title: Is educational attainment related to end-of-life decision-making? A large post-mortem survey in Belgium.
abstract: BACKGROUND
  Educational attainment has been shown to influence access to and quality of health care. However, the influence of educational attainment on decision-making at the end of life with possible or certain life-shortening effect (ELDs ie intensified pain and symptom alleviation, non-treatment decisions, euthanasia/physician-assisted suicide, and life-ending acts without explicit request) is scarcely studied. This paper examines differences between educational groups pertaining to prevalence of ELDs, the decision-making process and end-of-life treatment characteristics.
  
  
  METHODS
  We performed a retrospective survey among physicians certifying a large representative sample of Belgian deaths in 2007. Differences between educational groups were adjusted for relevant confounders (age, sex, cause of death and marital status).
  
  
  RESULTS
  Intensified pain and symptom alleviation and non-treatment decisions are more likely to occur in higher educated than in lower educated patients. These decisions were less likely to be discussed with either patient or family, or with colleague physicians, in lower educated patients. A positive association between education and prevalence of euthanasia/assisted suicide (acts as well as requests) disappeared when adjusting for cause of death. No differences between educational groups were found in the treatment goal in the last week, but higher educated patients were more likely to receive opioids in the last day of life.
  
  
  CONCLUSIONS
  There are some important differences and possible inequities between educational groups in end-of-life decision-making in Belgium. Future research should investigate whether the found differences reflect differences in knowledge of and adherence to patient preferences, and indicate a discrepancy in quality of the end of life.
authors.affiliation: End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussel 1090, Belgium. kenneth.chambaere@vub.ac.be.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Chambaere
authors.forename: Judith A C
authors.initials: JA
authors.lastname: Rietjens
authors.forename: Joachim
authors.initials: J
authors.lastname: Cohen
authors.forename: Koen
authors.initials: K
authors.lastname: Pardon
authors.forename: Reginald
authors.initials: R
authors.lastname: Deschepper
authors.forename: H Roeline W
authors.initials: HR
authors.lastname: Pasman
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium / Q000453:epidemiology; D003657:Decision Making; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000523:psychology* / Q000706:statistics & numerical data