15283-B-Blokker

24 Chapter 2 Comparison with the literature According to the SN death counts in the Netherlands increased from 110,000 in 1977 to 136,000 in 2011, which could be explained by the overall population growth. There was also a relative increase from 7.9 per 1000 in 1977 to 8.1 per 1000 in 2011, which is possibly due to the substantially increased number of deceased women in the age group of 80 years and older. For years, the life expectancy at birth has been lower for Dutch men than for Dutch women, which must have led to an excess of women within the Dutch population. These women have eventually reached an older age, and passed away. In 2003, the Dutch government eased budgetary constraints in the healthcare system, leading to increased healthcare delivery, including more active and life-prolonging treatments for the elderly. 67 As a result the life expectancy increased, and the increase of overall deaths ended. A possible explanation for the overall decline of in-hospital deaths could be the shortening of in-hospital stays, that was initially due to budgetary constraints of the Dutch government 67 and is now continued by altered healthcare policy for the terminal phase of life. Ploemacher et al. suggested that patients are currently more often discharged from hospitals to receive palliative care from external facilities 68 and as a result more patients die at home or in nursing homes. The decline of in-hospital deceased could further be explained by an increase of deaths due to cancer, especially within the age groups of 60 years and older. According to Van der Wal et al. a substantial number of cancer patients (48%) died at home. 69 A factor possibly related to the excess of in-hospital deceased men (and performed autopsies), is that men more often have health problems that correlate with higher mortality rates, whereas women have health problems with a higher disease burden. 70 As a direct result of decreasing in-hospital deaths, fewer autopsies were performed in the Netherlands. Also the autopsy rates declined, just as observed in other countries, 22,32,71 especially with increasing age of the deceased. 32,71 Among the age group of 60 to 79 years fewer autopsies were performed each year, which might be correlated with the increasing number of deaths due to cancer that is observed in that same age group. If a patient dies of cancer, the cause of death seems obvious to next- of-kin 45 and an autopsy superfluous. At the same time, the clinician might be less eager to ask for an autopsy 43 especially if end-of-life decisions were made and euthanasia was performed. The requirements for requesting euthanasia in the Netherlands are extensive, for instance, it has to be shown that the disease is intolerable and that treatment options are lacking. 69 To support this