Comment on "Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study" by Sprung et al.

Sir, We read with interest the paper by Sprung et al. on attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions [1]. The study compares preferences for end-of-life decisions between the above-mentioned groups from six European countries with different societal backgrounds. We agree with the authors that it is remarkable that one-third to half of the respondent groups wanted active euthanasia for pain, both when they would be diagnosed with a terminal illness and when they would be permanently unconscious; however, we question the interpretation of the answers for the second scenario, as in the questionnaire, active euthanasia was defined as the hastening of death at the patient's explicit request. In our opinion, this scenario is theoretical, since an unconscious patient cannot explicitly request euthanasia. In such a situation, alleviation of pain, without the intention of hastening death, is a much more plausible scenario. In all participating countries, the law does not allow hastening of death without the patient's explicit request.

In addition, the numbers probably represent an underestimation of the respondents' desire for euthanasia, as studies have shown that pain is not the only reason for a euthanasia request [2, 3]. In these studies, euthanasia requests were typically related to patients' sense of suffering without improvement and loss of dignity. Rietjens et al. showed that in 36% of the patients that received euthanasia, pain was the main reason for their request [2].

Regrettably, a multivariate logistic regression analysis was only presented for value of life vs quality of life, and the desire to go into the ICU. Especially for the euthanasia scenario, it would be interesting to compare countries, as it is known that marked differences between countries exist [4, 5].