How accurately is euthanasia reported on death certificates in a country with legal euthanasia: a population-based study



Death certificates are the main source of information on the incidence of the direct and underlying causes of death, but may be unsuitable for monitoring the practice of medical assistance in dying, e.g. euthanasia, due to possible underreporting. This study examines the accuracy of certification of euthanasia.


Mortality follow-back survey using a random sample of death certificates (N = 6871). For all cases identified as euthanasia we checked whether euthanasia was reported as a cause of death on the death certificate. We used multivariable logistic regression analysis to evaluate whether reporting varied according to patient and decision-making characteristics.


Through the death certificates, 0.7% of all deaths were identified as euthanasia, compared with 4.6% through the mortality follow-back survey. Only 16.2% of the cases identified from the survey were reported on the death certificate. Euthanasia was more likely to be reported on the death certificate where death was from cancer (14% covered), neurological diseases (22%) and stroke (28%) than from cardiovascular disease (7%). Even when the recommended drugs were used or the physician self-labelled the end-of-life decision as euthanasia, euthanasia was only reported on the death certificate in 24% of cases.


Death certificates substantially underestimate the frequency of euthanasia as a cause of death in Belgium. Mortality follow-back studies are essential complementary instruments to examine and monitor the practice of euthanasia more accurately. Death certificate forms may need to be modified and clear guidelines provided to physicians about recording euthanasia to ensure more accurate certification.

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The authors wish to thank the entire team of the Flemish Agency for Care and Health, Jef Deyaert, MSc, and Lenzo Robijn, MSc, of the End-of-Life Care Research Group of Vrije Universiteit Brussel (VUB) & Ghent University, Brecht Haex, MSc, and lawyer Wim De Brock for their contributions in the data collection. We are also deeply indebted to the thousands of Flemish physicians participating in the survey. We further thank the Belgian Medical Disciplinary Board for recommending the study and Jane Ruthven for a critical and language review of this manuscript.


This work was supported by a grant from the Flemish government agency for Innovation by Science and Technology (SBO IWT nr. 100036) and was part of the Flanders Study to Improve End-of-Life Care and Evaluation Tools (FLIECE) project, a collaboration between the Vrije Universiteit Brussel, Ghent University, the Katholieke Universiteit Leuven, Belgium, and VU University Medical Centre Amsterdam, the Netherlands. Analysis and writing were supported by the Research Council of the Vrije Universiteit Brussel (SRP4).

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Correspondence to Sigrid Dierickx.

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Cohen, J., Dierickx, S., Penders, Y.W.H. et al. How accurately is euthanasia reported on death certificates in a country with legal euthanasia: a population-based study. Eur J Epidemiol 33, 689–693 (2018).

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