OBJECTIVES: To investigate why physicians label end-of-life acts as either 'euthanasia/ending of life' or 'alleviation of symptoms/palliative or terminal sedation', and to study the association of such labelling with intended reporting of these acts. METHODS: Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response: 55%). They were asked to label six hypothetical end-of-life cases: three 'standard' cases and three cases randomly selected (out of 47), that varied according to (1) type of medication,(2) physician's intention,(3) type of patient request,(4) patient's life expectancy and (5) time until death. We identified the extent to which characteristics of cases are associated with physician's labelling, with multilevel multivariable logistic regression. RESULTS: The characteristics that contributed most to labelling cases as 'euthanasia/ending of life' were the administration of muscle relaxants (99% of these cases were labelled as 'euthanasia/ending of life') or disproportional morphine (63% of these cases were labelled accordingly). Other important factors were an intention to hasten death (54%) and a life expectancy of several months (46%). Physicians were much more willing to report cases labelled as 'euthanasia'(87%) or 'ending of life'(56%) than other cases. CONCLUSIONS: Similar cases are not uniformly labelled. However, a physicians' label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not.

Introduction: The Dutch Euthanasia Act (2002) states that euthanasia is not punishable if the attending physician acts in accordance with the statutory due care criteria. These criteria hold that: there should be a voluntary and well-considered request, the patient's suffering should be unbearable and hopeless, the patient should be informed about their situation, there are no reasonable alternatives, an independent physician should be consulted, and the method should be medically and technically appropriate. This study investigates whether physicians experience problems with these criteria in medical practice. METHODS: In 2006, questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response rate: 56%). Physicians were asked about problems in their decision-making related to requests for euthanasia or assisted suicide after enforcement of the 2002 Euthanasia Act. RESULTS: Of all physicians who had received a request for euthanasia or assisted suicide (75%), 25% had experienced problems in the decision-making with regard to at least one of the criteria of due care. Physicians who had experienced problems mostly indicated to have had problems related to evaluating whether or not the patient's suffering was unbearable and hopeless (79%) and whether or not the patient's request was voluntary or well considered (58%). DISCUSSION: Physicians in The Netherlands most frequently reported problems related to aspects in which they have to evaluate the patient's subjective perspective(s). However, it can be questioned whether placing emphasis on these subjective aspects is an adequate fulfilment of the duties imposed on physicians, as laid down in the Dutch Euthanasia Act.

This fall, an extensive study will start to evaluate the Dutch Euthanasia Act. This law was enacted in 2002. According to this law, physicians must report cases of euthanasia and physician-assisted suicide. The cases are then judged by regional euthanasia review committees consisting of a lawyer, a physician and an ethicist. Only if they conclude that the case does not meet the requirements for prudent practice, it will be sent to the public prosecutor. The study will be focused on the practice of medical end-of-life decision-making, the functioning and effects of the Euthanasia Act, and opinions of physicians about the scope of the law and the demarcation between different end-of-life decisions. The study will comprise 4 sub-studies: a judicial evaluation, a death certificate study, a survey among physicians and a panel study among physicians, nurses, members of euthanasia review committees, lawyers and ethicists. This study is the fourth in a row of nationwide studies into end-of-life practices that have been performed since 1990. The previous studies contributed to the public debate about medical care at the end of life and to the development of policy in this field. It is expected that this study, by providing up-to-date information on and insight into end-of-life care in the Netherlands, will do the same.

OBJECTIVE: To provide insight into the relationship between the drugs used for euthanasia and its notification. DESIGN: Retrospective and descriptive. METHODS: By comparing the drugs used for euthanasia according to different components of studies carried out in 1990, 1995 and 2000, insight was obtained into the drugs used in all cases of euthanasia satisfying the definition thereof (death-certificate studies), those cases of euthanasia that, in addition, were defined as such by the physician (physician interviews), and the cases of euthanasia that, in addition, had been reported (reported case studies). RESULTS: In 2001, standard drugs for euthanasia were used in 76% of cases and opioids in 23%. Euthanasia with standard drugs was reported in 73% of cases in 1995, and in 71% of cases in 2000, while euthanasia with opioids was reported in 2% and 1% of cases, respectively. The total percentage of euthanasia reported was higher in 2001 than in 1995 (54% versus 44%), since in 2001 euthanasia was apparently performed more often with standard drugs and less with opioids. CONCLUSION: An increasing proportion of cases of euthanasia is being carried out with the drugs recommended for this purpose. Euthanasia with opioids was rarely reported. Possibly, physicians did not always consider these cases to be euthanasia.

OBJECTIVE: To establish whether the practice of end-of-life decision-making for neonates and infants under the age of 1 in the Netherlands in 2000 was different from that in 1995. DESIGN: Retrospective descriptive and comparative study. METHODS: In both years, all deaths of children under the age of one year that took place in August-November (1995: n = 338; 2001: n = 347) were studied. The response rate was 96% in 1995 and 84% in 2001. The questionnaires which were sent to the physicians who reported the deaths, included structured questions about whether or not death had been preceded by end-of-life decisions, i.e. decisions to withhold or withdraw potentially life-prolonging treatment or to administer (potentially) life-shortening drugs, and questions about the decision-making process. RESULTS: The proportion of end-of-life decisions increased slightly from 62% to 68% of all deaths in the first year of life, but the difference was not statistically significant. The large majority of these decisions involved withholding or withdrawing life-sustaining treatment. The frequency of decisions to actively terminate the life of an infant who was not dependent on life-sustaining treatment remained stable at 1%. The proportion of decisions that had been discussed with the parents increased slightly, from 91% in 1995 to 97% in 2001; similar percentages of the decisions had been discussed with other physicians. The percentage of decisions that had been discussed with the nursing staff decreased from 40 in 1995 to 28 in 2001. CONCLUSION: The findings suggest that the practice of end-of-life decision-making in neonatology was rather stable between 1995 and 2001. The frequency of the active termination of life had not increased, despite the new euthanasia regulation in the Netherlands.

OBJECTIVE: To investigate the emotional feelings reported by physicians in The Netherlands after having performed euthanasia or other medical end-of-life decisions. DESIGN: Nationwide interview study in The Netherlands, November 1995 through February 1996. PARTICIPANTS AND SETTING: A random sample of 405 physicians (general practitioners, nursing home physicians, and clinical specialists). MAIN OUTCOME MEASURES: Subsequent feelings of physicians about their most recent cases (if any) of euthanasia, assisted suicide, life-ending without an explicit request from the patient, and alleviation of pain and other symptoms with high doses of opioids. RESULTS: The response rate was 89%. In 52% of all cases of hastening death, physicians had feelings of comfort afterwards, which included feelings of satisfaction in 44% and of relief in 13%. Feelings of discomfort were reported in 42%, most frequently referred to as emotional (28%) or burdensome (25%). Feelings of discomfort were highest for euthanasia (75%; P<0.000). 95% of physicians were willing to perform euthanasia or assisted suicide again in similar situations. Afterwards, 5% had doubts, but none had regrets, about performing euthanasia. CONCLUSIONS: Hastening the death of a patient evokes different feelings among physicians. Although performing euthanasia is often experienced as burdensome and emotional, granting the ultimate wish of a competent patient may also give physicians a feeling of having contributed to the quality of the dying process.

In the second half of 2001, an extensive study will start which will evaluate the review procedure for euthanasia in the Netherlands. Since the end of 1998, euthanasia has to be reviewed by regional review committees, which include a physician and an ethicist, in addition to a legal expert. The aim of this study is to examine whether the reporting procedure meets the aim and whether there are any points which require improvement. This study follows on from those carried out in 1990/1991 and 1995/1996, which investigated euthanasia and other medical end-of-life decisions (assisted suicide, termination of life without the patient's explicit request, treatment of pain and symptoms with a possible life-shortening effect, and forgoing potentially life-prolonging treatment). The study consists of an analysis of cases of death (in which the numbers and nature of various medical end-of-life decisions will be established), physician interviews (to gain insight into the context in which medical end-of-life decisions are made), a study of reported cases (to give an overview of doctors' experiences with the review committees), and a study carried out amongst the general public (around 1,500 Dutch adults will be given a written questionnaire about their opinions concerning medical end-of-life decisions and the reporting procedure). In addition to this Dutch study, a European study subsidized by the European Commission is being carried out which will examine attitudes and experiences regarding medical end-of-life decisions in six European countries (Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland). This will, for the first time, enable a true comparison to be made between the Netherlands and other countries in terms of euthanasia and other medical end-of-life decisions.

BACKGROUND AND METHODS: The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in The Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death. RESULTS: In 114 cases, the physician's intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5). CONCLUSIONS: There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In The Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide.

BACKGROUND: In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. METHODS: We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. RESULTS: Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. CONCLUSIONS: Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.

In this article I intend to describe an issue of the Dutch euthanasia practice that is not common knowledge. After some general introductory descriptions, by way of formulating a frame of reference, I shall describe the effects of this practice on patients, physicians and families, followed by a more philosophical reflection on the significance of these effects for the assessment of the authenticity of a request and the nature of unbearable suffering, two key concepts in the procedure towards euthanasia or physician-assisted suicide. This article does not focus on the arguments for or against euthanasia and the ethical justification of physician-assisted dying. These arguments have been described extensively in Kimsma and Van Leeuwen (Asking to die. Inside the Dutch debate about euthanasia, Kluwer Academic Publishers, Dordrecht, 1998).

Objective To investigate attitudes towards physician-assisted death in minors among all physicians involved in the treatment of children dying in Flanders, Belgium over an 18-month period, and how these are related to actual medical end-of-life practices. Design Anonymous population-based postmortem physician survey. Setting Flanders, Belgium. Participants Physicians signing death certificates of all patients aged 1-17 years who died between June 2007 and November 2008. Main outcome measures Attitudes towards physician-assisted death in minors and actual end-of-life practices in the deaths concerned. Results 124 physicians for 70.5% of eligible cases (N=149) responded. 69% favour an extension of the Belgian law on euthanasia to include minors, 26.6% think this should be done by establishing clear age limits and 61% think parental consent is required before taking life-shortening decisions. Cluster analysis yielded a cluster (67.7% of physicians) accepting of, and a cluster (32.2% of physicians) reluctant towards physician-assisted death in minors. Controlling for physician specialty and patient characteristics, acceptant physicians were more likely to engage in practices with the intention of shortening a patient's life than were reluctant physicians. Conclusion A majority of surveyed Flemish physicians appear to accept physician-assisted dying in children under certain circumstances and favour an amendment to the euthanasia law to include minors. The approach favoured is one of assessing decision-making capacity rather than setting arbitrary age limits. These stances, and their connection with actual end-of-life practices, may encourage policy-makers to develop guidelines for medical end-of-life practices in minors that address specific challenges arising in this patient group.

OBJECTIVES: To estimate the prevalence of end-of-life decisions and to describe their characteristics and the preceding decision-making process in minors in Belgium. DESIGN: Population-based postmortem anonymous physician survey. SETTING: Flanders, Belgium. PARTICIPANTS: All physicians signing the death certificates of all patients (N = 250) aged 1 to 17 years who died between June 2007 and November 2008 in Flanders, Belgium. OUTCOME MEASURES: Prevalence and characteristics of end-of-life decisions and the preceding decision-making process. RESULTS: For 165 of the 250 deaths, a physician questionnaire was returned (70.5%). In 36.4%, death was preceded by an end-of-life decision. Drugs were administered to alleviate pain and symptoms with a possible life-shortening effect in 18.2% of all deaths, nontreatment decisions were made in 10.3%, and lethal drugs without the patient's explicit request were used in 7.9%. No cases of euthanasia, ie, the use of drugs with the explicit intention to hasten death at the patient's explicit request, were reported. Poor clinical prospects (84.6%) and low quality of life expectations (61.5%) were important reasons for the physicians to engage in end-of-life decisions. Parents were involved in decision making in 85.2% of these decisions, patients in 15.4%. CONCLUSIONS: Medical end-of-life decisions are frequent in minors in Flanders, Belgium. Whereas parents were involved in most end-of-life decisions, the patients themselves were involved much less frequently, even when the ending of their lives was intended. At the time of decision making, patients were often comatose or the physicians deemed them incompetent or too young to be involved.

BACKGROUND:: When suffering becomes unbearable for patients they might request for euthanasia. OBJECTIVE:: To study which patients request for euthanasia and which requests actually resulted in euthanasia in relation with diagnosis, care setting at the end of life, and patient demographics. DESIGN:: A cross-sectional study covering all Dutch health care settings. PARTICIPANTS:: In 2005, of death certificates of deceased persons, a stratified sample was derived from the Netherlands central death registry. The attending physician received a written questionnaire (n = 6860; response 78%). MEASUREMENTS:: If deaths were reported to have been nonsudden, the attending physician filled in a 4-page questionnaire on end-of-life decision-making. Data regarding the deceased person's age, sex, marital status, and cause of death were derived from the death certificate. RESULTS:: Of patients whose death was nonsudden, 7% explicitly requested for euthanasia. In about two thirds, the request did not lead to euthanasia or physician-assisted suicide being performed, in 39% because the patient died before the request could be granted and in 38% because the physician thought the criteria for due care were not met. Factors positively associated with a patient requesting for euthanasia are (young) age, diagnosis (cancer, nervous system), place of death (home), and involvement of palliative teams and psychiatrist in care. Diagnosis and place of death are also associated with requests resulting in euthanasia. CONCLUSIONS:: Only a minority of patients request euthanasia at the end of life and of these requests a majority is not granted. Careful decision-making is necessary in all requests for euthanasia.

BACKGROUND: Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal. METHODS: We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007. RESULTS: The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient's explicit re quest, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids. INTERPRETATION: Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.

BACKGROUND: Belgium's law on euthanasia allows only physicians to perform the act. We investigated the involvement of nurses in the decision-making and in the preparation and administration of life-ending drugs with a patient's explicit request (euthanasia) or without an explicit request. We also examined factors associated with these deaths. METHODS: In 2007, we surveyed 1678 nurses who, in an earlier survey, had reported caring for one or more patients who received a potential life-ending decision within the year before the survey. Eligible nurses were surveyed about their most recent case. RESULTS: The response rate was 76%. Overall, 128 nurses reported having cared for a patient who received euthanasia and 120 for a patient who received life-ending drugs without his or her explicit request. Respectively, 64%(75/117) and 69%(81/118) of these nurses were involved in the physician's decision-making process. More often this entailed an ex change of information on the patient's condition or the patient's or relatives' wishes (45%[34/117] and 51%[41/118]) than sharing in the decision-making (24%[18/117] and 31%[25/118]). The life-ending drugs were administered by the nurse in 12% of the cases of euthanasia, as compared with 45% of the cases of assisted death without an explicit re quest. In both types of assisted death, the nurses acted on the physician's orders but mostly in the physician's absence. Factors significantly associated with a nurse administering the life- ending drugs included being a male nurse working in a hospital (odds ratio [OR] 40.07, 95% confidence interval [CI] 7.37-217.79) and the patient being over 80 years old (OR 5.57, 95% CI 1.98-15.70). INTERPRETATION: By administering the life-ending drugs in some of the cases of euthanasia, and in almost half of the cases without an explicit request from the patient, the nurses in our study operated beyond the legal margins of their profession.

Introduction In 2007, a national review committee was instituted in The Netherlands to review cases of active ending of life for newborns. It was expected that 15-20 cases would be reported. To date, however, only one case has been reported to this committee. Reporting is essential to obtain societal control and transparency; the possible explanations for this lack of reporting were therefore explored. Methods Data on end-of-life decision-making were scrutinised from Dutch nation-wide studies (1995, 2001 and 2005), before institution of the committee. Physicians received a questionnaire about their medical decision-making for stratified samples of deceased infants up to 1 year, drawn from the central death registry. Results In 2005, 58% of all deaths were preceded by an end-of-life decision, compared with 68% in 2001 and 62% in 1995. The use of drugs with a possible life-shortening effect tended to be lower. In 2005, all four cases in the study in which an infants' life was actively ended were preceded by a decision to forego life-prolonging treatment. In three cases, the infant's life expectancy was short; one case involved a longer life expectancy. Discussion The expected number of cases is probably an overestimation due to changes in medical practice such as the tendency to attribute less life-shortening effects to opioids. The lack of reports is probably also associated with requirements in the regulation; it may be difficult to fulfil them due either to time constraints or the nature of the suffering that is addressed. If societal control of active ending of life is considered useful, changes in the regulation may be needed.

OBJECTIVES:: To study the reported medical practice of euthanasia in Belgium since implementation of the euthanasia law. RESEARCH DESIGN:: Analysis of the anonymous database of all euthanasia cases reported to the Federal Control and Evaluation Committee Euthanasia. SUBJECTS:: All euthanasia cases reported by physicians for review between implementation of the euthanasia law on September 22nd, 2002 and December 31, 2007 (n = 1917). MEASURES:: Frequency of reported euthanasia cases, characteristics of patients and the decision for euthanasia, drugs used in euthanasia cases, and trends in reported cases over time. RESULTS:: The number of reported euthanasia cases increased every year from 0.23% of all deaths in 2002 to 0.49% in 2007. Compared with all deaths in the population, patients who died by euthanasia were more often younger (82.1% of patients who received euthanasia compared with 49.8% of all deaths were younger than 80, P < 0.001), men (52.7% vs. 49.5%, P = 0.005), cancer patients (82.5% vs. 23.5%, P < 0.001), and more often died at home (42.2% vs. 22.4%, P < 0.001). Euthanasia was most often performed with a barbiturate, sometimes in combination with neuromuscular relaxants (92.4%) and seldom with morphine (0.9%). In almost all patients, unbearable physical (95.6%) and/or psychological suffering (68%) were reported. A small minority of cases (6.6%) concerned nonterminal patients, mainly suffering from neuromuscular diseases. CONCLUSIONS:: The frequency of reported euthanasia cases has increased every year since legalization. Euthanasia is most often chosen as a last resort at the end of life by younger patients, patients with cancer, and seldom by nonterminal patients.

OBJECTIVES: To study trends in reporting rates of euthanasia from 1990 to 2005 in relation to whether recommended or nonrecommended drugs were used, and the most important differences between reported and unreported cases in 2005. RESEARCH DESIGN: Questionnaires were sent to a sample of 6860 physicians who had reported a death in 2005 (response 78%). Previously, 3 similar studies were done at 5-year intervals. The total number of euthanasia and physician-assisted suicide cases was estimated using a "gold standard" definition: death was-according to the physician-the result of the use of drugs at the explicit request of the patient with the explicit goal of hastening death (denominator). The Euthanasia Review Committees provided the number of reported cases (numerator). RESULTS: The reporting rate of euthanasia and physician-assisted suicide increased from 18% in 1990, 41% in 1995, and 54% in 2001 to 80% in 2005. The reporting rate in the subgroup of euthanasia with recommended drugs (barbiturates and muscle relaxants) was 73% in 1995, 71% in 2001, and 99% in 2005. The reporting rate of euthanasia with nonrecommended drugs (eg, opioids) was below 3% in 1995, 2001, and 2005. Unreported euthanasia differed also from reported euthanasia in the fact that physicians less often labeled their act as euthanasia. CONCLUSIONS: Euthanasia with nonrecommended drugs is almost never reported. The total reporting rate increased because of an increase in the use of recommended drugs for euthanasia between 1995 and 2001, and an increase in the reporting rate for euthanasia with recommended drugs between 2001 and 2005.

BACKGROUND: Continuous sedation, contrary to euthanasia, has been increasingly accepted among medical professionals worldwide. In the Netherlands, a national guideline for continuous palliative sedation has been developed to contribute to the quality of palliative sedation practice. The present follow-up study investigated whether the practice of continuous sedation has changed after the introduction of this guideline. METHODS: This study compared the practice of continuous sedation before and after the introduction of the guideline on December 7, 2005. A baseline measurement was performed between February 1, 2003, and May 1, 2005, with an enrollment of 492 physicians (medical specialists, general practitioners, and nursing home physicians). From January 1 to June 30, 2007, after the introduction of a national guideline for palliative sedation, a follow-up study was performed with the respondents of the baseline study. Physicians were asked to report on their last case of deep and continuous sedation in the past 12 months. RESULTS: This study reports the results of the follow-up study and compares them to the results of the baseline study. The response rate was 69.3%(n = 341). Of these physicians, 160 reported a last case of continuous sedation in both the baseline and the follow-up studies. Physicians reported a significant increase in patient involvement in decision making, from 72.3% to 82.2%. Pain remained the most often reported reason to start sedation, whereas exhaustion as a reason for sedation increased. The use of benzodiazepines increased from 69.9% to 90.4%. In the first and second measurements, symptom-directed treatment during sedation was applied in 56% to 58% of the cases. In the second period, there was more often an explicit decision to not give artificial hydration during sedation (78.8% vs 56.3%). Of the physicians, 34.2% were convinced that sedation shortened the life of the patient because of dehydration. CONCLUSIONS: After the introduction of the guideline, physicians reported that changes in palliative sedation practice conform to the recommendations of this guideline. For example, benzodiazepines were used for sedation more frequently than before and patient involvement in the decision-making process improved. Possible effects of dehydration and the large variation in symptom-directed treatment during sedation deserve careful attention.