There are differences between physicians in the countries under study regarding experiences with ELDs, willingness to perform ELDs and frequency with which requests for EAS are received. In general, physicians in Italy have least experience with these issues, followed at some distance by Sweden, while physicians in the Netherlands have the most experience. Foregoing treatment and alleviation of pain and symptoms by intensifying medication to a level, which risks hastening death are accepted by physicians in all countries, since only a small minority have never performed them and would never do so. These are also the ELDs that were found to occur most frequently in the first EURELD (death certificate) study.
The main strength of this study was that the same methodology was used in all countries, which made it possible to compare countries. We are not aware of any other international surveys on this subject. A limitation of this study is that it was retrospective, which may have resulted in recall bias.
A number of the authors currently work or research in end-of-life areas. Our experience suggests that since physicians sent in this questionnaire in 2003, the question arises whether there are reasons to believe that physicians' practices have changed since then. In the Netherlands, ELDs have been studied extensively since then . It showed that the practice of ELDs remained stable over the years, with the exception of euthanasia, which occurred less frequently in 2005 compared with 2001. In Belgium things may have changed, as the euthanasia law is only now in full effect. Recent data obtained by another method than the death certificate method suggest that there is more euthanasia in Flanders than before, 1.6% in 2005–2006 instead of 0.3%. There is also a rise in the total number of potentially life-shortening ELDs, from 38% to 50% . The general increase may of course be reflected in physicians' experiences with ELDs.
Although reasons for the differences between countries can only be speculative, in the Netherlands the reason that physicians have more experience with ELDs may be a more liberal tradition and higher respect for patient autonomy. A religious influence is not evident, as Belgium, with a substantial Catholic population, has the second highest experience with ELD, and Sweden, which is a Protestant country, has the lowest together with Italy, a Catholic country. Denmark, which also has a Protestant population, is closest to Belgium. The results do indicate that a non-religious philosophy of life seems to increase the willingness to perform EAS, possibly out of respect for patient autonomy. Cohen et al  have studied life-stance and general attitudes towards ELDs in more detail. They found that teachings of religious bodies indeed have an influence on end-of-life decision-making, but are certainly not blankly accepted by physicians. The influence of doctrinal teachings is somewhat clearer on general attitudes towards end-of-life decision-making. It can perhaps be explained by the fact that most people embrace (theistic) belief not in strict metaphysical terms, but in non-imperative ways, allowing for adaptation to particular situations, for instance to the needs and wishes of the dying and to considerations of humaneness.
Physicians can only perform EAS when a patient requests it. Physicians in all countries receive euthanasia requests, most often in the Netherlands, where physicians also have most experience with performing EAS.
The results show that physicians with training in palliative care are more inclined to make ELDs. While this may be expected for some of the ELDs, it is somewhat surprising for EAS. One hypothesis may be that palliative care physicians develop a higher attention to patients' wishes. Further research is needed to clarify and explain this finding.
Furthermore, the findings indicate that the legislation and medical guidelines are reflected in physicians' experiences. In all countries, physicians had the highest experiences of non-treatment decisions and alleviation of pain and other symptoms with possible life-shortening effect: kinds of ELDs, which are legal in all participating countries. The fact that experiences of continuous deep sedation, which is legal in all countries, is relatively low, demonstrates that this ELD is more strongly influenced by situational factors such as uncontrollable pain and symptoms than by legal regulations. The different legal regulations concerning EAS are also reflected in physicians' experiences. Shortly before this study was performed, the Netherlands and Belgium changed their legislation, in 2001 and 2002, and now permit EAS under certain conditions. In the Netherlands EAS are regulated as two possible end-of-life options. In Belgium the law only regulates euthanasia. In both countries the patient involved must be a mentally competent adult when requesting help. Doctors can only proceed when they know the patient well enough to be able to assess whether their request for euthanasia is voluntary and well-considered, whether the patients' medical situation is without prospect of improvement and whether the individual's suffering is unbearable. The ability to refuse a request for euthanasia guarantees a doctor's freedom of conscience in both countries . Whether this has influenced experiences and attitudes remains to be studied in Belgium. For the Netherlands, the evaluation of the euthanasia law showed that the incidence of EAS decreased from 2.8% in 2001 to 1.8% in 2005 (see ).
In Switzerland, assistance in suicide is allowed provided that the person seeking assistance has decisional capacity and the person assisting is not motivated by reasons of self-interest; euthanasia is forbidden in all circumstances. Experiences with ELDs can be associated with two types of factors. One is the opportunity the physician has for making ELDs. The second is the attitude of the physician towards questions about philosophy of life, e.g. whether people have a right to decide to hasten the end of life and whether physicians should always aim at preserving life. Older physicians may have been practising medicine longer and thereby have an increased chance of ever having performed an ELD. Further, the number of terminal patients attended to by the physician within a given time period varies from one speciality to another. However, since having had palliative care training is positively associated with having experience with all ELDs, independent of the number of terminal patients under the physician's care, this factor probably reflects an attitude. Female physicians have less experience with ELDs, which does not seem to be related to opportunity and attitude. A similar finding comes from Italy, where male anaesthesiologists had greater experience with foregoing treatment . However, the reason is not obvious and ought to be studied in the future.