Elsevier

Health Policy

Volume 104, Issue 3, March 2012, Pages 272-278
Health Policy

Implementation of a service for physicians’ consultation and information in euthanasia requests in Belgium

https://doi.org/10.1016/j.healthpol.2011.12.001Get rights and content

Abstract

Aim

To study the implementation of LEIF, the consultation service which provides access to specially trained physicians to act as the legally required second physician in requests for euthanasia in Flanders and Brussels, Belgium, the use of which has been to shown to be beneficial to the careful practice of euthanasia.

Method

A representative sample of 3006 Belgian physicians from the area where LEIF is active received a questionnaire investigating their attitude and practice regarding euthanasia, asking about their knowledge of LEIF, their attitude towards the service, their use of the service and their intentions regarding its future use.

Findings

Seventy-eight per cent of physicians knew about the existence of the organization, 90% felt supported by the idea of being able to consult a LEIF physician and 90% intended to use LEIF in the future. Only 35% of those who had received a euthanasia request since LEIF became active had made use of LEIF. Awareness, use and intended use of LEIF were lower among specific groups of physicians (e.g. specialists). Positive attitudes towards consultation and training were positively associated with future use of LEIF.

Conclusion

Implementation can be considered successful but LEIF should continue promoting its services as widely as possible, with specific attention paid to specialists.

Introduction

In Belgium, consultation with an independent physician is one of the due care requirements for the attending physician considering a request for euthanasia, i.e. the intentional ending of life by the physician at the patient's explicit request [1]. This second physician must be independent from both the attending physician and the patient, must have read the patient's file, must examine the patient and must be satisfied that they are experiencing unbearable physical or psychological suffering due to a serious incurable disease. Similar requirements apply in the Netherlands and Luxembourg, the only other countries where euthanasia is legal [2], [3]. In previous studies, it was found that almost half of the euthanasia requests to physicians likely to be involved in the care of dying patients are performed in Belgium and that euthanasia occurs in 1.9% of all deaths in Flanders [4], [6].

In the year following the enactment of the Belgian euthanasia law in September 2002, a special non-governmental service called the Life End Information Forum (LEIF) was created in Flanders by individuals (physicians, psychologist) with experience in palliative care together with the association Right to Die With Dignity. The main aim of this initiative was to inform physicians about end-of-life care and specifically euthanasia, since many did not have much knowledge or experience of this matter [5], [15] and to provide trained people able to act as mandatory second physicians in euthanasia requests, since such physicians would probably be hard to find given that cases of euthanasia are rare and require specific procedure [6]. The organization of LEIF was partly based on an existing Dutch service called Support and Consultation for Euthanasia in the Netherlands (SCEN), which had been operating since 1997 [7], [8]. LEIF provides training for physicians in the skills and knowledge necessary to act as independent consultants in euthanasia requests. Attending physicians who receive a euthanasia request and who want to consult with an independent physician can call a central telephone number and a LEIF physician is then assigned to them, or they can contact a LEIF physician directly. Previous research has already demonstrated that consulting a LEIF physician contributes to the careful practice of euthanasia. For instance, involving a LEIF physician was a better guarantee of the independence of the second physician from the attending physician and the patient than was involving a non-LEIF physician [9]. Beside this, LEIF physicians can also act as informal consultants for colleagues who need advice on end-of-life decisions other than euthanasia [10]. Since 2010, there is also a LEIF service in Wallonia but this service is still small-scale and was non-existent at the time of the study.

Since its foundation, the Life End Information Forum has been promoting its services through various channels including a website and the weekly periodical De Huisarts sent to all GPs. Moreover, their information brochure has been distributed widely to pharmacists, public libraries and communities. Until now, however, it has not been known to what extent the service has been successfully implemented in the region where it is active, namely Flanders and Brussels. In this study, we assess the four steps which, based on the innovation theory of Rogers, are considered to be necessary for the implementation of such a service: awareness, attitude, past use and future use [11]. These same aspects were also used in the implementation study of SCEN in the Netherlands [14]. Prevalence of these aspects should be as high as possible for implementation to be successful. Our research questions are: how many physicians in Flanders and Brussels know about the existence of LEIF (awareness)? How supported do they feel about being able to call a LEIF physician for consultation in cases of euthanasia requests (attitude)? How many of them have already made use of LEIF in the past as part of a euthanasia request (use)? How many would use LEIF in the future in case of a euthanasia request (future use)? Are physician characteristics (and if so, which characteristics) associated with awareness of LEIF, with feeling supported by the idea that there is a service such as LEIF for consultation, with having used LEIF in the past or with having the intention of using LEIF in the future?

Section snippets

Study design

In March 2009, a mail questionnaire was sent to a sample of 3006 registered medical practitioners who worked in Belgium, had graduated in their specialty at least 12 months beforehand and were likely to be involved in the care of the dying. Specialties for which little or no experience in care for the dying could be expected were excluded. The sample comprised general practitioners, anesthesiologists, gynecologists, internists, neurologists, pulmonologists, gastroenterologists, psychiatrists and

Response

Of the 3006 physicians sent a questionnaire, 222 were unreachable, deceased or no longer in practice. From the non-response survey another 57 were identified as no longer practicing or not having received the questionnaire. There were 2726 eligible respondents, from whom 914 questionnaires were returned, bringing the overall response rate to 34%. Significant differences between the responders to the survey and the responders to the non-response survey were found for attitude towards euthanasia,

Discussion

This study assessed the implementation of the Life End Information Forum (LEIF) after five years of existence in terms of awareness, use, future use and the attitudes of Dutch-speaking Flemish and Brussels physicians likely to be involved in end-of-life care [11]. Three aspects of implementation according to the innovation theory of Rogers were fulfilled: over three quarters of responding physicians knew of the existence of LEIF, almost 90% would consult with a LEIF physician in the future in

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