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BMC Public Health. 2012; 12: 447.
Published online Jun 18, 2012. doi:  10.1186/1471-2458-12-447
PMCID: PMC3489592
Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey
Kenneth Chambaere,corresponding author1 Judith A C Rietjens,1 Tinne Smets,1 Johan Bilsen,1 Reginald Deschepper,1 H Roeline W Pasman,2 and Luc Deliens1,2
1End-of-life Care Research Group, Ghent University & Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, 1090, Belgium
2Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands
corresponding authorCorresponding author.
Kenneth Chambaere: kenneth.chambaere/at/vub.ac.be; Judith A C Rietjens: judith.rietjens/at/vub.ac.be; Tinne Smets: tinne.smets/at/vub.ac.be; Johan Bilsen: johan.bilsen/at/vub.ac.be; Reginald Deschepper: reginald.deschepper/at/vub.ac.be; H Roeline W Pasman: hrw.pasman/at/vumc.nl; Luc Deliens: luc.deliens/at/vub.ac.be
Received October 18, 2011; Accepted April 12, 2012.
Abstract
Background
A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the ‘slippery slope’ hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal.
Method
We performed a post-mortem survey among physicians certifying a large representative sample (n = 6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%.
Results
While the rates of non-treatment decisions (NTD) and administration of life ending drugs without explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant.
Conclusion
Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.
Keywords: Ageism, Age inequalities, End of life, End-of-life decisions, Slippery slope, Euthanasia, Palliative care, Belgium
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