No increase in palliative sedation in Dutch general practice
In Dutch general practice, a small proportion of dying patients receive palliative sedation. Although the percentage fluctuated between 2005 and 2011, there was no increase during this period. Nine out of every ten patients who received palliative sedation were involved in decision making, and people with cancer participated in this more frequently than those with other terminal diseases. Researchers from NIVEL, the Netherlands Institute for Health Services Research and the VU Medical Centre published these findings in the British Journal of General Practice.
In the final weeks of life, palliative sedation can be used to lessen pain and suppress other symptoms when there are no other ways of doing so and there is no chance for recovery. When used appropriately, palliative sedation does not hasten death. Since the introduction of the Dutch guideline for palliative sedation in 2005, opinions on palliative sedation among both, doctors and the public, have changed, and they have become more familiar with it. Palliative sedation is not being used more often, but patients are being involved in decision making at an earlier stage.
Involvement in decision making
Between 2005 and 2011, 56 Dutch general practices (sentinel GP network) from the NIVEL Primary Care Database reported 183 cases of palliative sedation. Palliative sedation was used in 5.7 per cent of all deaths, and was used relatively frequently in younger patients with cancer. Of the patients, 87.4 per cent were involved in decision making. Elderly people, people with cardiovascular disease, and those with chronic obstructive pulmonary disease (COPD) in particular were not always able to be involved in decision making, possibly because of a sudden deterioration in their condition at that time.
A request for euthanasia had been made in 20.8 per cent of cases where palliative sedation had been used. In these cases, the choice for palliative sedation was based on a rapid worsening of the disease, an incomplete euthanasia request, or because the patients and their family ultimately chose for palliative sedation after all. The reasons for applying palliative sedation were clearly motivated in all of these cases.
NIVEL project manager, epidemiologist, and general practitioner (GP) Gé Donker: “Our study was conducted within a national network of general practices over a seven-year period. It shows that, in the final stages of their lives, only about one in every twenty patients had refractory symptoms causing the use of palliative sedation. This percentage is not increasing. There is also no indication of an indistinct boundary between euthanasia and palliative sedation. On the contrary: for one out of five patients who had requested euthanasia, the choice of palliative sedation was clearly motivated. And this was almost always done in consultation with the patient and those close to him or her.”
The study made use of data from the sentinel GP Network participating in the NIVEL Primary Care Database. The sentinel practices form a representative group of 59 Dutch GPs in 42 practices. Their patient population comprises around 0.8 per cent of the Dutch population, and is representative with regard to region and distribution among urban and rural areas. The sentinel GPs report every week (making it possible to identify trends rapidly) or every year on the prevalence of a number of diseases, events, and procedures missing from – and which are hard to include in – standard databases. The sentinel GP Network was established in 1970.