Review Medical end-of-life decisions: Does its use differ in vulnerable patient groups? A systematic review and meta-analysis Judith A.C. Rietjens a, * , Reginald Deschepper a , Roeline Pasman b , Luc Deliens a, b a End-of-life Care Research Group, Ghent University & Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium b Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands article info Article history: Available online 17 February 2012 Keywords: Medical end-of-life decisions Prevalence Systematic review Random effects Meta-analysis Inequalities Age Gender abstract Medical end-of-life decisions, defined as end-of-life practices with a potential or certain life-shortening effect, precede almost 50% of deaths in Western countries, and receive ample medical-ethical attention. This systematic review aims to detect whether there are differences in the prevalence of medical end-of- life decisions in ‘vulnerable’ patient groups. In 2009, five major databases were scrutinized for publi- cations containing original data on the prevalence of euthanasia/physician-assisted suicide, life-ending without explicit patient request, intensified symptom alleviation, non-treatment decisions and pallia- tive sedation by social factors (eg age, gender and SES). Heterogeneous findings were pooled using a random effects model. We identified 6377 papers of which 51 papers were selected, involving over 1.09 million patients. Most publications reported the prevalence of non-treatment decisions. The most studied social factors were age and gender. Among patients older than eighty years, non-treatment decisions occurred more frequently compared with younger patients, while intensified symptom alle- viation, palliative sedation, euthanasia/physician-assisted suicide and life-ending without explicit request were practiced less often. Similar patterns of association, although less strong, were found for female patients compared with males and those with lower levels of education versus more highly- educated patients. We conclude that the administration of medication with a potential or certain life- shortening effect seemed generally to be practiced less often among the elderly, females and less well-educated patients compared with younger, male or more educated patients, while decisions that include the withdrawal or withholding of treatments seem to be more common in these groups. Further studies should focus on investigating whether these differences reflect less than optimal end-of-life care for specific patient groups. Ó 2012 Elsevier Ltd. All rights reserved. Introduction Medical care and decision-making at the end of life has changed rapidly in recent decades due to the ageing of patient populations, an epidemiological shift from acute care to chronic care trajectories (Rosen, 1993), and the increasing influence of medical- technological developments. While life now often can be extended, this does not always result in a better quality of life for the patient. As a result, medical end-of-life decisions with a possible or certain life-shortening effect are part of contemporary end-of-life care. Today, a myriad of medical end-of-life decisions occur in clinical practice. First, the withholding or withdrawal of potential life-prolonging treatments that are no longer considered beneficial; such decisions are often referred to as non-treatment decisions. Further, to alleviate pain and other intractable suffering, dosages of opioids can be intensified, or a patient’s consciousness can be reduced by the administration of sedating drugs, in some cases with the hastening of death as a possible or certain side effect. In some rare, last resort, cases, life can be deliberately ended by the administration by the physician of lethal drugs at the explicit request of the patient (euthanasia), by the patient themselves (physician-assisted suicide), or without an explicit request from the patient. A European study conducted in 2003 reported end-of-life decisions to be practiced between 23% (Italy) to 51% (Switzer- land) of all deaths (van der Heide et al., 2003). Non-treatment decisions (4e28%) and intensified symptom alleviation (19e26%) were most common, while euthanasia (0.04e2.59%) and physician-assisted suicide (0e0.36%) were more rarely practiced. * Corresponding author. E-mail addresses: jrietjen@vub.ac.be (J.A.C. Rietjens), reginald.deschepper@ vub.ac.be (R. Deschepper), hrw.pasman@vumc.nl (R. Pasman), luc.deliens@ vub.ac.be (L. Deliens). Contents lists available at SciVerse ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2011.12.046 Social Science & Medicine 74 (2012) 1282e1287