of-life practices.15.89.30.049 Life shortening not intendedcExcludes cases of continuous deep sedation until death performed with euthanasia. Information on life-shortening intention was missing in 10 cases (2.0%) for French-speaking physicians and in three cases (1.9%) for Dutch-speaking physicians; percentages of life-shortening intention were not adjusted.11.56.80.129 Life shortening intendedcExcludes cases of continuous deep sedation until death performed with euthanasia. Information on life-shortening intention was missing in 10 cases (2.0%) for French-speaking physicians and in three cases (1.9%) for Dutch-speaking physicians; percentages of life-shortening intention were not adjusted.2.40.70.332a Calculated with Fisher's exact test (two-sided).b Continuous deep sedation can be performed in combination with other end-of-life practices.c Excludes cases of continuous deep sedation until death performed with euthanasia. Information on life-shortening intention was missing in 10 cases (2.0%) for French-speaking physicians and in three cases (1.9%) for Dutch-speaking physicians; percentages of life-shortening intention were not adjusted. Open table in a new tab These results support earlier findings of differences in end-of-life care between the French- and Dutch-speaking communities. Furthermore, our results demonstrate that these differences are present irrespective of geographical separation. Medical (end-of-life) culture seems to differ between language communities in Belgium.5Ganz F.D. Benbenishty J. Hersch M. et al.The impact of regional culture on intensive care end of life decision making: an Israeli perspective from the ETHICUS study.J Med Ethics. 2006; 32: 196-199Crossref PubMed Scopus (44) Google Scholar Although euthanasia is more often performed in the Dutch-speaking community, its performance in the French-speaking community is possibly met with more reluctance. This may be because of a lesser degree of familiarity with euthanasia in the latter community, as after the euthanasia law, the issue did not pervade the social and medical arena as much as in the Dutch-speaking community. Also, since the euthanasia law, Life End Information Forum, a voluntary association, was established in the Dutch-speaking community to provide physicians with information and assist in issues concerning (predominantly) euthanasia. This kind of initiative arose considerably later in the French-speaking community and is less developed. As a result, more uncertainty regarding the performance of euthanasia may exist among French-speaking physicians. Alternatively, French-speaking physicians perform continuous deep sedation until death more often than their Dutch-speaking colleagues. This practice, better known as palliative or terminal sedation, has enjoyed growing acceptance among medical professionals but has also been criticized for its potential use in hastening death.6Levy M. Cohen S. Sedation for the relief of refractory symptoms in the imminently dying: a fine intentional line.Semin Oncol. 2005; 32: 237-246Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Our study shows that a life-shortening intention was present in some instances: in 2.4% of French-speaking physicians and in 0.7% of Dutch-speaking physicians. The criticism, thus, seems to hold. These findings, however, also raise the question whether less inclination to perform euthanasia leads to more continuous deep sedation with a life-shortening intention. Our data are inconclusive, and further research on this matter is needed. We conclude that French-speaking physicians in Brussels seem more reluctant to perform euthanasia than their Dutch-speaking colleagues; the former more often opt for continuous deep sedation until death, which, in some cases, is carried out with a life-shortening intention.