Do-not-resuscitate decisions in six European countries

Objective: To study and compare the incidence and main background characteristics of do-not-resuscitate (DNR) decision making in six European countries. Design: Retrospective. Setting: We studied DNR decisions simultaneously in Belgium (Flanders), Denmark, Italy (four regions), the Netherlands, Sweden, and Switzerland (German-speaking part). In each country, random samples of death certificates were drawn from death registries to which all deaths are reported. The deaths occurred between June 2001 and February 2002. Participants. Reporting physicians received a mailed questionnaire about the medical decision making that had preceded death. The response percentage was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61 % for Sweden, 59% for Belgium, and 44% for Italy. The total number of deaths studied was 20,480. Interventions. None. Measurements and Main Results: Measurements were frequency of DNR decisions, both individual and institutional, and patient involvement. Before death, an individual DNR decision was made in about 50-60% of all nonsuddlen deaths (Switzerland 73%, Italy 16%). The frequency of institutional decisions was highest in Sweden (22%) and Italy (17%) and lowest in Belgium (5%). DNR decisions are discussed with competent patients in 10-84% of cases. In the Netherlands patient involvement rose from 53% in 1990 to 84% in 2001. In case of incompetent patients, physicians bypassed relatives in 5-37% of cases. Conclusions. Except in Italy, DNR decisions are a common phenomenon in these six countries. Most of these decisions are individual, but institutional decisions occur frequently as well. In most countries, the involvement of patients in DNR decision making can be improved.