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Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey

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Abstract
Background: A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the 'slippery slope' hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal. Method: We performed a post-mortem survey among physicians certifying a large representative sample (n = 6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%. Results: While the rates of non-treatment decisions (NTD) and administration of life ending drugs withouFWOt explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant. Conclusion: Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.
Keywords
HEALTH-CARE, PATIENT AGE, MAJOR TRAUMA, SERIOUSLY ILL, ELDERLY-PATIENTS, UNIT ENVIRONMENT, EUROPEAN COUNTRIES, RESUSCITATE ORDERS, NURSING-HOME RESIDENTS, SPECIALIST PALLIATIVE CARE, Belgium, Palliative care, Euthanasia, Slippery slope, End-of-life decisions, End of life, Age inequalities, Ageism

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MLA
Chambaere, Kenneth et al. “Age-based Disparities in End-of-life Decisions in Belgium: a Population-based Death Certificate Survey.” BMC PUBLIC HEALTH 12 (2012): n. pag. Print.
APA
Chambaere, K., Rietjens, J. A., Smets, T., Bilsen, J., Deschepper, R., Pasman, H. R. W., & Deliens, L. (2012). Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey. BMC PUBLIC HEALTH, 12.
Chicago author-date
Chambaere, Kenneth, Judith AC Rietjens, Tinne Smets, Johan Bilsen, Reginald Deschepper, H Roeline W Pasman, and Luc Deliens. 2012. “Age-based Disparities in End-of-life Decisions in Belgium: a Population-based Death Certificate Survey.” Bmc Public Health 12.
Chicago author-date (all authors)
Chambaere, Kenneth, Judith AC Rietjens, Tinne Smets, Johan Bilsen, Reginald Deschepper, H Roeline W Pasman, and Luc Deliens. 2012. “Age-based Disparities in End-of-life Decisions in Belgium: a Population-based Death Certificate Survey.” Bmc Public Health 12.
Vancouver
1.
Chambaere K, Rietjens JA, Smets T, Bilsen J, Deschepper R, Pasman HRW, et al. Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey. BMC PUBLIC HEALTH. 2012;12.
IEEE
[1]
K. Chambaere et al., “Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey,” BMC PUBLIC HEALTH, vol. 12, 2012.
@article{3142570,
  abstract     = {Background: A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the 'slippery slope' hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal. 
Method: We performed a post-mortem survey among physicians certifying a large representative sample (n = 6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%. 
Results: While the rates of non-treatment decisions (NTD) and administration of life ending drugs withouFWOt explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant. 
Conclusion: Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.},
  articleno    = {447},
  author       = {Chambaere, Kenneth and Rietjens, Judith AC and Smets, Tinne and Bilsen, Johan and Deschepper, Reginald and Pasman, H Roeline W and Deliens, Luc},
  issn         = {1471-2458},
  journal      = {BMC PUBLIC HEALTH},
  keywords     = {HEALTH-CARE,PATIENT AGE,MAJOR TRAUMA,SERIOUSLY ILL,ELDERLY-PATIENTS,UNIT ENVIRONMENT,EUROPEAN COUNTRIES,RESUSCITATE ORDERS,NURSING-HOME RESIDENTS,SPECIALIST PALLIATIVE CARE,Belgium,Palliative care,Euthanasia,Slippery slope,End-of-life decisions,End of life,Age inequalities,Ageism},
  language     = {eng},
  pages        = {10},
  title        = {Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey},
  url          = {http://dx.doi.org/10.1186/1471-2458-12-447},
  volume       = {12},
  year         = {2012},
}

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