Empirical research on end-of-life decisions in medical practice in Belgium (Flanders)

Belgium is a country with no formal registration or authorization procedure for end-of-life decisions. Acts of euthanasia ('the administration of drugs with the explicit intention of ending the patient's life at the patient's request') are treated as murder under criminal law. In 1996, a study of euthanasia and other medical practices concerning the end of life was conducted in Hasselt, a city in the Flemish part of Belgium. All physicians who signed a death certificate in 1996 received an anonymous self-administered mail questionnaire. The response rate was 55% (75% among family physicians and 44% among clinical specialists). This chapter explores the incidence of end-of-life decisions in Belgium (Flanders). Based on the corrected data obtained from the study in Hasselt, incidence estimates are presented for euthanasia and physician-assisted suicide, ending of life without the patient's explicit request, alleviation of pain and symptoms with a potential life-shortening effect, and withholding or withdrawing of a potential life-prolonging treatment. Furthermore, the circumstances of these end-of-life decisions that are relevant to legislation and to ethical acceptability are discussed. Based on our research experience in the domain of end-of-life decisions, we are of the opinion that the following topics deserve more attention in future research: assessment of the criteria used by physicians to define and establish the '(in)competence' of patients; patient-physician communication about the end of life under conditions of secrecy and prohibition (versus regulated conditions); research into the role of paramedical personnel, and, in particular, nurses; development and testing of causal models to explain why end-of-life decisions happen; the design of comparative international research.