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Dutch doctors often withhold treatment from dying elderly

But concern for patient’s comfort and dignity, not ageism, behind the increase with age

Louise Prime

Tuesday, 21 April 2015

Although doctors in the Netherlands withhold or withdraw treatment more often from elderly patients than from younger people, this probably results less from ageism than from considerations of comfort and respect and an intention to avoid pointless treatment, researchers have concluded in a study* published today in the Journal of Medical Ethics.

A large team of international researchers led from Amsterdam wanted to find out whether withholding or withdrawal of treatment was more common in particular age groups. So they sent a questionnaire about end-of-life decision-making to all doctors who had certified deaths, and got responses covering 6,600 patients who had died in the Netherlands between August and November 2010. Of these, 27% were aged 17-64 years, 33% were 65-79 years old, and 40% were at least 80; the latter group were significantly more likely than the others to be women, unmarried, have dementia and live in a nursing home.

Overall, treatment was withheld or withdrawn in more than a third (37%) of cases, but this was reported much more often in the oldest group (42% of cases) than in the youngest (25%). The most likely treatment to be withheld was artificial feeding and fluids, followed by antibiotics, and these had occurred more than twice as often in older than in younger patients.

Doctors’ most common stated reasons for their decision to withdraw or withhold treatment were “no chance of improvement” (72%) and the futility of prolonging treatment (62%). They were also about twice as likely to give “loss of dignity” or “patient request” as a reason for withholding or withdrawing treatment in the oldest group compared with the youngest. Although in more than half (56%) of cases doctors said they hadn’t discussed end-of-life decisions with patients, in most (93%) of these cases this was because the patient lacked capacity.

More than a third (35%) of doctors said their decision had not in fact shortened life, and about a quarter (27%) said it had shortened life by up to a week.

The study authors said: “Our results show that forgoing treatment decisions were made for a substantial percentage of patients in the Dutch population, and increased steadily with age. The three types of treatment most frequently withheld or withdrawn were artificial hydration/nutrition, medication and antibiotics, with significant differences among the age groups studied.”

But they went on: “Based on our results, we cannot assume that age-related differences in withholding/withdrawing treatment are the result of ageism. In fact, our findings indicate that care for older people is focused on providing comfort and avoiding burdensome treatment, suggesting better acceptance that these patients are nearing death.

“This is particularly relevant for the discussion on what it means to die well in old age, impacting on older people’s end-of-life experiences and care.”

* Martins Pereira S, et al. Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands. J Med Ethics 2015, doi:10.1136/medethics-2014-102367

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