Our study is the first to describe and compare how consultation services in cases of a euthanasia request have been established in the Netherlands and Belgium. In both countries, these consultation services are delivered by specially trained physicians who can be consulted in cases of a request for euthanasia and who offer support and information about the subject. The context in which the two organisations were founded, as well as the way they are organised and regulated, is different in each country: by providing information on all end-of-life care matters the Belgian Life End Information Forum seems to have a broader consultation role than the Dutch Support and Consultation in Euthanasia.
A methodological limitation of this study is that the description of both organisations is based on documents and therefore reflects the theoretical situation but not necessarily the situation in real terms.
One important difference between the consultation organisations in Belgium and the Netherlands is that the Belgian LEIF has a broader focus: its physicians can be consulted not only in cases of euthanasia requests but for all end-of-life issues. The context in which the legislation was developed in Belgium may account for this; in Belgium there was much more controversy than in the Netherlands and the legislature (government) wanted to put the focus on a wider range of options at the end of life. This may explain why a law optimizing the accessibility of palliative care and a law on patient rights emphasizing the right of the patient to choose the care they receive, were passed almost simultaneously with the euthanasia law [30
]. In this context the initiators of LEIF, who have a broad background in palliative care, aimed to create a health provision not linked solely to euthanasia. The emphasis on palliative care is not so pronounced with SCEN, although SCEN physicians must consider other palliative options when doing a consultation. As the line between euthanasia and other end-of-life decisions is not always clear to attending physicians and their patients, it can be beneficial to have a service which provides consultation not only in the context of euthanasia but also concerning all medical aspects of the end of life. On the other hand, this requires consultants to have a wider area of expertise.
Another difference between the Dutch SCEN and the Belgian LEIF is that SCEN is more highly-regulated. A historical explanation for this can be found in differences in the development of the euthanasia laws and the fact that, as opposed to Belgium, euthanasia had been tolerated in the Netherlands long before the law was enacted. SCEN also has a longer history than LEIF. Another reason may be that the Royal Dutch Medical Society, which organises SCEN, is controlled and strongly supported financially by the Dutch government, whereas LEIF has no controlling body and little funding. Also a general cultural inclination to formalize practices in the Netherlands may explain why SCEN is more regulated [32
The heavier regulation of SCEN may provide more of a guarantee that its consultations take place according to best-practice criteria. The more informal contact procedures of LEIF (e.g. that the attending physician may make direct contact with those in the network) could on the other hand have the advantage of making the service more approachable. If implemented in other countries, such a provision is probably best designed to fit in with the prevailing cultural characteristics.
Several similarities between SCEN and LEIF can be noted. Both organisations were founded to improve (the practice of) consultation in euthanasia requests by specifically training physicians for that purpose. These physicians also support and inform their colleagues on euthanasia. The amount of training time and the guidelines for consultation that are thought during this training are similar in both countries. Furthermore, both associations organise additional meetings to discuss concrete cases. SCEN as well as LEIF have a controlling board consisting of physicians, experts and academics to continuously evaluate the organisations' functioning.
Both The Netherlands and Belgium have been careful to set in place firm and substantial procedural due care requirements in order to safeguard good practice and it can be assumed that other countries intending to legalize euthanasia would do the same. However, the practical implications of legalization are not always covered by legislation. For instance, once euthanasia is legalized, what should a physician do when confronted with a request for euthanasia, and whom should they consult? The creation of specialized service for a priori consultation in euthanasia cases can play an important role. It helps physicians to relatively easily consult a competent second physician when they are confronted with a euthanasia request. Such a service may also guarantee more compliance with the due care requirements and hence function as an additional control mechanism. Research has already demonstrated such services to be of great importance to the careful performance of euthanasia [14
]. For instance, the criteria for good consultation (e.g. independence from patient and attending physician, seeing the patient, writing a report) were more often met in consultations with SCEN physicians than with other physicians, and a strong relationship was found between a consultation with SCEN and notification of euthanasia [33
]. It is important, however, that the physicians who are part of such services are fully trained to be able to judge the conditions for euthanasia and guarantee a good practice. Both SCEN and LEIF put emphasis on knowledge of the law and of palliative care, and on communication with the patient and the attending physician.
The evaluation report of the euthanasia law showed that SCEN physicians had been involved in 89% of all notified euthanasia cases in the Netherlands [33
]. The notification reports in Belgium and a first assessment of LEIF activities [34
] indicate that LEIF physicians have acted as a second physician in 54% of reported euthanasia cases in Flanders [35
]. This shows the important involvement of this service in euthanasia. SCEN and LEIF can be an example for countries that have recently legalized euthanasia, like Luxembourg, or are discussing legalization. These countries can learn from the similarities and differences between both initiatives in organising such a service according to their law, health system and culture.