End of life decisions and quality of care before death

In the linked study (doi:10.1136/bmj.b2772), Van den Block and colleagues report a national mortality follow-back study of end of life care in Belgium conducted during 2005 and 2006.1 Information was obtained from a prospective weekly surveillance survey of general practitioners regarding non-sudden deaths. It included information about the goals of care, medical decisions, and interventions used during the last three months of life.

The findings are a valuable contribution to understanding the context of dying in Belgium. They detail the frequency of team based palliative care; involvement of generalists; use of intensive alleviation of symptoms, which can extend to palliative sedation (termed continuous deep sedation); and the incidence of euthanasia and physician assisted suicide. However, the authors’ interpretation of the data and the conclusions they reach raise questions. Their conclusion that life shortening decisions, including euthanasia and physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care, misrepresents the frequencies they report and is tangential to the main findings.

More importantly, the results show that intensive management of symptoms during the last three months of life was highly correlated with more frequent involvement of patients’ general practitioners and with referral to multidisciplinary palliative …