Article Text

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation
  1. A Stef Groenewoud1,
  2. Femke Atsma1,
  3. Mina Arvin1,
  4. Gert P Westert1 and
  5. Theo A Boer2
  1. 1Radboud Institute for Health Sciences/Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
  2. 2Research Program Mediating Good Life, Protestant Theological University - Groningen, Groningen, The Netherlands
  1. Correspondence to Dr A Stef Groenewoud, IQ healthcare, Radboudumc, Nijmegen, The Netherlands; stef.groenewoud{at}radboudumc.nl

Abstract

Background The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.

Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.

Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.

Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.

Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.

  • end of life care
  • quality of life

Data availability statement

Data are available upon reasonable request with the first author of the article. The results will be disseminated to both patient organisations (NVVE, NPV, Dutch Patient Federation), and physicians organisations (NHG, LHV, KNMG).

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Data availability statement

Data are available upon reasonable request with the first author of the article. The results will be disseminated to both patient organisations (NVVE, NPV, Dutch Patient Federation), and physicians organisations (NHG, LHV, KNMG).

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Footnotes

  • Twitter @stefgroenewoud

  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

  • Contributors All authors meet the requirements for authorship, have seen and approved the final version of this manuscript, and are aware of and agree to this submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.