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A comparison of physicians’ end-of-life decision making for non-western migrants and Dutch natives in the Netherlands

Hilde M. Buiting , Judith A.C. Rietjens , Bregje D. Onwuteaka-Philipsen , Paul J. van der Maas , Johannes J. M. van Delden , Agnes van der Heide
DOI: http://dx.doi.org/10.1093/eurpub/ckn084 681-687 First published online: 27 September 2008

Abstract

Background: Non-western migrants have a different cultural background that influences their attitudes towards healthcare. As the first wave of this relatively young group is growing older, we investigated, for the first time, whether end-of-life decision-making practices for non-western migrants differ from Dutch natives. Methods: In 2005, we sent questionnaires to physicians who attended deaths identified from the central death registry of Statistics Netherlands (n = 9651; non-western migrants: n = 627, total response: 78%). We performed multivariate logistic regression analyses adjusted for age, sex and cause of death. Results: Of all deaths of non-western origin, 54% were non-sudden, whereas 67% of all deaths with a Dutch origin were non-sudden (P = 0.00). A relatively large number of non-suddenly deceased persons of non-western origin had died under the age of 65 (53%) as compared to Dutch natives (15%). Euthanasia was performed in 2.4% of all non-suddenly deceased persons in the non-western migrant group as compared to 2.7% in the native Dutch group (adjusted odds ratio = 0.82, P = 0.63). Alleviation of symptoms with a potential life-shortening effect was somewhat lower for non-western migrants (30% vs. 38%; adjusted odds ratio = 0.78, P = 0.07). Physicians decided to forgo potentially life-prolonging treatment in comparable rates (26% vs. 23%; adjusted odds ratio = 1.1, P = 0.73). Yet, the type of treatments forgone and underlying reasons differed. Conclusion: Euthanasia was not less common among non-suddenly deceased non-western migrants as compared to Dutch natives. However, intensive symptom alleviation was used less frequently and forgoing potentially life-prolonging treatment involved different characteristics. These findings suggest that cultural factors may affect end-of-life decision making.

  • culture
  • decision-making
  • end-of-life
  • ethnicity
  • migrant

Introduction

Today, many European countries have a multiethnic society with a rising proportion of people who originate from non-western countries. In the Netherlands, 10% of the population is from non-western origin.1 This ethnically diverse group predominately originates from Turkey (20%) and Morocco (20%). Another 30% comes from (former) Dutch colonies and 30% comes from other African or Asian countries. Their arrival was the result of several migration waves starting in 1946 and mainly related to better work opportunities in the Netherlands or political developments in the countries of origin.2 In the Netherlands, at least half of the non-western migrants are Muslim.1 Most of them live in larger cities, in densely concentrated neighbourhoods.3,4

The health of non-western migrants is on average worse compared to the Dutch natives, especially in migrants who recently arrived in the Netherlands.3,5 A different social and economic position, substandard housing and limited access to healthcare services might be explanatory factors.6 As compared to the native Dutch population, death rates among non-western migrants are higher (especially at young age) and cause-specific mortality varies.7 The higher susceptibility to illness is in line with the lower self-reported health of non-western migrants and the more frequent visits to general practitioners. Yet, the use of specialized hospital care is often lower indicating possible cultural differences in attitudes towards health and healthcare.8–10 It has further been shown that such cultural differences and migrant's illiteracy or inadequate control of the language might complicate effective communication between patient and physician.11

As the first wave of non-western migrants is growing older, medical care and medical decision making at the end-of-life increases in importance. End-of-life decisions, e.g. decisions to withhold or withdraw potentially life-prolonging treatment or to alleviate pain or symptoms with opioids in potentially life-shortening dosages, are known to be an aspect of end-of-life care in a substantial proportion of all deaths. Such decisions are based upon a balanced consideration of medical, ethical, psychosocial, societal and cultural/ethnic aspects.12,13 In most western countries, terminally ill patients generally consider quality of life as highly important and hastening of death can sometimes be an accepted result of end-of-life care.14,15 For migrants from non-western countries, their original religion or culture, in which sanctity of life is often highly valued while explicitly hastening death is considered unacceptable, is probably often important.16,17 As a result, the frequency and characteristics of end-of-life decision-making practices might differ for this group. However, few empirical data are available on end-of-life practices in different ethnic groups. In this empirical study we investigated, for the first time, whether the frequency and characteristics of end-of-life practices of non-western migrants differed from Dutch natives. This study provides partial results of a larger study aimed at evaluating the Dutch Euthanasia Act.18

Methods

Death certificates

We obtained a stratified sample of death certificates of deceased persons from the central death registry of Statistics Netherlands. This sample was drawn between August and November 2005 (n = 9965). In this paper we used data about 9651 persons aged 17 years or older at their time of death; 627 of them concerned non-western migrants. Further details about the sampling procedure have been published elsewhere.18

Data on the deceased persons’ country of origin, age, sex, marital status, cause and place of death were derived from the death certificate and municipal administration registers without breaking their anonymity. The following definition of non-western migrants was used: the person had lived in the Netherlands and had at least one parent who was born in Africa, Latin America or Asia (excluding Indonesia and Japan). Thus, this group included both first-generation migrants (persons migrated to the Netherlands themselves) and second-generation migrants (persons born in the Netherlands but with at least one parent born abroad). Migrants from other western countries, such as Germany and Belgium, were included in the native Dutch group.

Questionnaire

Physicians who signed the death certificate for a non-sudden death received a four-page written questionnaire about their medical decision making prior to the patient's death. We guaranteed strict anonymity for the responding physicians; the questionnaires were only opened after all identifying information had been removed. Of the 6860 questionnaires sent out, 5342 were sent back (total response: 78%). According to Dutch policy, the study did not require review by an ethics committee because the data collection was anonymous with regard to the deceased patient and the attending physician.

The questionnaire consisted of 25 questions. Key questions were whether the physician:

  1. had withheld or withdrawn medical treatments while taking into account or explicitly intending (potential) hastening of death;

  2. had intensified the alleviation of pain or other symptoms while taking into account or appreciating possible hastening of death; and

  3. had administered, supplied or prescribed drugs with the explicit intention of hastening death, which act resulted in the patient's death.

If the third question was answered affirmatively and if this act was performed upon the explicit request of the patient, the act was classified as euthanasia or physician-assisted suicide. For deaths in which more than one of the three key questions were answered with yes, the decision with the most explicit intention concerning hastening death was determinative, whereas in case of similar intentions, questions 2 and 3 prevailed over question 1.

If one of these acts had been performed, questions about the decision making followed. The physician was further asked to estimate the patient's competence, that is, the patient's ability to assess his or her situation and to decide adequately. Further, additional information was gathered on the type of treatment forgone, the type of drugs used, the most important reasons for the decision and the estimated degree of life shortening. We also asked whether the patient had been deeply and continuously sedated prior to death.

Analyses

The results were made representative of all deaths in 2005 by weighting the data for stratification and response by the patients’ age, sex, marital status and cause and place of death. Further, χ2-tests were applied to assess the significance of differences in background characteristics between non-western migrants and Dutch natives. Univariate and multivariate logistic regression analyses were conducted to assess the association between the patients’ origin and the occurrence of different end-of-life practices; we calculated odds ratios adjusted for age, sex and cause of death. P-values of <0.05 were considered to indicate statistical significance. Percentages were corrected for missing values when these comprised <5% of all cases. Statistical analyses were performed using the Statistical Package for Social Sciences 11.0 (SPSS Inc, Chicago, IL, USA).

Results

Population characteristics

Of all deceased persons with a non-western origin, 46% died suddenly and unexpectedly; this percentage was significantly lower for persons with a Dutch origin (33%) (table 1). Among non-western migrants, the majority concerned people from Turkey (16%), Suriname (38%) or people from other non-western countries (26%). This group most frequently involved first-generation migrants (93%). In the relatively young non-western migrant population, 53% of all non-sudden deaths concerned persons under the age of 65 as compared to 15% in the native Dutch population. Non-western migrants less frequently died due to cancer (31% vs. 36%) or pulmonary diseases (6.5% vs. 12%) than Dutch natives. They more often died in a hospital than Dutch natives (59% and 32%, respectively). Physicians reported that patients had suffered from severe pain and dyspnoea during the last 24 h of their lives in comparable frequencies.

View this table:
Table 1

Characteristics of deceased persons with a non-western origin or Dutch origin (weighted percentages, unweighted absolute numbers)

Non-western migrants n = 627Dutch nativesan = 9024
All deaths studied (%)298100
%%P-valueb
Sudden and unexpected death
    Yes46330.00
    No5467
Non-sudden deathsn = 307n = 3476
Country of origin
    Turkey16NA
    Morocco8.3NA
    Surinamec38NA
    Dutch Antilles or Aruba12NA
    Other countries in Africa or Asia26NA
Generation
    First93NA
    Second7NA
Age
    18–6453150.00
    65–792733
    80+2052
Sex
    Male54470.02
    Female4653
Marital status
    Married48420.06
    Unmarried5258
Cause of death
    Cancer31360.00
    Circulatory disease2525
    Pulmonary disease6.512
    Diseases of the nervous system1.53.0
    Other/unknown3523
Place of death
    Hospital59320.00
    Nursing home1830
    Home for the elderly3.711
    Home1623
    Other2.73.4
Presence of symptoms
    Severe paind19210.44
    Severe dyspnoead28320.17
  • a: Western migrants were included in the native Dutch group

  • b: χ2-test

  • c: Persons from Surinam are diverse in itself and originate from West Africa, India, Java, China and persons of mixed origin2

  • d: Scores 4 or 5 on a scale of 1 (symptom not present) to 5 (symptom strongly present despite treatment) during the last 24 h before death. Symptoms were missing from 7.4% up to 8.1% of all non-sudden deaths

End-of-life practices

Euthanasia was performed in 2.4% and 2.7% of all non-sudden deaths in non-western migrants and Dutch natives, respectively (adjusted odds ratio = 0.82, P = 0.63) (table 2). The percentage of euthanasia cases among all deaths was 1.3% and 1.8%. Ending of life without an explicit patient request occurred less frequently, these percentages were 0.2% (one case observed) and 0.5% (15 cases observed). The proportion in which potentially life-prolonging treatment had been forgone did not substantially vary between the two groups (26% vs. 23%; adjusted odds ratio = 1.1, P = 0.73). Yet, the percentage in which the alleviation of symptoms was intensified with hastening of death as a potential result was lower in non-western migrants (30% vs. 38%; adjusted odds ratio = 0.78, P = 0.07). Continuous deep sedation was provided in 14% of all non-sudden deaths in non-western migrants and in 12% of all non-sudden deaths in the native Dutch population (adjusted odds ratio = 0.93, P = 0.67).

View this table:
Table 2

End-of-life practices among non-sudden deaths: non-western migrants vs. Dutch natives (weighted percentages, unweighted absolute numbers)

Number of studied deathsNon-western migrants n = 307Dutch nativesan = 3476UnadjustedAdjusted
End-of life practices%n%nOdds ratiobP-valueOdds ratiocP-value
Euthanasia and physician-assisted suicide2.492.73010.890.760.820.63
Ending of life without an explicit patient request0.210.5150.470.520.200.18
Forgoing potentially life-prolonging treatment2671236421.20.231.10.73
Alleviation of symptoms with a potentially life-shortening effect30993813510.700.010.780.07
Continuous deep sedationd1442124491.20.260.930.67
  • a: Western migrants were included in the native Dutch group

  • b: Univariate regression analysis, likelihood that an end-of-life decision concerned non-western migrants

  • c: Multivariate logistic regression analysis, likelihood that an end-of-life decision concerned non-western migrants after adjusting for differences in age, sex, and cause of death

  • d: Continuous deep sedation may have been provided together with end-of-life decisions

Decision-making characteristics

Treatments were less frequently withheld in non-western migrants (12%) than in the native Dutch (15%), but more frequently withdrawn (20% vs. 12%) (data not in table). The types of treatment forgone varied between the two groups (table 3). Artificial respiration (38% vs. 16%, adjusted odds ratio = 1.8, P = 0.04) and cardiovascular medication (30% vs. 11%, adjusted odds ratio = 2.8, P = 0.00) were more often forgone in the non-western migrant group. Artificial nutrition or hydration on the other hand, were less often forgone in non-western migrants (12% vs. 28%, adjusted odds ratio = 0.40, P = 0.02).

View this table:
Table 3

Type of treatment withheld or withdrawn: non-western migrants vs. Dutch natives (weighted percentages, unweighted absolute numbers)

Number of studied deathsNon-western migrants n = 71Dutch nativesan = 642UnadjustedAdjusted
%n%nOdds ratiobP-valueOdds ratiocP-value
Artificial respiration382616863.30.001.80.04
Cardiopulmonary resuscitation5.644.4231.30.661.50.52
Cardiovascular medication302111593.50.002.80.00
Antibiotics7.9615800.490.120.780.61
Other medication1813181240.970.921.40.36
Surgery6.347.4450.860.770.670.46
Oncotherapy003.135
Renal dialysis1173.6203.20.011.90.20
Hospital admission/diagnostics5.2411710.430.130.590.36
Artificial nutrition or hydration1210281810.360.010.400.02
  • a: Western migrants were included in the native Dutch group

  • b: Univariate regression analysis, likelihood that the decision to forgo potentially life-prolonging treatment concerned non-western migrants

  • c: Multivariate logistic regression analysis, likelihood that the decision to forgo potentially life-prolonging treatment concerned non-western migrants after adjusting for differences in age, sex and cause of death

In both groups, the most important reason to forgo treatment was the absence of perspectives of improvement. This percentage was, however, significantly higher in the non-western migrant group (83% vs. 71%) (table 4). Physicians less frequently indicated that the patient's or family's request were the most important reasons for their decision for non-western migrants (3.4% and 3.8%) than for Dutch natives (25% and 18%). These differences were found for both competent and incompetent patients. An estimated shortening of life due to the forgoing of treatment of >1 week was reported less often for non-western migrants than for Dutch natives (5.9% vs. 14%). Alleviation of symptoms that potentially hastened death had the same characteristics in both groups: physicians had usually administered morphine, sometimes combined with benzodiazepines (data not in table). Physicians’ most important reasons for their decision were in both groups the presence of severe pain (52% and 48% in non-western migrants and Dutch natives, respectively) and severe other symptoms of the patient (42% vs. 42%) (table 4). The estimated shortening of life due to the alleviation of symptoms did not significantly differ between the two groups: life shortening of >1 week occurred in 4.6% (non-western migrants) and 3.0% (Dutch natives) of all cases.

View this table:
Table 4

Physician's most important reason to make an end-of-life decision and the estimated life shortening: non-western migrants vs. Dutch nativesa (weighted percentages, unweighted absolute numbers)

Forgoing treatmentAlleviation of symptoms
Non-western migrants (n = 71) %Dutch nativesb (n = 642) %Non-western migrants (n = 99) %Dutch nativesb (n = 1351) %
Most important reasons for the decisionc
    Severe pain7.4105248
    Severe symptoms21234242
    Loss of dignity9.3114.27.7
    Patient's request3.4d25d7.813
    Family's request3.8d18d8.69.9
    Expected suffering of the patient19281819
    No perspectives of improvement83d71d4341
    Other treatment too burdensome12d23d10.69.3
Estimated life shortening
    <1 week83738481
    >1 week5.9144.63.0
    Unknown11141216
χ2 (P = 0.04)χ2 (P = 0.63)
  • a: The most important reasons to perform euthanasia are not included because of the small number of cases

  • b: Western migrants were included in the native Dutch group

  • c: More than one answer possible

  • d: χ2-test (P < 0.05)

Competence

In general, non-western migrants for whom an end-of-life decision was made were significantly more often considered incompetent than Dutch natives (60% vs. 45%) (table 5). If patients were competent, physicians frequently discussed the decision with patients themselves in both non-western migrants (85%) and Dutch natives (83%). For non-western migrants, physicians more often mentioned that decisions were not discussed with the competent patient because they thought that the decision was evidently the best choice (39% vs. 25%). If patients were incompetent, 4.5% of the non-western migrants and 17% of the Dutch natives had expressed a wish to hasten their end of life in an earlier stage of their disease. For non-western migrants, incompetent patients more frequently died in hospital (67% vs. 37%) where an estimated life shortening of <1 week was reported for >90% of the cases. In general, physicians more frequently discussed decisions with other physicians when non-western migrants (57%) instead of Dutch natives (37%) were involved.

View this table:
Table 5

Competence of patients for whom an end-of-life decision had been made and physician's discussion: non-western migrants vs. Dutch natives (weighted percentages, unweighted absolute numbers)

Non-western migrants (n = 180) %Dutch nativesa (n = 2309) %
Patient was competent (95% CI)27 (22–34)35 (33–36)
• Patient ever expressed wish to hasten deathb8.0
• Discussed with patientb8583
• Discussed with relativesb6365
• Not discussed with patient nor relatives1112
Patient was incompetent (95% CI)60 (52–66)45 (43–48)
• Patient ever expressed wish to hasten deathb4.517
• Discussed with patientb3122
• Discussed with relativesb7171
• Not discussed with patient nor relatives1724
Competence unknown (95% CI)13 (8.9–18)20 (18–22)
Discussion with other caregiversb
• Other physician5737
• Nursing staff3734
• No discussion with other caregivers2433
  • a: Western migrants were included in the native Dutch group

  • b: More than one answer possible

Discussion

Medical end-of-life decisions were made for a substantial percentage of deceased persons of both non-western and Dutch origin. Euthanasia, continuous deep sedation and forgoing potentially life-prolonging treatment were practiced in comparable rates, whereas the incidence of intensive symptom alleviation tended to be lower in people of non-western origin.

The high response rate, the endorsement of the study by authoritative medical bodies and the guarantee of anonymity of patients and physicians strengthen the validity and reliability of our results. However, our study has some restrictions too. First, we only studied the physician perspective. Second, we were not able to distinguish in migrants’ religions. As a result, it is likely that we missed some additional differentiation given the variety in attitudes in end-of-life practices across religious and non-religious groups.19 Another potential restriction has to do with the absence of information on duration of residence. Migrants who have lived in the Netherlands for a long time may be more comparable with the native Dutch population than migrants who arrived more recently. However, it is probable that most migrants for whom end-of-life decisions were made had lived in the Netherlands for quite a period, because end-of-life decisions are generally taken in the elderly, first-generation population. Finally, the absolute number of end-of-life practices and decision-making characteristics for non-western migrants was too small to be able to give the percentages for each country separately. This study on end-of-life practices provides a good starting point for discussion on migrant's attitudes and wishes towards the end of life. Future studies, reflecting the views of other healthcare providers and/or family, would increase our understanding of end-of-life decision making in the non-western migrant population.

The different age structure of the non-western migrant population is the main cause of the relatively high number of deaths at a young age in this group.1 The younger age at death is a reasonable explanatory factor for the higher prevalence of sudden deaths, which probably mainly included deaths caused by traffic accidents. The variety in incidence rates for specific diseases might be explained by the younger age as well, or, by different genetic or lifestyle factors in people from non-western origin.7,20

Euthanasia

In this study we found no significant differences in the occurrence of euthanasia between non-western migrants and Dutch natives, although euthanasia is deemed unacceptable in different religious doctrines16,17 and euthanasia acceptance is quite low in the countries of origin of non-western migrants (e.g. Turkey).19 Apparently, non-western migrants in the Netherlands are relatively open towards euthanasia, possibly as a result of the continuous medical and public discussions that eventually resulted in the adoption of the Euthanasia Act (2002). Legalization of euthanasia is a topic of debate in many countries21,22 and secularization still proceeds in many western European countries.23,24 Such developments might be correlated with an increased acceptance of euthanasia among non-western migrants as well.

Intensified alleviation of symptoms

The percentage of the alleviation of symptoms with a potential life-shortening effect tended to be lower in non-western migrants. A previous study showed that percentages of the alleviation of pain and symptoms were rather similar across six European countries with various cultural backgrounds.13 The lower frequency of the alleviation of symptoms with a potential life-shortening effect seems to be in conflict with the finding that physicians reported equal rates of severe pain and dyspnoea in the two groups. One explanation for the lower rate of alleviation of symptoms might be related to the possibility that patients’ needs at the end of life are different due to cultural variances: many Turkish people for example believe that a certain extent of suffering should be part of life.25 The relative importance of physical health as compared to eternal salvation plays an important role in several religions. Another possibility is that physicians themselves did not understand the patients’ needs due to cultural misunderstandings or language barriers.26 Intuitively, physicians might have avoided decisions that possibly hastened death, assuming that non-western migrants prefer less medical involvement in the dying process. However, the fact that euthanasia was performed in comparable rates suggests that this assumption may not always be true. It is not likely that financial motives are related to the observed differences, because nearly all healthcare costs are covered by either mandatory private health insurance or public financing in the Netherlands. Whether the disparities reflect some form of undertreatment cannot be shown with these data. However, there are no indications that this is related to some explicit form of discrimination.

Forgoing potentially life-prolonging treatment

The frequency of forgoing potentially life-prolonging treatment did not significantly differ between the two groups. However, among non-western migrants treatments were less frequently withheld than withdrawn (12% and 20%) and the estimated degree to which life was shortened was clearly less, which might indicate that non-western migrants were treated later in the course of their disease. Possibly, physicians were more hesitant to stop life-prolonging treatment unless death was clearly inevitable and/or treating would be medically futile. The significantly higher frequency of ‘no perspectives of improvement’ as physicians’ most important reason to forgo treatment supports this assumption. Further, in non-western migrants the type of treatments forgone more frequently concerned high- instead of low-technology interventions: artificial respiration, renal dialysis and cardiovascular medication were more frequently forgone, whereas the frequency of forgoing artificial nutrition or hydration was much lower. These findings are in line with the traditional religious viewpoints that exist in the migrant's countries of origin: high-technology treatment is easier perceived as disproportionate and therefore forgoing them is sometimes permitted, whereas administering food and fluids is often considered as a form of basic care that should not be denied to anyone. This perspective is deeply rooted in cultural beliefs.16,17,27

Cultural aspects in end-of-life decision making

In our study, non-western migrants were relatively often considered to be incompetent. Non-western migrants most frequently died in hospital, where the number of incompetent patients is relatively high in general. Probably, patients dying in hospital are more often incompetent to participate in the decision making due to the fact that the attending clinical specialists have their first encounter with patients relatively late in the course of illness. General practitioners typically know their patients much longer and have much more opportunity to discuss issues concerning end-of-life care and end-of-life decision making. Language barriers and not understanding patients’ preferences might be an explanatory factor as well.26 As compared to native Dutch patients, end-of-life decisions for non-western migrants were rarely the result of the patient's or the family's expressed wishes. Possibly, non-western migrants are not used to or do not want to express such wishes, either because they just prefer a more natural death or because they trust their physician to make the right decisions. Dutch physicians sometimes seem to have a more paternalistic attitude towards non-western migrants; since they more frequently said not to have discussed their decision with competent non-western patients because it was ‘simply the best for the patient’. A couple of studies performed in Turkey found comparable reasons for not disclosing a severe diagnosis to the patient.25,28 However, although we have no insight in the quality of the communication, decisions were discussed with the large majority of both competent non-western migrants and Dutch natives, which is typical for the Dutch open culture towards end-of-life decision making.29

The comparable incidence rates and the differences in the decision-making characteristics, could be the result of acculturation. This is in line with the results of a cross-cultural survey in which the attitudes and desires concerning end-of-life issues of Japanese Americans, Japanese-speaking Americans and Japanese living in Japan were compared. It showed that attitudes of Japanese-Americans shifted towards western values while at the same time some traditional Japanese values retained that influenced the end-of-life decision making.30

Conclusion

The incidence rates of medical end-of-life decisions for non-western migrants and Dutch natives were rather similar, even in case of euthanasia. Yet, compared to Dutch natives, non-western migrants somewhat less often received intensive symptom alleviation with hastening of death as a potential result, and forgoing potentially life-prolonging treatment involved different underlying characteristics. On the one hand, it seems that migrants’ confrontation with western individualistic thinking and lifestyle could have resulted in a more liberal attitude towards end-of life decision making as compared to their country of origin. On the other hand, our results indicate that cultural issues may indeed play a role in medical end-of-life decision making, and that adequate patient-centred end-of-life care should include the consideration of cultural aspects.

Funding

Dutch Ministry of Health.

Conflict of interest: None declared.

Acknowledgements

We thank the thousands of physicians who provided the study data, the assistants to the project at Statistics Netherlands for their skilful help in collecting the data and the members of the Steering Committee, the Royal Dutch Medical Association and the Chief Inspector for Health Care for their support of the study.

Key points

What is already known on this subject?

  • Non-western migrants’ actual and perceived health is generally worse as compared to the native Dutch.

  • Qualitative studies examining aspects of end-of-life care describe the importance of the original religion or culture held by patients and families from different ethnic backgrounds.

What this study adds?

  • This is a first quantitative overview of end-of-life practices in the Netherlands for non-western migrants and Dutch natives.

  • Incidence rates of end-of-life practices are largely similar in both groups implying that migrants’ confrontation with western individualistic thinking and lifestyle may result in a more liberal attitude towards end-of-life decision making.

  • The underlying characteristics of end-of-life practices varied, which points out that adequate patient-centred end-of-life care should include the consideration of cultural aspects.

References

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