P.J. van der Maas

Euthanasia and other medical decisions concerning the end of life

This article presents the first results of the Dutch nationwide study on euthanasia and other medical decisions concerning the end of life (MDEL). The study was done at the request of the Dutch government in preparation for a discussion about legislation on euthanasia. Three studies were undertaken: detailed interviews with 405 physicians, the mailing of questionnaires to the physicians of a sample of 7000 deceased persons, and the collecting of information about 2250 deaths by a prospective survey among the respondents to the interviews. The alleviation of pain and symptoms with such high dosages of opioids that the patients life might be shortened was the most important MDEL in 17.5% of all deaths. In another 17.5% a non-treatment decision was the most important MDEL. Euthanasia by administering lethal drugs at the patients request seems to have been done in 1.8% of all deaths. Since MDEL were taken in 38% of all deaths (and in 54% of all non-acute deaths) we conclude that these decisions are common medical practice and should get more attention in research, teaching, and public debate.

Estimating clinical morbidity due to ischemic heart disease and congestive heart failure : the future rise of heart failure

OBJECTIVES Many developed countries have seen declining mortality rates for heart disease, together with an alleged decline in incidence and a seemingly paradoxical increase in health care demands. This paper presents a model for forecasting the plausible evolution of heart disease morbidity. METHODS The simulation model combines data from different sources. It generates acute coronary event and mortality rates from published data on incidences, recurrences, and lethalities of different heart disease conditions and interventions. Forecasts are based on plausible scenarios for declining incidence and increasing survival. RESULTS Mortality is postponed more than incidence. Prevalence rates of morbidity will decrease among the young and middle-aged but increase among the elderly. As the milder disease states act as risk factors for the more severe states, effects will culminate in the most severe disease states with a disproportionate increase in older people. CONCLUSIONS Increasing health care needs in the face of declining mortality rates are no contradiction, but reflect a tradeoff of mortality for morbidity. The aging of the population will accentuate this morbidity increase.

The MISCAN simulation program for the evaluation of screening for disease

The computer program MISCAN is developed for use in evaluation of mass screening for disease. The program uses Monte Carlo simulation. It produces output on the results of screening projects and on the effects of screening on morbidity and mortality on the individual and population level. The calculations are based on models of the natural history of the disease and of the impact of screening on the natural history. The approach is such that considerable flexibility exists in specifying the structure of the model and its parameters. The program consists of two parts. The DISEASE part can be used for simulating the epidemiology of the disease when no screening is taking place; it requires input on the population and on the disease process. The SCREENING part is to be used in combination with the DISEASE part. It is intended for simulation of the results and effects of a screening project. It requires input on the properties of the screening tests, the consequences of early detection by screening, and the policy (ages and intervals between screens) of the project. MISCAN can be used for finding model assumptions regarding the disease process and the impact of screening that give a good explanation of the observed results of a screening project. Such an analysis proceeds in two steps. First, MISCAN is used to calculate simulated results of the project, based on specific assumptions. Next, these results are tested against the observed results, in order to assess the acceptability of the assumptions. MISCAN can also be used for optimization of the screening policy by simulating the cost and benefit components of a large number of different screening policies.

Health of migrants and migrant health policy, the Netherlands as an example

In The Netherlands, as in many other countries, many studies have addressed the health situation of migrant groups. After a discussion on methodological pitfalls in migrant studies, the article reviews the most important results. The data show that there are differences in the health status and mortality patterns between migrant groups and the indigenous population. Most, but not all, of the differences are in disfavour of ethnic groups. Possible determinants of these differences are evident in socio/cultural, genetic and socio-economic factors. A model is presented that demonstrates the relation between these factors and health and disease. Implications for research and for health policy are discussed.

Interval cancers in the Dutch breast cancer screening programme.

The nationwide breast cancer screening programme in The Netherlands for women aged 50–69 started in 1989. In our study we assessed the occurrence and stage distribution of interval cancers in women screened during 1990–1993. Records of 0.84 million screened women were linked to the regional cancer registries yielding a follow-up of at least 2.5 years. Age-adjusted incidence rates and relative (proportionate) incidences per tumour size including ductal carcinoma in-situ were calculated for screen-detected and interval cancers, and cancers in not (yet) screened women, comparing them with published data from the UK regions North West and East Anglia. In total 1527 interval cancers were identified: 0.95 and 0.99 per 1000 woman-years of follow-up in the 2-year interval after initial and subsequent screens respectively. In the first year after initial screening interval cancers amounted to 27% (26% after subsequent screens) of underlying incidence, and in the second year to 52% (55%). Generally, interval cancers had a more favourable tumour size distribution than breast cancer in not (yet) screened women. The Dutch programme detected relatively less (favourable) invasive cancers in initial screens than the UK programme, whereas the number of interval cancers confirms UK findings. Measures should be considered to improve the detection of small invasive cancers and to reduce false-negative rates, even if this will lead to increasing referral rates.

Physician-Assisted Death in Psychiatric Practice in the Netherlands

BACKGROUND In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patients request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare.

In search of the best upper age limit for breast cancer screening

The aim of this study was to determine the best upper age limit for a breast cancer screening programme. We used a model-based study using optimistic and pessimistic assumptions, concerning improvement of prognosis due to screen-detection and duration of the period of mammographic detectability, resulting in upper and lower limits for favourable and unfavourable effects. Under pessimistic assumptions, the balance between positive and negative effects of screening remains favourable up to an age of around 80 years. Under optimistic assumptions, this balance never becomes clearly negative with increase of the upper age limit of a screening programme. When including the costs in the analysis, the balance between effects and costs of increasing the upper age limit from 69 to 75 years is likely to be at least as favourable as intensifying a screening programme within the age group 50-69 years. A further increase leads to a markedly less favourable balance. Competing causes of death do not lead to missing net benefit for women up to at least age 80 years, but the disproportional rise of negative effects of screening with age in older women leads to a lower cost-effectiveness ratio than intensifying screening at ages 50-69 years.

Reduction in breast cancer mortality due to the introduction of mass screening in the Netherlands: comparison with the United Kingdom

Objective To assess the impact of the national breast cancer screening programme on breast cancer mortality in the first years after its introduction. Setting The Netherlands and United Kingdom. Methods —MISCAN models, incorporating demographic, epidemiological, and screening characteristics of the region under study, were used to assess the mortality in the presence and absence of screening. Results Breast cancer mortality decreased in women aged 55–74 as the Dutch nationwide screening programme built up, and was 5% lower in 1996 than before the start of the programme. The mortality reduction due to screening in the age group 55–74 is expected to increase gradually to 18% in 1999, 10 years after the introduction of screening, and to 29% in the long term. In the United Kingdom screening was expected to achieve a mortality reduction of 5% and 18% in the age group 55–69 five and 10 years respectively after screening was started. A maximum mortality reduction of 24% in this age group is predicted. Conclusions —The effects of screening will be small in the first years after the start of the programme. Accordingly, it was expected that the reduction in breast cancer mortality due to the Dutch nationwide breast screening programme, which started around 1989, would be statistically significant from 1997 onwards, the point at which the target population of women was completely covered; 70% of the reported 12% mortality reduction in England and Wales in 1994 is expected to be attributed to screening.

The Role of Parents in End-of-Life Decisions in Neonatology: Physicians' Views and Practices

Objective. End-of-life decisions for newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Our study was aimed at providing an empirical background for the ethical discussion on the parents versus the physicians role in decision-making. Methods. We conducted face-to-face interviews with a stratified sample of pediatricians. The response rate was 99%. The most recent decisions in newborn infants to hasten death or not prolong life and the most recent cases in which such decisions were not made because either the parents or the physician objected were comprehensively discussed. Results. Decisions to hasten death or not prolong life were usually made after discussing it with parents and did not occur while parents were known to disagree. Situations in which an end-of-life decision was not made because parents did not consent predominantly involved infants with complications of prematurity (24%) or perinatal asphyxia (40%), whereas situations in which parents requested an end-of-life decision that was not acceded to by the pediatrician involved Down syndrome as the main diagnosis in 43% and as a concurrent diagnosis in 21%. Pediatricians afterwards often expressed feelings of discontent about situations in which there had been disagreement with parents. Conclusions. The opinion of parents about which medical decision is in the best interest of their child is for pediatricians only decisive in case it invokes the continuation of treatment. The principle of preserving life is abandoned only when the physician feels sufficiently sure that the parents agree that such a course of action is in the best interest of the child.

Regression analysis of recent changes in cardiovascular morbidity and mortality in The Netherlands.

Abstract Objectives: To test whether recent declines in mortality from coronary heart disease were associated with increased mortality from other cardiovascular diseases. Design: Poisson regression analysis of national data on causes of death and hospital discharges. Setting and subjects: Population of the Netherlands, 1969-93. Main outcome measures: Annual changes in mortality from coronary heart disease, stroke, and other cardiovascular diseases and annual changes in hospital discharge rates for acute coronary events, stroke, and congestive heart failures. Results: Patterns of cardiovascular mortality changed abruptly in 1987-93. Annual decline in mortality from coronary heart disease increased sharply for women and men: from −1.9% (95% confidence interval −2.2% to −1.6%) and −1.7% (−1.9% to −1.4%) respectively in 1979-86 to −3.1% (−3.5% to −2.6%) and −4.2% (−4.6% to −3.9%) in 1987-93. The longstanding decline in mortality from stroke levelled off: from annual change of −3.3% (−3.7% to −2.8%) and −3.2% (−3.7% to −2.8%) in 1979-86 to −0.1% (−0.7% to 0.4%) and −1.1% (−1.7% to −0.5%) in 1987-93. Mortality from other cardiovascular diseases, however, started to increase: from −2.0% (−2.4% to −1.6%) and −0.2% (−0.5% to 0.2%) in 1979-86 to 1.5% (1.0% to 2.0%) and 1.9% (1.5% to 2.3%) in 1987-93. Hospital discharge rates for acute coronary heart disease, congestive heart failure, and stroke increased during 1980-6. During 1987-93 discharge rates for stroke and coronary heart disease stabilised but rates for congestive heart failure increased. Conclusion: Improved management of coronary heart disease seems to have reduced mortality, but some of the gains are lost to deaths from stroke and other cardiovascular diseases. The increasing numbers of patients with coronary heart disease who survive will increase demands on health services for long term care.