The practice of continuous deep sedation until death in Belgium, the Netherlands and the United Kingdom: A comparative study

Research aims
Continuous deep sedation until death (CDS) is given in about 15% of all deaths in Belgium (BE), 8.2% in the Netherlands (NL) and 17% in the UK. This study compares characteristics of CDS to explain these varying frequencies.
Study design and methods
In BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about CDS and other decisions were sent to the certifying physicians of each death from a stratified sample (BE: n=6927; NL: n=6860). In UK in 2007-8, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended.
Results
The total number of deaths studied was 11704 of which 1517 involved CDS. In Dutch hospitals, CDS was significantly less often provided (11%) compared to Belgian (20%) and British hospitals (17%). In UK home settings CDS was more common (19%) than in BE (9.9%) or NL (7.7%). In NL in both settings, CDS was more often involved benzodiazepines and lasted less than 24 hours. Belgian physicians combined CDS with a decision to provide physician-assisted death more often than in both other countries. Overall, younger patients, men and people dying with malignancies were more likely to receive CDS, although not always significant within each country.
Conclusion
Differences in the prevalence of CDS in the three countries appear to reflect complex legal, cultural and organizational factors, more than differences in patients' characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.