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End-of-life decision-making across cancer types: results from a nationwide retrospective survey among treating physicians

British Journal of Cancervolume 118pages13691376 (2018) | Download Citation



The treatment of advanced cancer often involves potentially life-shortening end-of-life decisions (ELDs). This study aimed to examine the prevalence and characteristics of ELDs in different cancer types.


A nationwide death certificate study was conducted based on a large random sample of all deaths in Flanders, Belgium, between 1 January and 30 June 2013. All cancer deaths were selected (n = 2392). Attending physicians were sent a questionnaire about ELDs and the preceding decision-making process.


The response rate was 58.3%. Across cancer types, a non-treatment decision occurred in 7.6–14.0%, intensified pain and symptom alleviation in 37.5–41.7%, euthanasia or physician-assisted suicide in 8.7–12.6%, and life shortening without explicit patient request in 1.0–2.4%. ELD prevalence did not differ significantly by cancer type. Reasons for ELDs were most frequently patient’s physical suffering and lack of prospect of improvement. ‘Anticipated further suffering’ and ‘unbearable situation for relatives’ were reasons more often reported in haematological cancer than in other cancer types. Patient, family, and caregiver involvement in decision-making did not differ across cancer types.


Euthanasia or physician-assisted suicide rates were relatively high in all cancer types. Neither the prevalence of ELDs nor characteristics of the decision-making process differed substantially between cancer types. This indicates a uniform approach to end-of-life care, including palliative care, across oncological settings.

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The authors thank the entire team of the Flemish Agency for Care and Health; Jef Deyaert, MSc, Sigrid Dierickx, MSc, and Lenzo Robijn, MSc, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University; Brecht Haex, MSc, and lawyer Wim De Brock, LLM, for their contributions in the data collection. The authors thank the thousands of Flemish physicians participating in the survey. The authors thank the Belgian Medical Disciplinary Board for recommending the study and Jane Ruthven, PhD, for providing assistance with linguistic editing.

Authors contributions:

J.C., K.C., and L.D. contributed to the study concept and design and data acquisition. M.N.V., D.H., and K.C. contributed to the statistical analysis and first draft of the manuscript. All authors contributed to the interpretation of the data and further drafts of the manuscript. All authors read and approved the final version of the manuscript. K.C. and L.D. contributed equally as last author.

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Author notes

  1. These authors contributed equally: Kenneth Chambaere, Luc Deliens.


  1. End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium

    • Mariëtte N. Verkissen
    • , Dirk Houttekier
    • , Joachim Cohen
    • , Kenneth Chambaere
    •  & Luc Deliens
  2. Department of Clinical Haematology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium

    • Rik Schots


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This study was part of the ‘Flanders Study to Improve End-of-Life Care and Evaluation Tools (FLIECE) project,’ a collaboration between the Vrije Universiteit Brussel, Ghent University, the Katholieke Universiteit Leuven, Belgium, and VU University Medical Centre Amsterdam, the Netherlands. The study was supported by a grant from the Flemish Government Agency for Innovation by Science and Technology (Agentschap voor Innovatie door Wetenschap en Technologie; SBO IWT no. 100036). The first author, M.N.V., has received funding from the seventh Framework Programme for Research and Technological Development (FP7) (proposal no. 602541-2). The funding sources had no role in the design and collection, analysis, and interpretation of data and in writing the manuscript.

Competing interests

R.S. has reported that he has received honoraria for attendance at advisory board meetings from Celgene, Takeda, AbbVie, and Amgen. He has also received travel funding from Bristol-Myers Squibb (BMS) to attend the American Society of Hematology 2016 Annual Meeting (December 2016). All remaining authors declare no competing interests.

Ethics approval and consent to participate

Ethical approval was obtained from the Ethical Review Board of the University Hospital of the Vrije Universiteit Brussel (ref no. 143201316288, 8 February 2013). Patients were deceased, and consent was not required. Physicians’ participation was regarded as implicit consent, which was noted in the accompanying letter introducing the study.

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Correspondence to Mariëtte N. Verkissen.

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