Table 1 shows the incidence of continuous deep sedation in the Netherlands by specialty of the physician. As reported previously,19
of all patients who died in 2005, 8.2% (95% confidence interval 7.6% to 8.9%) were continuously and deeply sedated until death. In 7.1% (6.5% to 7.6%) of deaths, such sedation was provided in conjunction with decisions that potentially hastened death (such as decisions to withhold potentially life prolonging treatments), which is a significant increase compared with the 5.6% (5.0% to 6.2%) in 2001. This increase was significant among general practitioners: 3.9% (3.3% to 4.7%) in 2001 v
6.6% (5.7% to 7.6%) in 2005.Compared with the other specialties, in 2005 the percentage of continuous deep sedation was highest (10%, 8.7% to 11.5%) in patients attended by clinical specialists.
Table 1 Incidence of continuous deep sedation*. Figures are percentages† of patients with 95% confidence intervals where applicable
Sixty one per cent of patients who received continuous deep sedation were aged <80 years, while 51% of all deaths in the Netherlands were in those aged <80 (table 2). In 2005, 47% (42% to 52%) of patients who received continuous deep sedation had cancer, compared with 33% (28% to 38%) in 2001. In general practice, the proportions of those with cancer were 72% in 2005 and 69% in 2001. Among clinical specialists, continuous deep sedation was also commonly used for patients with cardiovascular diseases (19%). Nursing home physicians used continuous deep sedation for patients with cardiovascular diseases (24%) and diseases related to the nervous system (12%).
Table 2 Characteristics of patients who received continuous deep sedation and of all deaths in the Netherlands*. Figures are percentages† of patients with 95% confidence intervals where applicable
For 47% of all patients who received continuous deep sedation, the sedation was started in the last 24 hours before death (see table 4). For these patients, 42-55% were reported as experiencing pain, fatigue, dyspnoea, and unclear consciousness in the last 24 hours of life and 23% and 21% had confusion and anxiety (table 3). Most patients had more than one symptom, and 74% experienced symptoms that are common indications for sedation—that is, pain, dyspnoea, confusion, or anxiety. Sedated patients had more symptoms than other patients who did not die suddenly and more often experienced dyspnoea, pain, and anxiety.
Table 3 Signs or symptoms* in last 24 hours of life for deaths preceded by continuous deep sedation and for all other non-sudden deaths in 2005. Figures are percentages† of patients with 95% confidence intervals
Table 4 examines the characteristics of the practice of continuous deep sedation in 2005. No comparable data were available from 2001. In 83%, continuous deep sedation was induced with benzodiazepines often combined with morphine. Such a combination was most often used by clinical specialists. Morphine was used without benzodiazepines in 15%. Nursing home physicians and general practitioners reported using benzodiazepines relatively often (89% and 87%, respectively), whereas clinical specialists were more likely to administer morphine for sedation (19% of cases). Palliative consultation in the month before death was quite rare (9%), and most often sought by general practitioners (20% of cases). Palliative consultation was positively related to the use of benzodiazepines (whether or not combined with other drugs) (P<0.01). For almost all of the patients for whom sedation was used, general practitioners and nursing home physicians withheld artificial nutrition and hydration, whereas this was true for 30% of the patients attended by clinical specialists. In two thirds, physicians estimated that the effect of the decision making before death on shortening life was 24 hours or less. In 6% of the cases, patients were sedated for more than one week (11% among clinical specialists). In 9% of the cases, the decision to use continuous deep sedation was preceded by an explicit request from the patient to end his or her life by means of euthanasia or assisted suicide, which was not granted. General practitioners reported this more often (16%) than clinical specialists (4%) and nursing home physicians (9%). The most frequently cited reason why the physician had not granted the patient’s request was that the time frame to complete the euthanasia procedure was too short—for example, because of the obligation to consult another physician (40%, n=24). Other reasons mentioned were that the suffering of the patient was not considered to be unbearable (10%, n=4) and that the patient had withdrawn the request for euthanasia (9%, n=6).
Table 4 Characteristics of continuous deep sedation in 2005*. Figures are percentages† of physicians