Review of end-of-life acceptance in deceased patients across four European countries

Background Acceptance of death is an important aspect of a good death and an indicator of high-quality palliative care. Limited evidence exists on the extent to which patients accept their approaching death and which socio-demographic or end-of-life care characteristics are associated with acceptance, in both cancer and non-cancer patients. Methods We conducted a retrospective cross-sectional survey in representative GP networks in the Netherlands and Italy (2013-2015), and Belgium and Spain (2013-2014). GPs registered all deceased adult patients in their practice, reporting health and care characteristics in the last three months of life and the level of acceptance of approaching death on a four-point scale (1. Yes, completely to 4. No, not at all). Non-sudden deaths were included, totaling 2,796 patients (1,474 cancer; 1,322 non-cancer). Results Acceptance was recorded for 97% of patients (n=2,713), of which 17% were assessed as unknown. GPs assessed that 30% of patients had complete acceptance, with similar proportions in cancer and non-cancer patients (30% vs 29%). Multivariable logistic regression showed that older age (OR 1.03, 95%CI 1.02-1.04, p<0.01), country (OR 0.27 Belgium, OR 0.11 Italy, OR 0.10 Spain; reference: Netherlands), and palliative care by the GP until death (OR 1.39, 95%CI 1.07-1.79, p<0.01) were independently associated with complete acceptance. Conclusion Socio-demographic, contextual, and end-of-life care factors influence GP-assessed acceptance of approaching death, whereas a cancer diagnosis does not. These findings emphasize the importance of culturally sensitive, age-appropriate, and palliative care-oriented approaches to support patient acceptance at the end of life.