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Objective: To investigate the emotional feelings reported by physicians in the Netherlands after having performed euthanasia or other medical end-of-life decisions. Design: Nationwide interview study in the Netherlands, November 1995 through February 1996. Participants and setting: A random sample of 405 physicians (general practitioners, nursing home physicians, and clinical specialists). Main outcome measures: Subsequent feelings of physicians about their most recent cases (if any) of euthanasia, assisted suicide, life-ending without an explicit request from the patient, and alleviation of pain and other symptoms with high doses of opioids. Results: The response rate was 89%. In 52% of all cases of hastening death, physicians had feelings of comfort afterwards, which included feelings of satisfaction in 44% and of relief in 13%. Feelings of discomfort were reported in 42%, most frequently referred to as emotional (28%) or burdensome (25%). Feelings of discomfort were highest for euthanasia (75%; P

OBJECTIVE To investigate how often physicians act as a consultant in the review of intended euthanasia and assisted suicide (EAS), by whom physicians are asked to act as a consultant, and the consultant's reasons for not agreeing with the intended performance of EAS. DESIGN A retrospective descriptive study. SETTING The Netherlands. PARTICIPANTS A stratified random sample of 405 Dutch physicians. MAIN OUTCOME MEASURES Number of times the physician has been a consultant; how often a physician had previously been asked to be a consultant by the same treating physician; why consultants advised against EAS. RESULTS 42% of interviewed physicians had acted as a consultant for EAS and 11% had been a consultant more than three times. Half the physicians who acted as a consultant more than once were invited to do so by the same attending physician, and 41% of consultants had previously consulted the attending physician. The main reasons consultants advised against EAS were because treatment options were still available, the patient's request was not well-considered or persistent, and the patient's suffering was not unbearable and hopeless. CONCLUSIONS Many physicians have at some time been a consultant in a case of intended EAS, but only very few have been able to gain experience in consultancy. To guarantee high standards of consultation, it may be advisable to appoint and train specific consultants for EAS.

Na dagelijkse orale toediening van glycyrrhizine gedurende 4 weken bij acht mannelijke en acht vrouwelijke menselijke vrijwilligers gelijkelijk verdeeld over twee doseringsgroepen (400 mg en 800 mg glycyrrhizine/dag) werden over de hele lijn duidelijke biologische effecten vastgesteld. Deze effecten waren het meest duidelijk af te lezen aan de daling van de aldosteronconcentratie in het plasma en de plasma renine activiteit. Daarnaast bleken er duidelijke effecten te constateren bij de controle parameters (parameter ter controle van de veiligheid voor de proefpersonen). Bij vijf vrijwilligers was het nodig om het onderzoek vroegtijdig af te breken, wegens het optreden van klinische symptomen. Bij een vrijwilliger was dit terug te voeren op een intercurrente ziekte. Bij vier vrijwilligers waren er effecten in de zin van hoofdpijn, extreme gewichtstoename en oedemen die aanleiding gaven tot het vroegtijdig stoppen. De vrouwelijke vrijwilligers bleken gevoeliger dan de mannelijke vrijwilligers (meer en sterkere effecten). De glycyrrhetinezuur bepaling in bloed bleek meer geschikt dan de bepaling van glycyrrhizine om de kinetiek te vervolgen.

Teneinde een "no effect level" van glycyrrhizine vast te stellen, werd een dubbelblind, gerandomiseerd, gecontroleerd onderzoek uitgevoerd bij 39 gezonde vrouwelijke vrijwilligers. Gedurende 8 weken werd glycyrrhizine in een dosis van 0, 1, 2 of 4 mg per kg lichaamsgewicht ingenomen. De doseringen en de keus voor vrouwelijke deelnemers waren gebaseerd op een voorafgaand pilot onderzoek. De volgende parameters werden bestudeerd: gewicht, bloeddruk, electrolyten concentratie in plasma, 24-uurs excretie van electrolyten in urine, plasma renine activiteit, plasma aldosteron concentratie, atriaal natriuretisch peptide concentratie en de concentratie van glycyrrhetinezuur in plasma. De deelnemers hielden een klachtenlogboek en eetdagboekjes bij. Alleen in de hoogste doseringsgroep van 4 mg glycyrrhizine per kg lichaamsgewicht werden effecten waargenomen. Deze betroffen volume expansie enerzijds en veranderingen in plasma electrolyten anderzijds. De volume expansie tijdens glycyrrhizine-inname kwam tot uiting in suppressie van het renine-angiotensine-aldosteron systeem en toename van gewicht. Tevens daalde de atriaal natriuretisch peptide-concentratie na het staken van de glycyrrhizine-inname. De electrolytveranderingen betroffen daling van plasma kalium en stijging van plasma bicarbonaat-concentratie tijdens de glycyrrhizine-inname. Op grond van deze gegevens kan een "no effect level" van 2 mg glycyrrhizine per kg lichaamsgewicht per dag worden afgeleid.

Summary Background Empirical data about end-of-life decision-making practices are scarce. We aimed to investigate frequency and characteristics of end-of-life decision-making practices in six European countries: Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. Methods In all participating countries, deaths reported to death registries were stratified for cause (apart from in Switzerland), and samples were drawn from every stratum. Reporting doctors received a mailed questionnaire about the medical decision-making that had preceded the death of the patient. The data-collection procedure precluded identification of any of the doctors or patients. All deaths arose between June, 2001, and February, 2002. We weighted data to correct for stratification and to make results representative for all deaths: results were presented as weighted percentages. Findings The questionnaire response rate was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. Total number of deaths studied was 20 480. Death happened suddenly and unexpectedly in about a third of cases in all countries. The proportion of deaths that were preceded by any end-of-life decision ranged between 23% (Italy) and 51% (Switzerland). Administration of drugs with the explicit intention of hastening death varied between countries: about 1% or less in Denmark, Italy, Sweden, and Switzerland, 1·82% in Belgium, and 3·40% in the Netherlands. Large variations were recorded in the extent to which decisions were discussed with patients, relatives, and other caregivers. Interpretation Medical end-of-life decisions frequently precede dying in all participating countries. Patients and relatives are generally involved in decision-making in countries in which the frequency of making these decisions is high. Published online June 17, 2003 http://image.thelancet.com/extras/03art3298web.pdf

In discussions on breast cancer screening, much attention has been focussed on the possible morbidity generated by screening. Favourable effects like the prevention of advanced disease seem underestimated, probably because quantification is that difficult. To analyse the amount of care and treatment given to women with advanced breast cancer, we report on patients followed from first recurrence until death using patient files and national sources. A random sample of 60 female cases from computerised registries of two cancer centres and a sample of 20 cases from a non-computerised hospital registry was taken. A total of 68 patient files were sufficiently documented. A woman with advanced breast cancer is estimated to have a 39% loss in utility compared to a healthy woman (range 27-45%). Hormonal treatment is the main modality during 14 and chemotherapy during 4 months. Total medical cost from diagnosis of advanced disease until death amounts to 17,100 US dollars, or 21,000 when including extramural cost. The effect of breast cancer screening by preventing the occurrence of advanced disease is quantified. The resulting gain in quality of life contributes 70% of the total gain in quality of life. In the long run, almost half of the annual cost of screening will be offset by savings in the cost for advanced disease. Only the changes in palliative surgery and/or radiotherapy will be small in contrast to primary treatment changes. Besides the mortality reduction, screening is justified by the improvements in quality of life and cost savings for women prevented from reaching advanced disease.

In the Dutch Longitudinal Study among the Elderly, a probability sample of 3149 persons from the population of the Netherlands, initial ages 65-99 years, was followed from 1955 for 28 years. Vital status was determined in 1983 for 84% of the original sample. Multivariate regression models were used to predict the realized probability of dying (RPD), a measure of longevity based on actual survival time, sex and age at baseline. Predictor variables included physical, mental and social indicators of health status. The total variance explained was 20.2%. Objective health (rated by the examining physician) showed the strongest relationship with the RPD. Upon removing objective health from the model, 19.5% of the variance remained explained. Separate analyses were performed for (1) bio-medical, physical and mental examination variables, (2) disability and health care use variables, and (3) social and psychological variables; in each case the variance explained was over 11%, demonstrating considerable interdependence among predictors. Across different regression models, bio-medical and disability variables proved to be the most stable predictors of longevity.