Forgoing treatment at the end of life in 6 European countries

Arch Intern Med. 2005 Feb 28;165(4):401-7. doi: 10.1001/archinte.165.4.401.


Background: Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient's life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.

Methods: Between June 2001 and February 2002, samples were obtained from deaths reported to registries in Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. The reporting physician was then sent a questionnaire about the medical decision-making process that preceded the patient's death.

Results: The incidence of nontreatment decisions, whether or not combined with other end-of-life decisions, varied widely from 6% of all deaths studied in Italy to 41% in Switzerland. Most frequently forgone in every country were hydration or nutrition and medication, together representing between 62% (Belgium) and 71% (Italy) of all treatments withheld or withdrawn. Forgoing treatment estimated to prolong life for more than 1 month was more common in the Netherlands (10%), Belgium (9%), and Switzerland (8%) than in Denmark (5%), Italy (3%), and Sweden (2%). Relevant determinants of treatment being withheld rather than withdrawn were older age (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.31-1.79), death outside the hospital (death in hospital: OR, 0.80; 95% CI, 0.68-0.93), and greater life-shortening effect (OR, 1.75; 95% CI, 1.27-2.39).

Conclusions: In all of the participating countries, life-prolonging treatment is withheld or withdrawn at the end of life. Frequencies vary greatly among countries. Low-technology interventions, such as medication or hydration or nutrition, are most frequently forgone. In older patients and outside the hospital, physicians prefer not to initiate life-prolonging treatment at all rather than stop it later.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cause of Death / trends
  • Child
  • Child, Preschool
  • Decision Making*
  • Europe / epidemiology
  • Female
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Infant
  • Life Support Care / statistics & numerical data*
  • Male
  • Middle Aged
  • Physician-Patient Relations
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Refusal to Treat / statistics & numerical data
  • Registries / statistics & numerical data
  • Retrospective Studies
  • Surveys and Questionnaires
  • Terminally Ill*
  • Treatment Refusal / statistics & numerical data*