title: International changes in end-of-life practices over time: a systematic review.
abstract: End-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices.
  
  
  
  We conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians' actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression.
  
  
  
  Among 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X2> 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients' death.
  
  
  
  The use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.
authors.affiliation: University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada.
authors.forename: Yi-Sheng
authors.initials: YS
authors.lastname: Chao
authors.affiliation: University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada. antoine.boivin@umontreal.ca.|Institut de recherche en santé publique de l'Université de Montréal, Montréal, Canada. antoine.boivin@umontreal.ca.
authors.forename: Antoine
authors.initials: A
authors.lastname: Boivin
authors.affiliation: Interdisciplinary School of Health Science, University of Ottawa, Ottawa, Canada.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Marcoux
authors.affiliation: Université de Sherbrooke, Sherbrooke, Canada.
authors.forename: Geneviève
authors.initials: G
authors.lastname: Garnon
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Mays
authors.affiliation: Département d'administration de la santé, Université de Montréal, Montreal, Canada.
authors.forename: Pascale
authors.initials: P
authors.lastname: Lehoux
authors.affiliation: École nationale d'administration publique, Montreal, Canada.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Prémont
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Nijmegen, Nijmegen, The Netherlands.
authors.forename: Evert van
authors.initials: EV
authors.lastname: Leeuwen
authors.affiliation: Département de santé publique de Montréal, Institut National de Santé Publique du Québec, Montreal, Canada.
authors.forename: Raynald
authors.initials: R
authors.lastname: Pineault
mesh_terms: D005065:Euthanasia / Q000639:trends; D014943:Global Health; D006801:Humans; D011364:Professional Practice / Q000639:trends*; D017236:Suicide, Assisted / Q000639:trends; D013727:Terminal Care / Q000379:methods / Q000639:trends*; D028761:Withholding Treatment / Q000639:trends*
keywords: Aid in dying; Assisted suicide; End-of-life practice; Euthanasia; Treatment withdrawal