Summary of main findings
GPs in Belgium were interviewed about actual euthanasia cases in their practice, and their adherence to legal due care requirements was studied. In all cases, patients were in a condition for which medical treatment was unavailing and there was no prospect of improvement, and they had made an explicit, well-considered, and repeated request for euthanasia. However, procedural requirements such as the consultation of a second physician or the reporting of euthanasia were ignored in some cases. Euthanasia was most often performed with barbiturates and/or neuromuscular relaxants. During the interview, all but one physician labelled the end-of-life decision as euthanasia. Cases of euthanasia were least often reported to the Federal Review Committee when the physician did not consider them to be euthanasia, when they were performed with opioids, and when no legal consultation with another physician had taken place.
Strengths and limitations of the study
This study is the first to provide detailed information on actual euthanasia cases in Belgium, taking place at home under the care of a GP. Because data were gathered through extensive face-to-face interviews with GPs, the study offers unique and thorough information on a practice about which little scientific and medical information exists to date. The cases presented were identified via a large-scale retrospective mortality study representative of all deaths in Belgium,15
and are therefore likely to be representative of euthanasia cases at home in Belgium. The reliability of the surveillance system from which GPs were selected for interview has been demonstrated elsewhere.16–18
Recall bias was minimised, as interviews were conducted within a few months of the GP registering the case.
The study also has some limitations. During the 2-year study period, only 11 cases of euthanasia were identified and an interview could be conducted in only nine of these. The study conclusions are thus based on a very small number of cases. Furthermore, the study is limited to euthanasia cases at home and cannot claim to be representative of euthanasia practice in hospitals or care homes. Future research could produce a sample from all care settings by identifying all euthanasia cases, including those in hospital, via death certificates, and asking the involved physicians to be interviewed. Lastly, as interviews were conducted with GPs about their own adherence and non-adherence to the law, the possibility of social desirability bias cannot be excluded.
Comparison with existing literature
In five out of the nine cases, all or almost all legal due care requirements were met, indicating that the majority of physicians interviewed seemed to be aware of the importance of adhering to them in practice. However, in a few cases the procedural requirements concerning consultation of an independent physician and reporting of euthanasia were not met. The study suggests a number of possible reasons for this: the self-labelling of the act, the drugs used, lack of knowledge about legal requirements, and attitudes towards the law and towards control.
The study suggests that GPs are not always aware that they are engaging in an act that is legally regarded as euthanasia. When GPs are not aware that they are performing euthanasia, they will not feel obliged to comply with the law. This finding is in accordance with findings from the Netherlands.23
For example, when asked during the interview whether the case was one of euthanasia, one GP preferred to call it terminal sedation with the explicit intention of hastening death. However, as official guidelines state, when a patient requests their life to be ended and the physician performs terminal sedation or administers opioids in doses higher than needed merely to alleviate pain or other symptoms, and with an explicit intention of hastening death, the act equals euthanasia and the same legal due care requirements as for euthanasia apply.24,25
Although four physicians used barbiturates and/or neuromuscular relaxants to perform euthanasia,26,27
some reported having used only opioids. Opioids are considered unsuitable for euthanasia because their effectiveness as lethal drugs is uncertain and there can be unwanted side-effects.9,26,27
GPs who used opioids felt either very reluctant to perform euthanasia or had a negative opinion about certain procedures of the euthanasia law. They may have chosen opioids because these drugs are not normally associated with euthanasia. By disguising the end-of-life decision as normal medical practice, whether deliberately or not, they may have felt they had granted their patient's wish without, in their eyes, having performed real euthanasia and without having to comply with the euthanasia law. When cases of euthanasia were performed with opioids or other non-recommended drugs, there was considerably less adherence to the procedural legal due care requirements. At present, the euthanasia law does not specify which drugs and which dosages should be used to perform euthanasia and uniform guidelines, such as those that exist in the Netherlands,26
are lacking in Belgium.
Physicians also sometimes fail to comply with the law because of lack of knowledge about the due care requirements or uncertainty about how the legal requirements must be interpreted. However, there were also indications in the interviews that physicians sometimes fail to adhere to due care requirements because of a negative attitude towards aspects of the law; certain legal requirements, such as consultation and reporting, are deemed too burdensome or unnecessary.
Implications for clinical practice
This study found that while most GPs adhered to the substantive requirements, some demonstrated limited adherence to the procedural requirements. Although legalisation of euthanasia in Belgium has changed it from a covert practice to a more societally controlled one, legalisation alone does not seem sufficient to guarantee due care. It seems warranted that legalisation of euthanasia, rather than being a final destination, should be seen as a starting point for further debate about standards and guidelines for careful end-of-life practice, and should go together with the proper education of, and provision of information to, all physicians potentially involved. Incorporation in medical education, feedback from the Federal Review Committee to reporting GPs about their medical actions, and accessible, adequate support for GPs who are confronted with an explicit request for euthanasia could help them in understanding which practices are regarded as euthanasia, and could help overcome their limited knowledge of the euthanasia law.