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End-of-life decision-making in Belgium, Denmark, Sweden and Switzerland: does place of death make a difference?
  1. Joachim Cohen1,
  2. Johan Bilsen1,
  3. Susanne Fischer3,
  4. Rurik Löfmark4,
  5. Michael Norup5,
  6. Agnes van der Heide6,
  7. Guido Miccinesi7,
  8. Luc Deliens2,
  9. on behalf of the EURELD Consortium
  1. 1
    End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
  2. 2
    VU University Medical Center, Department of Public and Occupational Health, EMGO Institute, Amsterdam, The Netherlands
  3. 3
    Center of Health Sciences, Zurich University of Applied Sciences Winterthur, Zurich, Switzerland
  4. 4
    Centre for Bioethics, LIME, Karolinska Institutet and Uppsala University, Stockholm, Sweden
  5. 5
    Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Copenhagen, Denmark
  6. 6
    Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  7. 7
    Centre for Study and Prevention of Cancer, Florence, Italy
  1. Joachim Cohen, End-of-Life Care Research Group, Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium; joachim.cohen{at}


Objective: To examine differences in end-of-life decision-making in patients dying at home, in a hospital or in a care home.

Design: A death certificate study: certifying physicians from representative samples of death certificates, taken between June 2001 and February 2002, were sent questionnaires on the end-of-life decision-making preceding the patient’s death.

Setting: Four European countries: Belgium (Flanders), Denmark, Sweden, and Switzerland (German-speaking part).

Main outcome measures: The incidence of and communication in different end-of-life decisions: physician-assisted death, alleviation of pain/symptoms with a possible life-shortening effect, and non-treatment decisions.

Results: Response rates ranged from 59% in Belgium to 69% in Switzerland. The total number of deaths studied was 12 492. Among all non-sudden deaths the incidence of several end-of-life decisions varied by place of death. Physician-assisted death occurred relatively more often at home (0.3–5.1%); non-treatment decisions generally occurred more often in hospitals (22.4–41.3%), although they were also frequently taken in care homes in Belgium (26.0%) and Switzerland (43.1%). Continuous deep sedation, in particular without the administration of food and fluids, was more likely to occur in hospitals. At home, end-of-life decisions were usually more often discussed with patients. The incidence of discussion with other caregivers was generally relatively low at home compared with in hospitals or care homes.

Conclusion: The results suggest the possibility that end-of-life decision-making is related to the care setting where people die. The study results seem to call for the development of good end-of-life care options and end-of-life communication guidelines in all settings.

  • decision making
  • epidemiology
  • euthanasia
  • terminal care
  • withholding treatment

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  • Funding support: This study was supported by a grant from the Fifth Framework Program of the European Commission, Brussels, Belgium (contract QLRT-1999-30859). The Swiss part of the project was funded by the Swiss Federal Office for Education and Research, Berne (contract BBW 99.0889).

  • Competing interests: None.

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