Policies on medical decisions concerning the end of life in Dutch health care institutions

Objective.-To describe the prevalence and some features of policies on medical decisions concerning the end of life (MDELs) in Dutch hospitals, nursing homes, and institutions for the mentally disabled. Design.-A cross-sectional descriptive postal survey of 558 Dutch health care institutions. Setting.-All Dutch hospitals, nursing homes, and general institutions for the mentally disabled. Participants.-Directors of patient care of the institutions. Main Outcome Measures.-Respondents' reports on the existence of policies and guidelines on the following MDELs: euthanasia/assisted suicide (EAS), life-terminating acts without explicit request of the patient, refusal of treatment by patient, withholding or withdrawing treatment, symptom and pain control, and do-not-resuscitate (DNR) decisions. Results.-Of 558 health care institution managers, 86% responded. Most of the hospitals (69.2%) and nursing homes (73.9%) but only 16.3% of the institutions for the disabled had a written EAS policy. Nursing homes with a ban on EAS often had religious affiliations. In 37% of nursing homes, 15% of hospitals, and 15% of institutions for the disabled, the management had written policies on terminating life without request. Sixty percent of the hospitals, 35% of the nursing homes, and 17% of the institutions for the disabled had guidelines for one or more of four other distinct MDELs. Forty-five percent, 20%, and 8% of hospitals, nursing homes, and institutions of mentally disabled, respectively, had guidelines on DNR decisions. The management of 89% of the hospitals and 94% of the nursing homes communicated their policies on EAS to physicians and nurses in their institutions without being asked. Far fewer of these hospitals (3.9%) and nursing homes (30.5%) made their policies on EAS known to patients without being asked. Conclusions.-This study indicates that an important step toward policy development on EAS has been made by Dutch hospitals and nursing homes. Particularly with respect to policies on such decisions as withholding or withdrawing treatment, symptom and pain control, and DNR orders, an unexplored field is open to management for policy development in the Netherlands.