535828 research-article2014

PMJ0010.1177/0269216314535828Palliative MedicineBerendsen et al.

Letter to the Editor Palliative Medicine 2014, Vol. 28(9) 1161­–1162 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216314535828 pmj.sagepub.com

Physician-assisted death is less frequently performed among women with a lower education: A survey among general practitioners To the Editor,

Background In the Netherlands, since its legalization (2002) the number of physician-assisted deaths (PAD; i.e. euthanasia and physician-assisted suicide) has increased from 2120 to 3695 per year, whereas the profile of the patients (age, gender, and diagnosis) concerned has not changed. The number of cases of PAD is higher than that reported (reporting rate 77%).1 Of all registered deaths, 2.8% were the result of euthanasia and 0.1% of physician-assisted suicide. Annually, over 80% of PAD was performed by general practitioners (GPs). It has been shown that the majority (55%) of the requests does not lead to PAD, especially in elderly patients and patients with diagnoses other than cancer.1 Of these cases, 44% of the patients were deceased before PAD could be performed; in 35%, the statutory criteria were not met. This concerned mostly the criteria “unbearable suffering” and “well-considered request.” Although concerns were raised that PAD might, in particular, affect people with a low educational status, there is no evidence of an elevated risk for this group.2 Earlier research showed that higher educated older people are more confident that their request for PAD will be granted.3 The question arises whether any barriers exist for patients with a lower education level to receive PAD.

Methods In the Netherlands, almost all citizens are registered with one GP, for many years. Experienced GPs were asked in February 2013 to estimate the educational level of their patients for whom they had performed PAD. Because of their intensive contact prior to PAD, we considered that these GPs would know their patients well enough to reliably estimate their educational level. GPs (n = 262; 75% male) were asked to indicate how often they had applied PAD in the past 5 years, to indicate age and gender of the

patients involved, and to estimate their educational level (primary, secondary, or tertiary education). Patient characteristics (age and gender) were compared with the Death Certificate Study 2010 to assess representativeness.1 This study is based on a sample from the death registry in 2010 of Statistics Netherlands (SN). Then, the reported cases of PAD were compared with data of SN on the educational level of the entire Dutch population by age and gender. Because data collection was anonymous with regard to the GPs as well as to the deceased patients, according to Dutch legislation this study did not need the approval of a medical ethics committee.

Results The questionnaire was returned by 147 (56%) GPs; a total of 342 eligible cases was reported. The age of the patients ranged from 23 to 95 years (median 69 years) and 57% were male. Almost 40% (38.5%) were aged ≤65 years. No differences were found when comparing the reported cases with the Death Certificate Study 2010.1 When comparing educational level of gender-nested age groups of reported cases of PADs with the general Dutch population aged over 23 years (SN23+ data from SN), less PAD (p < 0.05) was reported in the subgroups of women aged 65+ years with primary education, whereas in the subgroup with secondary education more women (p < 0.05) received PAD. No differences were found for younger women, women with a tertiary education, or in any of the male subgroups.

Discussion In this retrospective study, the responses might be affected by memory bias. As PAD is not performed frequently and usually has a deep impact on GPs, we assume that they were able to reliably estimate the number of PAD cases. That PAD is less frequently performed in elderly women with a primary education may be due to their lack of knowledge about PAD or because they are less able to convince their physician that their suffering is “unbearable.” GPs find the statutory criteria that “the doctor is convinced that the patient’s suffering is unbearable and hopeless” the most difficult to assess.4 A GP must be able to explain that the unbearable suffering of the patient was

Downloaded from pmj.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015

1162

Palliative Medicine 28(9)

at least recognizable for him. For a patient to present their perspective, a certain degree of eloquence is needed. Possibly, male GPs are less able to recognize an inexplicit request for a PAD of elderly women, as GP’s gender has an influence on the medical care provided. As the majority of the GP trainers are men aged ≤65 years, perhaps not only a difference in gender but also a difference in age might influence the interaction. In addition, older people may be more religious than the younger generation. This may also play a role. Our study shows that fewer PADs are performed in elderly women with a primary education. Further research is needed to establish which factors (gender, age, education, religion) contribute to this difference. GPs should be aware of the influence of these characteristics when providing end-of-life care to elderly women with a lower education level.

References 1. Van der Heide A and Brinkman-Stoppelenburg A. Death certificate study 2010 (in Dutch). The Hague: ZonMW (the Netherlands Organization for Health Research and Development), 2012, http://www.zonmw.nl/nl/publicaties/ detail/sterfgevallenonderzoek-2010-%20euthanasie-enandere-medische-beslissingen-rond-het-levenseinde/?no_cac he=1&cHash=a9b2c46c0065adeeb5b5518b5e71ce1c 2. Steck N, Junker C, Maessen M, et al. Suicide assisted by right-to-die associations: a population based cohort study. Int J Epidemiol 2014; 43: 614–622. 3. Buiting HM, Deeg DJ, Knol DL, et al. Older peoples’ attitudes towards euthanasia and an end-of-life pill in the Netherlands: 2001–2009. J Med Ethics 2012; 38: 267–273. 4. Kouwenhoven PS, Raijmakers NJ, van Delden JJ, et al. Opinions of health care professionals and the public after eight years of euthanasia legislation in the Netherlands: a mixed methods approach. Palliat Med 2013; 27: 273–280.

Acknowledgements The authors thank all the GP trainers who participated in this study and Donald van der Tol for his helpful comments.

Annette J Berendsen, Singh Joeloemsingh, Jan Schuling and Henk EP Bosveld

Declaration of conflicting interest

Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

The authors declare that there is no conflict of interest.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Corresponding author: Annette J Berendsen, Department of General Practice, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, The Netherlands. Email: [email protected]

Downloaded from pmj.sagepub.com at UNIV OF PENNSYLVANIA on April 12, 2015

Physician-assisted death is less frequently performed among women with a lower education: a survey among general practitioners.

Physician-assisted death is less frequently performed among women with a lower education: a survey among general practitioners. - PDF Download Free
312KB Sizes 2 Downloads 4 Views