title: Forgoing treatment at the end of life in 6 European countries.
abstract: BACKGROUND
  Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient's life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.
  
  
  METHODS
  Between June 2001 and February 2002, samples were obtained from deaths reported to registries in Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. The reporting physician was then sent a questionnaire about the medical decision-making process that preceded the patient's death.
  
  
  RESULTS
  The incidence of nontreatment decisions, whether or not combined with other end-of-life decisions, varied widely from 6% of all deaths studied in Italy to 41% in Switzerland. Most frequently forgone in every country were hydration or nutrition and medication, together representing between 62% (Belgium) and 71% (Italy) of all treatments withheld or withdrawn. Forgoing treatment estimated to prolong life for more than 1 month was more common in the Netherlands (10%), Belgium (9%), and Switzerland (8%) than in Denmark (5%), Italy (3%), and Sweden (2%). Relevant determinants of treatment being withheld rather than withdrawn were older age (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.31-1.79), death outside the hospital (death in hospital: OR, 0.80; 95% CI, 0.68-0.93), and greater life-shortening effect (OR, 1.75; 95% CI, 1.27-2.39).
  
  
  CONCLUSIONS
  In all of the participating countries, life-prolonging treatment is withheld or withdrawn at the end of life. Frequencies vary greatly among countries. Low-technology interventions, such as medication or hydration or nutrition, are most frequently forgone. In older patients and outside the hospital, physicians prefer not to initiate life-prolonging treatment at all rather than stop it later.
authors.affiliation: Institute of Legal Medicine, University of Zurich, Zurich, Switzerland. bosh@irm.unizh.ch
authors.forename: Georg
authors.initials: G
authors.lastname: Bosshard
authors.forename: Tore
authors.initials: T
authors.lastname: Nilstun
authors.forename: Johan
authors.initials: J
authors.lastname: Bilsen
authors.forename: Michael
authors.initials: M
authors.lastname: Norup
authors.forename: Guido
authors.initials: G
authors.lastname: Miccinesi
authors.forename: Johannes J M
authors.initials: JJ
authors.lastname: van Delden
authors.forename: Karin
authors.initials: K
authors.lastname: Faisst
authors.forename: Agnes
authors.initials: A
authors.lastname: van der Heide
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death / Q000639:trends; D002648:Child; D002675:Child, Preschool; D003657:Decision Making; D005060:Europe / Q000453:epidemiology; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016079:Refusal to Treat / Q000706:statistics & numerical data; D012042:Registries / Q000706:statistics & numerical data; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D019452:Terminally Ill; D016312:Treatment Refusal / Q000706:statistics & numerical data*