Active Euthanasia Rare for Dutch Children

NEW YORK (Reuters Health) - The Netherlands allows euthanasia under certain circumstances, but it is rarely applied in the case of terminally ill children, new research indicates.

More than a third of child deaths in Holland are preceded by an end-of-life decision, according to the study. While this decision may involve withholding potentially life-prolonging treatment, it is not often that it involves so-called active euthanasia, in which drugs are given for the express purpose of hastening death.

Previous studies have looked at end-of-life decision-making in the general population and in newborns, leaving the topic largely unexplored in children, lead author Dr. Astrid M. Vrakking, from Erasmus Medical Center in Rotterdam, and colleagues note in the Archives of Pediatrics and Adolescent Medicine.

To better understand end-of-life decision-making for children, the researchers conducted two studies. In the first study, they sent a written questionnaire to all 129 physicians in the Netherlands who reported a child death between August and December 2001. In the second, face-to-face interviews were held with 63 physicians in specialties that covered the majority of deaths in children, such as pediatric oncology and pediatric critical care.

Thirty-six percent of deaths involving patients between 1 and 17 years of age were preceded by an end-of-life decision. This included 12 percent in which potentially life-prolonging treatment was declined, 21 percent in which pain relievers or other symptom control drugs were given that may have shortened life, and 2.7 percent in which drugs were used with the explicit goal of hastening death.

In more than two thirds of cases in which a drug was administered explicitly to hasten death, the decision was made by the family. In the remaining cases, the child made the decision.

In the interview study, 76 cases involving end-of-life decision-making were evaluated. The parents were always included in the discussions as were all nine children deemed competent and three children considered partly competent. Other physicians were nearly always brought into the discussion and it was also common for nurses to be present.

"The take-home message is that end-of-life decision-making is part of the medical practice of severely ill children too, just like in adults," Vrakking told Reuters Health. "The decision-making process seems to be very careful because decisions are discussed with all people involved."

In an associated commentary, Dr. Jeffrey P. Burns and Christine Mitchell, from Harvard Medical School in Boston, note that despite what often appears in the media, "there is a broad consensus about many fundamental aspects of end-of-life care for children."

"That consensus forms around several core principles almost universally held: parents and families should be encouraged to be present and to comfort the dying child; children should not die experiencing preventable suffering, if at all possible; and not all children must stay connected to machines intended to support vital signs as they die," they add.

SOURCE: Archives of Pediatrics and Adolescent Medicine, September 2005.