Continuous deep sedation until death in different care settings in Belgium: a nationwide survey

Introduction The practice of continuous deep sedation until death as a last resort therapy in dying patients has come under broad clinical, ethical and societal attention. Performance guidelines for this end-of-life practice do exist, but none have been issued by Belgian medical authorities. This study examines the incidence of continuous deep sedation 2001-2007 and performance characteristics in different care settings in Flanders, Belgium.
Method In 2007 we repeated a retrospective postal survey, last conducted in 2001, among physicians who certified a representative sample of Flemish death certificates (N=6927). They answered anonymous questionnaires regarding performance of continuous deep sedation, drugs used, duration of sedation until death, the artificial administration of food and fluid, decision-making with patient and relatives, intention, and the possibility of alternative treatment.
Results Response rate was 58.4%. The incidence of continuous deep sedation until death increased significantly between 2001 and 2007 from 8.2% to 14.5%, in nearly all patient groups and in all care settings: to 9.8% at home, 19.5% in hospital and 9.4% in care homes. Benzodiazepines were used in 58% of cases, opioids as sole drug in 31% (48% in care homes). There was no patient or family consent in 20% of cases (27% in hospital), and the physician intended a hastened death in 17% (25% at home). Artificial food and fluid were rarely administered until death in sedated patients at home or in care homes, but in 63% of sedated hospital patients. Sedation rarely lasted longer than two weeks.
Discussion The increased use of continuous deep sedation in all settings points to its general acceptance as an end-of-life practice. Performance however differs substantially between care settings and does not always follow proposed directives, suggesting the need for official guidelines.
This study was funded by the Institute for the Promotion of Innovation by Science and Technology - Flanders.