Use of life-ending drugs without explicit patient request occurs in hospital, among elderly patients

Despite fears to the contrary, the use of drugs to end life without patient request has not increased since euthanasia was legalized in Belgium, states an article in CMAJ (Canadian Medical Association Journal)http://www.cmaj.ca/cgi/rapidpdf/cmaj.091876v1?ijkey=7e8aeb7d487df3b7630863f09968fab81968bfdd (www.cmaj.ca).

Euthanasia and physician-assisted suicide are controversial issues in the medical world. There are fears that the legalization of euthanasia will result in an increase in the use of life-ending drugs without explicit patient request, especially for vulnerable people such as seniors.

Euthanasia and/or physician-assisted suicide have been decriminalized in the US states of Oregon (1997) and Washington State (2009), as well as three European countries: Belgium and the Netherlands (2002) and Luxemburg (2009). Recently, the legalization debate has ignited in several countries, including Canada where a proposed bill was defeated by Parliament in April and the National Assembly of Quebec has launched consultations on the right to die through euthanasia.

The CMAJ study by a team of Belgian and Dutch researchers found 208 physician-assisted deaths in their sample of death certificates in Flemish Belgium. Euthanasia and physician-assisted suicide occurred in 2% of all Flemish deaths and the use of life-ending drugs without request occurred in 1.8% of deaths. Euthanasia and physician-assisted suicide were performed often in patients younger than 80 years (79.6%), in cancer patients (80.2%) and in people dying at home (50.3%). The use of life-ending drugs without explicit request often involved patients over the age of 80 (53%) and deaths in hospital ( 67%).

Despite the lack of explicit patient request, the use of life-ending drugs was in most cases discussed with patients' families and health professional colleagues.

"The use of life-ending drugs without explicit patient request occurs predominantly in hospital and among elderly patients who are mostly in an irreversible coma or demented," write Dr. Kenneth Chambaere, Vrije Universiteit, Brussel, and coauthors. "This fits the description of 'vulnerable' patient groups at risk of life-ending without request. Due attention should therefore be paid to protecting these particular patient groups from such practices. However, these patients are not proportionally more at risk than other patient groups."

The researchers also found that in deaths without explicit request, mostly opioids were used along with benzodiazepines, although the efficacy of opioids in hastening death may be overestimated. They urge the need for advance care planning in the case of unpredictable end-of-life illnesses and decision-making.