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Euthanasia is legally permitted in Netherlands. However, the physicians exercise extreme discretion when using such advance directives with elderly demented patients. A study proving that physicians resort to such a step when they are convinced that the patient has additional complications, which make them suffer unbearable pain is presented.

Physicians who have consulted in cases of legal euthanasia or assisted suicide (EAS) in the Netherlands may not be very experienced in considering end-of-life issues. Dutch law requires EAS cases to be reviewed by a consulting physician. Researchers interviewed 405 physicians, and found that 42% had consulted for a colleague, and 11% had consulted on EAS cases four or more times. Many physicians consulted for the same colleagues that consulted for them, forming consultation pairs. Consultants recommended against EAS when the patient was not persistent, or other medical options were still available. Trained consultants may more effectively perform an oversight role.

Specially designed case histories can play a valuable role in assessing the extent to which the assessment of physician-assisted death differs between the different categories of members of the public prosecution in the Netherlands. It has been established that the presence of an explicit request, the form of suffering and the anticipated life expectancy of the patient are all factors determining the way in which members of the public prosecution assess physician-assisted death. The most significant factor in the decision whether or not to recommend an inquest is the presence or absence of an explicit request.

Introduction The debate on containing the cost of health care is mainly focused on the supply side and the financing of health care.[1] Little attention is given to changes in [...]

Background: Population-based screening for prostate cancer is currently being evaluated in randomized clinical trials in the United States and in Europe. Side effects arising from the process of screening and from the earlier treatment of screen-detected prostate cancer may be important factors in the evaluation. To examine health-related quality of life (or health status) among men screened for prostate cancer, we conducted a longitudinal study of 626 attenders to the Rotterdam (The Netherlands) prostate cancer screening program and of 500 nonparticipants. Methods: Attenders of the screening program and nonparticipants completed self-assessment questionnaires (SF-36 [i.e., Medical Outcomes Study 36-Item Short-Form Health Survey] and EQ-5D [i.e., EuroQol measure for health-related quality of life] health surveys) to measure generic health status, as well as an additional questionnaire for anxiety and items relating to prostate cancer screening. Results: Physical discomfort during digital rectal examination and during transrectal ultrasound was reported by 181 (37%) of 491 men and by 139 (29%) of 487 men, respectively; discomfort during prostate biopsy was reported by 64 (55%) of 116 men. Mean scores for health status and anxiety indicated that the participants did not experience relevant changes in physical, psychological, and social functioning during the screening procedure. However, high levels of anxiety were observed throughout the screening process among men with a high predisposition to anxiety. Similar scores for anxiety predisposition were observed among attenders and nonparticipants. Conclusions: At the group level, we did not find evidence that prostate cancer screening induced important short-term health-status effects, despite the short-lasting side effects related to the biopsy procedure. However, subgroups may experience high levels of anxiety. The implication is that unfavorable health-status effects of prostate cancer screening occur mainly in the treatment phase. [J Natl Cancer Inst 1998; 90:925-31]

Introduction In the early 1970s mortality from cardiovascular diseases started to decline in many industrialized countries.[1] Despite considerable debate, most observers would agree that reductions in risk factors, particularly smoking [...]

Background: Results from five Swedish randomized trials may provide the most conclusive evidence on the effect of mammographic screening and have been used to forecast the expected reduction in breast cancer mortality in other programs. However, those trials demonstrated different degrees of reduction. The interpretation of observed mortality reduction after long follow-up for women aged 40-49 years at trial entry is both important and controversial. Purpose: We estimated what percentage of the observed mortality reduction for women aged 40-49 years at entry into the five Swedish screening trials might be attributable to screening these women at 50 years of age or older. Moreover, we calculated the most likely percentage mortality reduction for specific screening programs if the Swedish results were generalized and analyzed whether characteristics of each trial might at least partly explain the observed differences in reductions among the trials. Methods: Each Swedish trial was simulated with one underlying computer simulation model (MISCAN--MIcrosimulation SCreening ANalysis) of the natural history of the disease and the performance of screening, taking into account nine important trial characteristics. Improvement in prognosis for screen-detected case patients was estimated with age-specific reduction for all trials and each trial design as a reference. Results: An expected 7% reduction in breast cancer mortality for women aged 40-49 years at trial entry (relative risk [RR] = 0.93) was determined by computer modeling, assuming no improvement in prognosis for cancers that are screen detected before 50 years of age. This result indicates that, of the overall 10% observed reduction (RR = 0.90) in the five Swedish trials analyzed, most (70%) of this reduction might be attributable to screening these women in later rounds after their 50th birthday. Using additional trial information, predictions of breast cancer mortality reduction in women 50 years or older might be 11% larger than previously expected, assuming that high-quality mammographic screening can be achieved in nationwide programs. For women aged 50-69 years at trial entry, the differences in expected versus observed mortality reduction among the trials are estimated to be relatively small. (Expected mortality reductions range from 24% to 32%.) Conclusions: Results from the Swedish randomized breast cancer-screening trials should be seen as more favorable regarding the effect of mammographic screening in reducing breast cancer mortality for women aged 50-69 years than was estimated earlier. Our analyses also suggest that the improvement in prognosis due to screening for women aged 40-49 years is much smaller than that for women aged 50 years or older. Approximately, 70% of the 10% observed reduction in breast cancer mortality (i.e., 7%) for women aged 40-49 years at trial entry might be attributable to a reduction due to screening these women after they reach age 50. Implications: Detailed screening data for the 40- to 49-year age group of all Swedish trials should be analyzed to specifically estimate the natural history and performance of screening in this age group.

Background: Decisions to withhold or withdraw treatment (nontreatment decisions) become increasingly important because they have to be made more frequently and more explicitly. This nationwide study provides information on the occurrence and background of these nontreatment decisions. Methods: Three studies were undertaken: interviews with 405 physicians, 5197 answered questionnaires concerning deceased persons, and information about 2257 deaths collected by a prospective study. Results: Of all deaths, 30% appeared to be sudden and unexpected. In 39% of all nonsudden deaths, a nontreatment decision was made. This percentage varied by specialty (28% to 55%). Nontreatment decisions were made more often in older female patients. The decisions were made at the explicit request of the patient (19%), after discussion with the patient or after a previous wish (22%), or without any involvement of the patient (59%). Of this last group, 87% of patients were not competent at the time of the decision. In 24% of cases of nontreatment, life was shortened by at least a week. Of all physicians interviewed, 56% had changed their attitude since the beginning of their practice, most of them toward more nontreatment decisions at the end of life. Conclusions: Nontreatment decisions are made frequently in medical practice. Most often the physician has to weigh medical and nonmedical burdens and benefits. For this to be done properly, the patient should be involved whenever possible. Other requirements are optimal palliative treatment, better prognostic knowledge, consultation of other specialists, and the absence of defensive motives. (Arch Intern Med. 1995;155:286-292)

Objective--To gain insight into decisions made in general practice about the end of life. Design--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on [...]

The acid test for any society that claims to be civilised is whether it really protects the life and promotes the wellbeing of its most vulnerable citizens, including the very [...]

To study trends in reporting rates of euthanasia from 1990 to 2005 in relation to whether recommended or nonrecommended drugs were used, and the most important differences between reported and unreported cases in 2005.

Based on an extensive cost-effectiveness analysis, the Dutch nation-wide breast cancer screening programme started in 1990, providing a biennial screen examination to women aged 50 to 69 years. The programme is monitored by the National Evaluation Team, which annually collects tabulated regional evaluation data to determine performance indicators. This study presents (trends in) the outcomes of initial and subsequent screening rounds, 1990–1995, and compares them to the predictions of the cost-effectiveness-analysis. Up to 1996, 88% of the target population was covered by the programme and more than 2.4 × 10⁶ women were invited. The overall attendance rate was 77.5% with little differences between screening rounds and age groups; the highest rate was found in non-urbanised areas (82.4%). Of 1,000 initially (and 2 years thereafter) screened women, 13.4 (6.6) were referred for further investigation, 9.7 (4.4) were biopsied and 6.4 (3.4) had breast cancer. The positive predictive values of screen test and biopsy were 47% (51%) and 66% (78%), respectively. DCIS was diagnosed in 0.9 (0.5) and invasive cancers ≤10 mm in 1.5 (1.0) per 1,000 screens. Lymph node metastases were found in 28% (24%) of the invasive cancers. Except the increasing attendance, which was much higher than expected, the results were fairly constant over the years. Contrary to initial screens, the results of subsequent screens did not fulfil expectations with regard to breast cancer detection and tumour size distribution. We conclude that the nation-wide screening programme is being implemented successfully. Given the results, the programme should contribute to a substantial breast cancer mortality reduction in the future. The discrepancy between observed and expected results in subsequent screens has to be watched carefully. Int. J. Cancer 75:694–698, 1998.© 1998 Wiley-Liss, Inc.