A nationwide study of decisions to forego life-prolonging treatment in Dutch medical practice

Background: Decisions to withhold or withdraw life-prolonging treatment in terminally ill patients are common in some areas of medical practice. Information about the frequency and background of these decisions is generally limited to specific clinical settings. This article describes the practice of withholding or withdrawing life-prolonging treatment in the Netherlands. Methods: Questionnaires were sent to the attending physicians of a stratified sample of 6060 of all 43 002 cases of death in the Netherlands from August 1 through November 30, 1995. The questions concerned the treatments foregone, the patient characteristics, and the decision-making process. The response rate was 77%. Results: A nontreatment decision was made in 30% (95% confidence interval, 28%-31%) of all deaths in the Netherlands in 1995; this is an increase compared with 28% (95% confidence interval, 26%-29%) in 1990; in 20% of all deaths, this decision was the most important end-of-life decision. Artificial nutrition or hydration and antibiotics were the treatments most frequently foregone, each accounting for 25% of cases in which a nontreatment decision was made. Nursing-home physicians withheld or withdrew treatment more often than clinical specialists or general practitioners in 52%, 35%, and 17% of all deaths they were involved with, respectively. Of the patients in whom a nontreatment decision was the most important end-of-life decision, 26% were competent; of those, 93% were involved in the decision making. In 17% of patients, the nontreatment decision was made without being discussed with the patient or the patient's relatives and without knowledge of the patient's wishes. Life was shortened by an estimated 24 hours or less in 42% and 1 month or more in 8%, of patients. Conclusions: Decisions to forego life-prolonging treatment are frequently made end-of-life decisions in the Netherlands and may be increasing. Most of these decisions do not involve high-technology treatments, and the consequences, in terms of shortening of life, are relatively small.