End-of-life care often involves pain or symptom management

© Hollandse Hoogte / Robin Utrecht
Just over half of the 171 thousand deaths in 2021 involved a medical end-of-life decision. Thirty percent of deaths involved relief of pain or disease symptoms in which the physician took into account the possibility that it would shorten the patient’s life. In 18 percent, the decision was made to stop treatment or not institute new treatment. In nearly 6 percent, a drug was prescribed, dispensed or administered for the purpose of hastening death. This is reported by Statistics Netherlands (CBS).

Over 9 out of 10 cases in which a drug was prescribed, dispensed or administered for the purpose of hastening death involved euthanasia, concerning over 9 thousand deaths in 2021.
These figures were taken from the 2021 End of Life survey, conducted jointly by CBS, Amsterdam UMC and Erasmus MC and commissioned by ZonMw. Medical practitioners involved in a sample of deaths that occurred in 2021 completed a questionnaire on medical end-of-life decisions. This study has been conducted every five years since 1990. Due to the pressure on care during the coronavirus pandemic, the survey was not conducted in 2020, but one year later.

Medical end-of-life decisions by cause of death category, 2021
DoodsoorzaakNo end-of-life decision (%)Pain and symptom relief (%)Not instituting treatment or
stopping treatment (%)
Prescribing, dispensing
or administering drug (%)
Cardiovascular disease
(excl. stroke)
Respiratory diseases45.629.321.04.2
Diseases of the nervous
system (incl. stroke)

More drugs prescribed or administered in cancer than in other causes of death

Approximately half of all deaths in 2021 had cancer or cardiovascular disease as the cause of death. End-of-life decisions are more common among cancer patients compared to other diseases. Thirty-nine percent of dying cancer patients were given more pain relief; in 13 percent of the patients, the physician prescribed, dispensed or administered a drug that hastened death. Over 95 percent of the latter cases involved euthanasia; the remainder were cases of assisted suicide and life-terminating acts without an explicit request.

Among patients who died of cardiovascular disease, most (61 percent) had no medical decision around death. In those cases where the death did involve such a decision, either more pain relief was given, or treatment was waived or stopped. Slightly under 2 percent of these patients were given a drug, predominantly involving euthanasia.

In cases of death due to COVID-19, physicians almost exclusively used pain management or decided to forgo or stop treatment. The survey did not show any cases of euthanasia among these deaths.

Euthanasia rare among over-80s

More than half (54 percent) of the deaths in 2021 were people aged 80 or older. A third were between 65 and 79 years old, while 1 percent were under 18. In the youngest group, either no new treatment was started or treatment was stopped in 40 percent of patients. Prescribing, dispensing or administering a drug was not common in the very youngest group, nor in the oldest group (over 80).

Medical end-of-life decisions, deaths by age, 2021
LeeftijdNo end-of-life decision (%)Pain and symptom relief (%)Not instituting treatment
or stopping treatment (%)
Prescribing, dispensing or
administering drug (%)
0 to 17 yrs50.110.339.10.7
18 to 64 yrs49.328.014.88.0
65 to 79 yrs46.928.315.69.2
80 yrs and over45.331.719.83.2

One quarter of ELDs taken by family doctor

A medical end-of-life decision is made by the patient's attending physician, generally after discussion with colleagues and in consultation with the patient and the relatives. Fifty-three percent of all deaths in 2021 involved such a decision. The patient's treating physician was the family doctor (GP) in 24 percent of these cases. For 16 percent, it was a specialist in geriatrics; for 13 percent, an attending medical specialist in another discipline.

In cases where the attending physician made a medical decision - usually for patients dying at home - this was usually pain and symptom management (30 percent). The same was true for specialists in geriatrics (38 percent). Among medical specialists in another discipline, the medical decision was most often to forgo or stop treatment (32 percent).

Medical end-of-life decisions, by attending physician, 2021
BehandelaarNo end-of-life decision (%)Pain and symptom relief (%)Not instituting treatment
or stopping treatment (%)
Prescribing, dispensing
or administering drug (%)
Family doctor49.929.89.410.9
Specialist in geriatrics41.237.520.60.7
Other medical specialist43.922.731.61.8

Amsterdam UMC and Erasmus MC published their research results on medical end-of-life decisions at the same time as this news release.