The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study

J Pain Symptom Manage. 2012 Jul;44(1):33-43. doi: 10.1016/j.jpainsymman.2011.07.007. Epub 2012 May 30.


Context: Existing empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K.

Objectives: This study compares characteristics of continuous deep sedation to explain these varying frequencies.

Methods: In Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007-2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended.

Results: The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country.

Conclusion: Differences in the prevalence of continuous deep sedation 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.

Publication types

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

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Belgium
  • Child
  • Child, Preschool
  • Decision Making
  • Deep Sedation / statistics & numerical data*
  • Euthanasia / statistics & numerical data
  • Female
  • Health Care Surveys
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Middle Aged
  • Netherlands
  • Practice Patterns, Physicians'*
  • Prevalence
  • Suicide, Assisted / statistics & numerical data
  • Surveys and Questionnaires
  • Terminal Care / statistics & numerical data*
  • United Kingdom