title: Characteristics of Belgian "life-ending acts without explicit patient request": a large-scale death certificate survey revisited.
abstract: BACKGROUND
  "Life-ending acts without explicit patient request," as identified in robust international studies, are central in current debates on physician-assisted dying. Despite their contentiousness, little attention has been paid to their actual characteristics and to what extent they truly represent nonvoluntary termination of life.
  
  
  METHODS
  We analyzed the 66 cases of life-ending acts without explicit patient request identified in a large-scale survey of physicians certifying a representative sample of deaths (n = 6927) in Flanders, Belgium, in 2007. The characteristics we studied included physicians' labelling of the act, treatment course and doses used, and patient involvement in the decision.
  
  
  RESULTS
  In most cases (87.9%), physicians labelled their acts in terms of symptom treatment rather than in terms of ending life. By comparing drug combinations and doses of opioids used, we found that the life-ending acts were similar to intensified pain and symptom treatment and were distinct from euthanasia. In 45 cases, there was at least 1 characteristic inconsistent with the common understanding of the practice: either patients had previously expressed a wish for ending life (16/66, 24.4%), physicians reported that the administered doses had not been higher than necessary to relieve suffering (22/66, 33.3%), or both (7/66, 10.6%).
  
  
  CONCLUSIONS
  Most of the cases we studied did not fit the label of "nonvoluntary life-ending" for at least 1 of the following reasons: the drugs were administered with a focus on symptom control; a hastened death was highly unlikely; or the act was taken in accordance with the patient's previously expressed wishes. Thus, we recommend a more nuanced view of life-ending acts without explicit patient request in the debate on physician-assisted dying.
authors.affiliation: End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Chambaere
authors.affiliation: End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
authors.forename: Jan L
authors.initials: JL
authors.lastname: Bernheim
authors.affiliation: Department of Medicine, University Health Network, Toronto, Ont. ; University of Toronto, Toronto, Ont.
authors.forename: James
authors.initials: J
authors.lastname: Downar
authors.affiliation: End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium ; Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium.
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens