Physicians’ labelling of end-of-life practices: a hypothetical case study H M Buiting, 1 A van der Heide, 1 B D Onwuteaka-Philipsen, 2 M L Rurup, 2 J A C Rietjens, 1 G Borsboom, 1 P J van der Maas, 1 J J M van Delden 3 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands; 2 EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands; 3 Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Correspondence to: Ms H M Buiting, Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; h.buiting@ erasmusmc.nl Received 7 March 2009 Revised 27 October 2009 Accepted 5 November 2009 ABSTRACT Objectives: To investigate why physicians label end-of- life acts as either ‘euthanasia/ending of life’ or ‘alleviation of symptoms/palliative or terminal sedation’, and to study the association of such labelling with intended reporting of these acts. Methods: Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response: 55%). They were asked to label six hypothetical end-of-life cases: three ‘standard’ cases and three cases randomly selected (out of 47), that varied according to (1) type of medication, (2) physician’s intention, (3) type of patient request, (4) patient’s life expectancy and (5) time until death. We identified the extent to which characteristics of cases are associated with physician’s labelling, with multilevel multivariable logistic regression. Results: The characteristics that contributed most to labelling cases as ‘euthanasia/ending of life’ were the administration of muscle relaxants (99% of these cases were labelled as ‘euthanasia/ending of life’) or dispro- portional morphine (63% of these cases were labelled accordingly). Other important factors were an intention to hasten death (54%) and a life expectancy of several months (46%). Physicians were much more willing to report cases labelled as ‘euthanasia’ (87%) or ‘ending of life’ (56%) than other cases. Conclusions: Similar cases are not uniformly labelled. However, a physicians’ label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not. In The Netherlands, euthanasia is defined as deliberately ending a person’s life at the person’s explicit request. It accounts for 1.7% of all deaths in 2005. 1 In physician-assisted suicide, the patient self-administers medication that is prescribed by a physician. This practice is less common than euthanasia and accounts for 0.2% of all deaths. In 2002, The Netherlands passed the Euthanasia Act and so provided a legal ground for euthanasia and physician-assisted suicide. Physicians are required to report euthanasia and assisted suicide to the municipal coroner as an unnatural death, to enable review by a multidisciplinary review committee, in order to guarantee transparency and public control. Since the early 1990s, reporting rates increased gradually, from an estimated 18% of all cases in 1990, to 41% in 1995 and 54% in 2001, up to 80% in 2005. 1–3 However, non-reporting of physician- assistance in dying, which is a criminal offence, subsisted. Cases in which physicians had used opioids to deliberately end life were rarely reported. 14 Opioid use at the end of life has been extensively discussed in the literature. In general, two situa- tions can be distinguished. In the first situation, physicians alleviate the suffering of terminally ill patients by titrating the dosage of opioids against symptoms. This practice is generally considered to be part of normal medical practice. Yet, physicians have frequently expressed concerns about short- ening these patients’ lives, for example, by causing respiratory depression. 5 The principle of propor- tionality states that in such situations practices may be justified if the probable harms are out- weighed by the benefits for the patient (eg, death could be a negative consequence of a beneficial action). 6 However, as there is increasing evidence that the potential life-shortening effects of opioids are limited, the benefits probably predominate in such cases. 7–9 In the second situation, physicians intentionally administer opioids in high or rapidly increasing dosages to shorten life: such cases should be regarded as a form of physician-assisted dying. In actual medical practice a grey zone emerges in which it may be difficult to distinguish between these two types of situations. Correct labelling of end-of-life acts, including those where opioids are used, is important in countries where euthanasia is illegal because morphine and other potentially life-shortening drugs are often indispensable in end-of-life care. In countries that tolerate physician assistance in dying, there is an additional relevance due to the requirement to report cases where opioids are used in disproportionately high dosages. In this paper we explore the determi- nants of labelling acts as ‘euthanasia/ending of life’ and the extent to which such labelling is associated with physician’s intended reporting. We used hypothetical cases and studied the type and mode of medication, the physician’s intention, the type of request, the patient’s life expectancy and the time until death after the administration of medication. METHODS Population This study was a national questionnaire survey among 2100 Dutch physicians; 1300 clinical specialists (200 cardiologists, surgeons, lung spe- cialists, intensive care unit specialists and neurol- ogists and 300 specialists in internal medicine), 500 general practitioners and 300 nursing home physi- cians. The sample sizes were based on the frequency with which physicians have medical responsibility for dying patients, and on the total number of physicians working in a specific Law, ethics and medicine 24 J Med Ethics 2010;36:24–29. doi:10.1136/jme.2009.030155