title: Trends in end-of-life decision making in patients with and without cancer.
abstract: OBJECTIVE
  Because of cancer's high symptom burden and specific disease course, patients with cancer are more likely than other patients to face end-of-life decisions that have possible or certain life-shortening effects (ELDs). This study examines the incidence of ELDs in patients with cancer compared with patients without cancer and the trends in ELD incidence from 1998-2007.
  
  
  METHODS
  A nationwide death certificate study in Flanders, Belgium, was conducted in 2007, analogous to one completed in 1998. Physicians who had signed selected death certificates (n = 6,927) were sent a questionnaire.
  
  
  RESULTS
  The response rate was 58.4%. Nonsudden deaths were studied. Intensified symptom alleviation occurred more in patients with cancer than in those without (53.8% v 31.7%; P < .001) as did euthanasia (6.8% v 0.9%; P < .001). There was no difference between groups in nontreatment decisions and life-ending acts without patient's explicit request. Patients with cancer were less involved in the end-of-life decision-making process than patients without cancer (69.7% v 83.5%; P = .001). From 1998 to 2007, ELD incidence has increased in patients with cancer (+6.7%) and even more in patients without cancer (+14.9%) because of an increase in intensified symptom alleviation. In patients with cancer, euthanasia rates increased strongly and life-ending acts without the patient's explicit request decreased.
  
  
  CONCLUSIONS
  The higher ELD incidence in patients with cancer compared with those without is probably related to differences in disease trajectories and access to end-of-life care. During the period from 1998 to 2007, when euthanasia was legalized and palliative care intensified, overall ELDs increased, including those as a result of symptom alleviation and euthanasia, with a decrease in life-ending acts without explicit request.
authors.affiliation: End-of-life Care Research Group, Ghent University and Vrije Universiteit Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium. koen.pardon@vub.ac.be
authors.forename: Koen
authors.initials: K
authors.lastname: Pardon
authors.forename: Kenneth
authors.initials: K
authors.lastname: Chambaere
authors.forename: H Roeline W
authors.initials: HR
authors.lastname: Pasman
authors.forename: Reginald
authors.initials: R
authors.lastname: Deschepper
authors.forename: Judith
authors.initials: J
authors.lastname: Rietjens
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003644:Death Certificates; D003657:Decision Making; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology / Q000523:psychology / Q000628:therapy*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data / Q000639:trends; D017236:Suicide, Assisted / Q000523:psychology / Q000706:statistics & numerical data* / Q000639:trends; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000706:statistics & numerical data*; D055815:Young Adult