Medical end-of-life decisions: does its use differ in vulnerable patient groups? A systematic review and meta-analysis.

Medical end-of-life decisions, defined as end-of-life practices with a potential or certain life-shortening effect, precede almost 50% of deaths in Western countries, and receive ample medical-ethical attention. This systematic review aims to detect whether there are differences in the prevalence of medical end-of-life decisions in 'vulnerable' patient groups. In 2009, five major databases were scrutinized for publications containing original data on the prevalence of euthanasia/physician-assisted suicide, life-ending without explicit patient request, intensified symptom alleviation, non-treatment decisions and palliative sedation by social factors (eg age, gender and SES). Heterogeneous findings were pooled using a random effects model. We identified 6377 papers of which 51 papers were selected, involving over 1.09 million patients. Most publications reported the prevalence of non-treatment decisions. The most studied social factors were age and gender. Among patients older than eighty years, non-treatment decisions occurred more frequently compared with younger patients, while intensified symptom alleviation, palliative sedation, euthanasia/physician-assisted suicide and life-ending without explicit request were practiced less often. Similar patterns of association, although less strong, were found for female patients compared with males and those with lower levels of education versus more highly-educated patients. We conclude that the administration of medication with a potential or certain life-shortening effect seemed generally to be practiced less often among the elderly, females and less well-educated patients compared with younger, male or more educated patients, while decisions that include the withdrawal or withholding of treatments seem to be more common in these groups. Further studies should focus on investigating whether these differences reflect less than optimal end-of-life care for specific patient groups.