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Euthanasia and other end of life decisions and care provided in final three months of life: nationwide retrospective study in Belgium

BMJ 2009; 339 doi: (Published 30 July 2009) Cite this as: BMJ 2009;339:b2772
  1. Lieve Van den Block, professor of communication and education in general practice, and postdoctoral researcher12,
  2. Reginald Deschepper, anthropologist and professor of critical care16,
  3. Johan Bilsen, professor of public health14,
  4. Nathalie Bossuyt, researcher3,
  5. Viviane Van Casteren, senior researcher3,
  6. Luc Deliens, professor of public health and palliative care15
  1. 1Vrije Universiteit Brussel, End-of-Life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
  2. 2Vrije Universiteit Brussel, Department of General Practice, 1090 Brussels, Belgium
  3. 3Scientific Institute of Public Health, Department of Epidemiology, 1040 Brussels, Belgium
  4. 4Vrije Universiteit Brussel, Department of Public Health, 1090 Brussels, Belgium
  5. 5Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, 1007 MB Amsterdam, Netherlands
  6. 6Vrije Universiteit Brussel, Department of Critical Care, 1090 Brussels, Belgium
  1. Correspondence to: L Van den Block lvdblock{at}
  • Accepted 21 April 2009


Objective To explore the relation between the care provided in the final three months of life and the prevalence and types of end of life decisions in Belgium.

Design Two year nationwide retrospective study, 2005-6 (SENTI-MELC study).

Setting Data collection via the sentinel network of general practitioners, an epidemiological surveillance system representative of all general practitioners in Belgium.

Subjects 1690 non-sudden deaths in practices of the sentinel general practitioners.

Main outcome measures Non-sudden deaths of patients (aged >1 year) reported each week. Reported care provided in the final three months of life and the end of life decisions made. Multivariable regression analysis controlled for age, sex, cause, and place of death.

Results Use of specialist multidisciplinary palliative care services was associated with intensified alleviation of symptoms (odds ratio 2.1, 95% confidence interval 1.6 to 2.6), continuous deep sedation forgoing food/fluid (2.9, 1.7 to 4.9), and the total of decisions explicitly intended to shorten life (1.5, 1.1 to 2.1) but not with euthanasia or physician assisted suicide in particular. To a large extent receiving spiritual care was associated with higher frequencies of euthanasia or physician assisted suicide than receiving little spiritual care (18.5, 2.0 to 172.7).

Conclusions End of life decisions that shorten life, including euthanasia or physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care.


  • We thank Katrien Drieskens (Vrije Universiteit Brussel) and Sabien Bauwens (Brussels University Hospital) for their contribution in study conception and support in data collection; Johan Vanoverloop (Vrije Universiteit Brussel) for his statistical advice; Jane Ruthven for English editing; Rita De Boodt (Flemish Ministry of Welfare, Public Health and Family) for categorising the cause of death into ICD-10 codes; the participating sentinel general practitioners for providing the study data; and the Flemish Ministry of Welfare, Public Health and Family and the Brussels Observatory of Health and Wellness for giving us access to their death certificate data.

  • Contributors: LVdB, VVC, and LD conceived and designed the study. LVdB, NB, and VVC acquired the data, which was analysed by LVdB and NB. LVdB drafted the manuscript and is guarantor. LVdB, RD, VVC, and LD obtained funding. LVdB, RD, NB, and LD provided administrative and technical support. LVdB, RD, JB, VVC, and LD supervised the study. All authors analysed and interpreted the data, critically revised the manuscript for important intellectual content, and approved the final version.

  • Funding: LVdB is a postdoctoral researcher of the Fund for Scientific Research in Flanders, Belgium. This study was funded by the Research Council of the Vrije Universiteit Brussel in Belgium (project GOA27 2003-2007) and the Institute for the Promotion of Innovation by Science and Technology in Flanders as a Strategic Basic Research project (SBO) (contract SBO IWT 050158) (2006-2010), as part of the Monitoring Quality of End-of-Life Care (MELC) Study. The Belgian Sentinel Network of GPs is supported by the Flemish and Walloon Ministry of Welfare, Public Health and Family. The sponsors had no role in design and conduct of the study, in the collection, analysis, and interpretation of the data, in the writing of the report or in the decision to submit the article for publication. The researchers are independent from the funders.

  • Competing interest: None declared.

  • Ethical approval: The study protocol was approved by the ethical review board of Brussels University Hospital. All patients and physicians were anonymous.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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