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Takimoto Y, Nabeshima T. The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens. AJOB Empir Bioeth 2024:1-11. [PMID: 38588396 DOI: 10.1080/23294515.2024.2336907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment. METHODS Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment. RESULTS In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%). CONCLUSIONS A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.
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Affiliation(s)
- Yoshiyuki Takimoto
- Department of Biomedical Ethics, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Tadanori Nabeshima
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
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Terunuma Y, Mathis BJ. Cultural sensitivity in brain death determination: a necessity in end-of-life decisions in Japan. BMC Med Ethics 2021; 22:58. [PMID: 33985493 PMCID: PMC8120912 DOI: 10.1186/s12910-021-00626-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background In an increasingly globalized world, legal protocols related to health care that are both effective and culturally sensitive are paramount in providing excellent quality of care as well as protection for physicians tasked with decision making. Here, we analyze the current medicolegal status of brain death diagnosis with regard to end-of-life care in Japan, China, and South Korea from the perspectives of front-line health care workers. Main body Japan has legally wrestled with the concept of brain death for decades. An inability to declare brain death without consent from family coupled with cultural expectations of family involvement in medical care is mirrored in other Confucian-based cultures (China and South Korea) and may complicate care for patients from these countries when traveling or working overseas. Within Japan, China, and South Korea, medicolegal shortcomings in the diagnosis of brain death (and organ donation) act as a great source of stress for physicians and expose them to potential public and legal scorn. Here, we detail the medicolegal status of brain death diagnosis within Japan and compare it to China and South Korea to find common ground and elucidate the impact of legal ambiguity on health care workers. Conclusion The Confucian cultural foundation of multiple Asian countries raises common issues of family involvement with diagnosis and cultural considerations that must be met. Leveraging public education systems may increase awareness of brain death issues and lead to evolving laws that clarify such end-of-life issues while protecting physicians from sociocultural backlash.
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Affiliation(s)
- Yuri Terunuma
- School of Medicine, University of Tsukuba Medical School, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Affilated Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8575, Japan.
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Maura Y, Yamamoto M, Tamaki T, Odachi R, Ito M, Kitamura Y, Sobue T. Experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life. Int J Qual Stud Health Well-being 2019; 14:1632110. [PMID: 31213147 PMCID: PMC6586137 DOI: 10.1080/17482631.2019.1632110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 11/14/2022] Open
Abstract
Purpose: This study aimed to clarify the experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life. Methods: A semi-structured interview was performed for four family caregivers who wanted to refuse life-prolonging treatment suggested by the physicians. Results: In this study, four caregivers who refused life-prolonging treatment suggested by the physicians for their elderly parents completed semi-structured interviews. The obtained data were analyzed in relation to the theme "Experiences of caregivers who desire to refuse life-prolonging treatment for their elderly parents at the end of life." As a result, 38 subcategories and 12 categories were extracted. Conclusions: Participants in this study initially had a negative view of life-prolonging treatment. However, they agonized over the decision when they received conflicting advice from the physicians. The participants indicated that physicians' advice and attitudes complicated their decisions to reject life-prolonging treatment for their elderly parents.
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Affiliation(s)
- Yuki Maura
- Department of Nursing, Faculty of Nursing and Rehabilitation, Konan Women’s University, Kobe, Hyogo, Japan
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Mariko Yamamoto
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tomoko Tamaki
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Nursing, School of Nursing, Mukogawa Women’s University, Nishinomiya, Hyogo, Japan
| | - Ryo Odachi
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Nursing and Laboratory Science, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Mikiko Ito
- Department of Nursing, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yuri Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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Tsurukiri J, Ota T, Jimbo H, Okumura E, Shigeta K, Amano T, Ueda M, Matsumaru Y, Shiokawa Y, Hirano T. Thrombectomy for Stroke at 6-24 hours without Perfusion CT Software for Patient Selection. J Stroke Cerebrovasc Dis 2018; 28:774-781. [PMID: 30528603 DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/06/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. METHODS Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. RESULTS This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. CONCLUSIONS Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.
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Affiliation(s)
- Junya Tsurukiri
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eitaro Okumura
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medicine Center, Tokyo, Japan
| | - Tatsuo Amano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Masayuki Ueda
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Tokyo, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan.
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Cottereau A, Robert R, le Gouge A, Adda M, Audibert J, Barbier F, Bardou P, Bourcier S, Boyer A, Brenas F, Canet E, Da Silva D, Das V, Desachy A, Devaquet J, Embriaco N, Eon B, Feissel M, Friedman D, Ganster F, Garrouste-Orgeas M, Grillet G, Guisset O, Guitton C, Hamidfar-Roy R, Hyacinthe AC, Jochmans S, Lion F, Jourdain M, Lautrette A, Lerolle N, Lesieur O, Mateu P, Megarbane B, Mercier E, Messika J, Morin-Longuet P, Philippon-Jouve B, Quenot JP, Renault A, Repesse X, Rigaud JP, Robin S, Roquilly A, Seguin A, Thevenin D, Tirot P, Contentin L, Kentish-Barnes N, Reignier J. ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study. Intensive Care Med 2016; 42:1248-57. [PMID: 27155604 DOI: 10.1007/s00134-016-4373-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods. METHODS From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item. RESULTS Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity. CONCLUSION Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.
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Affiliation(s)
- Alice Cottereau
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - René Robert
- Medical Intensive Care Unit, University Hospital, Poitiers, France.,INSERM CIC 1402, Equipe 5 ALIVE, University Hospital, Poitiers, France
| | - Amélie le Gouge
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Mélanie Adda
- Medical Intensive Care Unit, University Hospital, Hopital Nord, Marseille, France
| | - Juliette Audibert
- Medical-Surgical Intensive Care Unit, District Hospital Center, Chartres, France
| | - François Barbier
- Orléans Medical Intensive Care Unit, District Hospital Center, Orléans, France
| | - Patrick Bardou
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montauban, France
| | - Simon Bourcier
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - François Brenas
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Puy-En-Velay, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Da Silva
- Medical-Surgical Intensive Care Unit, Delafontaine Hospital Center, Saint-Denis, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, District Hospital Center, Angoulême, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Foch Hospital Center, Suresnes, France
| | - Nathalie Embriaco
- Medical-Surgical Intensive Care Unit, District Hospital Center, Toulon, France
| | - Beatrice Eon
- Medical Intensive Care Unit, University Hospital, Hopital La Timone, Marseille, France
| | - Marc Feissel
- Medical-Surgical Intensive Care Unit, District Hospital Center, Belfort, France
| | - Diane Friedman
- Medical Intensive Care Unit, Raymond Poincaré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Garches, France
| | - Frédérique Ganster
- Medical-Surgical Intensive Care Unit, District Hospital Center, Mulhouse, France
| | | | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Olivier Guisset
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France
| | | | | | | | - Sebastien Jochmans
- Medical-Surgical Intensive Care Unit, Marc Jaquet Hospital Center, Melun, France
| | - Fabien Lion
- Medical-Surgical Intensive Care Unit, Institut Gustave Roussy, Villejuif, France
| | - Mercé Jourdain
- Medical Intensive Care Unit, University Hospital, Lille, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Nicolas Lerolle
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - Olivier Lesieur
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Rochelle, France
| | - Philippe Mateu
- Medical-Surgical Intensive Care Unit, District Hospital Center, Charleville-Mézières, France
| | - Bruno Megarbane
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Jonathan Messika
- Medical-Surgical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Colombes, France
| | - Paul Morin-Longuet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Saint-Nazaire, France
| | | | | | - Anne Renault
- Medical Intensive Care Unit, La Cavale Blanche University Hospital, Brest, France
| | - Xavier Repesse
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Boulogne, France
| | | | - Ségolène Robin
- Surgical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Antoine Roquilly
- Surgical Intensive Care Unit, Hotel Dieu University Hospital, Nantes, France
| | - Amélie Seguin
- Medical Intensive Care Unit, Côte de Nacre University Hospital, Caen, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lens, France
| | - Patrice Tirot
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Mans, France
| | - Laetitia Contentin
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Nancy Kentish-Barnes
- Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Diderot Sorbonne University, Paris, France
| | - Jean Reignier
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France. .,Service de Réanimation Médicale, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France.
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Ryu HG, Choi JE, Lee S, Koh J, Bae JM, Heo DS. Survey of controversial issues of end-of-life treatment decisions in Korea: similarities and discrepancies between healthcare professionals and the general public. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R221. [PMID: 24093519 PMCID: PMC4056664 DOI: 10.1186/cc13042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 08/07/2013] [Indexed: 11/19/2022]
Abstract
Introduction End-of-life (EOL) treatment issues have recently gained societal attention after the Korean Supreme Court’s ruling that the presumed wishes of an elderly woman in a persistent vegetative state (PVS) should be honored. We tried to evaluate what Koreans thought about controversial issues regarding EOL treatments. Methods We surveyed Koreans with the following questions: 1) are ventilator-dependent PVS patients candidates for end-of life treatment decisions? 2) Is withholding and withdrawing EOL treatment the same thing? 3) In an unconscious, terminally ill patient, whose wishes are unknown, how should EOL decisions be made? 4) How should we settle disagreement amongst medical staff and the patient’s family on EOL decisions? Results One thousand Koreans not working in healthcare and five hundred healthcare professionals responded to the survey. Fifty-seven percent of Koreans not working in healthcare and sixty seven percent of Korean healthcare professionals agreed that ventilator-dependent PVS patients are candidates for EOL treatment decisions. One quarter of all respondents regarded withholding and withdrawing EOL treatment as equal. Over 50% thought that EOL treatment decisions should be made through discussions between the physician and the patient’s family. For conflict resolution, 75% of Koreans not working in healthcare preferred direct settlement between the medical staff and the patient’s family while 55% of healthcare professionals preferred the hospital ethics committee. Conclusions Unsettled issues in Korea regarding EOL treatment decision include whether to include ventilator-dependent PVS patients as candidates of EOL treatment decision and how to sort out disagreements regarding EOL treatment decisions. Koreans viewed withholding and withdrawing EOL treatment issues differently.
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Clarke G, Harrison K, Holland A, Kuhn I, Barclay S. How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review. PLoS One 2013; 8:e61475. [PMID: 23613857 PMCID: PMC3628879 DOI: 10.1371/journal.pone.0061475] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 03/10/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity. METHODS AND FINDINGS We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles. CONCLUSIONS When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.
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Affiliation(s)
- Gemma Clarke
- CLAHRC End of Life Care, University of Cambridge, Cambridge, United Kingdom.
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Duke G. Attitudes regarding life-sustaining measures in people born in Japan, China, and Vietnam and living in Texas. Int J Palliat Nurs 2013; 19:76-83. [PMID: 23435536 DOI: 10.12968/ijpn.2013.19.2.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cultural beliefs about and preferences for care at the end of life are diverse and unique in many respects. This descriptive qualitative study presents findings about the attitudes and preferences of people born in Japan, China, and Vietnam and living in the southern part of the USA regarding life-sustaining measures. In-depth personal and focus group interviews were conducted with 46 participants and thematic analysis completed. The findings reflected some similarities and differences among the three groups concerning initiation and discontinuance of artificial nutrition and mechanical ventilation. They also demonstrated the requirement for sensitivity to individual needs when honouring the wishes of patients and surrogate decision makers. Interventional studies should follow that test educational strategies to improve practice outcomes for health-care providers who care for these populations at this vulnerable time of life.
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Rabkin J, Ogino M, Goetz R, McElhiney M, Marziliano A, Imai T, Atsuta N, Morita M, Tateishi T, Matsumura T, Mitsumoto H. Tracheostomy with invasive ventilation for ALS patients: neurologists' roles in the US and Japan. Amyotroph Lateral Scler Frontotemporal Degener 2012; 14:116-23. [PMID: 23039060 DOI: 10.3109/17482968.2012.726226] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Our objective was to determine whether substantial differences in rates of TIV utilization in the U.S. and Japan are associated with the role of the treating neurologist. Questionnaires in English and Japanese were sent to neurologists who treated ALS patients in both countries. Questions included queries about rates of TIV use in their practices, level of encouragement of TIV use, the role of the neurologist in TIV decision making, management of patient/family requests to discontinue TIV once initiated, and personal choices if neurologists themselves had ALS. Results showed that 84% of American neurologists reported fewer than 10% of their patients had TIV, compared to 32% of Japanese. Americans less often encouraged TIV use (79% of American and 36% of Japanese seldom or never suggested or encouraged TIV). Finally, neurologists were asked whether they would choose TIV for themselves in the hypothetical scenario where they had ALS: over 70% of both groups declined TIV for themselves. In conclusion, consistent with past findings, Japanese neurologists were more likely to recommend TIV and more of their patients received TIV. Both groups believed their recommendations influence patient decisions. While Americans seldom recommended TIV to patients and most would not choose TIV for themselves, Japanese neurologists' recommendations and personal choices diverged.
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Affiliation(s)
- Judith Rabkin
- New York State: Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA.
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Aita K, Kai I. Physicians' psychosocial barriers to different modes of withdrawal of life support in critical care: A qualitative study in Japan. Soc Sci Med 2009; 70:616-22. [PMID: 19932548 DOI: 10.1016/j.socscimed.2009.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Indexed: 11/28/2022]
Abstract
Despite a number of guidelines issued in Anglo-American countries over the past few decades for forgoing treatment stating that there is no ethically relevant difference between withholding and withdrawing life-sustaining treatments (LST), it is recognized that many healthcare professionals in Japan as well as some of their western counterparts do not agree with this statement. This research was conducted to investigate the barriers that prevent physicians from withdrawing specific LST in critical care settings, focusing mainly on the modes of withdrawal of LST, in what the authors believe was the first study of its kind anywhere in the world. In 2006-2007, in-depth, face-to-face, semistructured interviews were conducted with 35 physicians working at emergency and critical care facilities across Japan. We elicited their experiences, attitudes, and perceptions regarding withdrawal of mechanical ventilation and other LST. The process of data analysis followed the grounded theory approach. We found that the psychosocial resistance of physicians to withdrawal of artificial devices varied according to the modes of withdrawal, showing a strong resistance to withdrawal of mechanical ventilation that requires physicians to halt the treatment when continuation of its mechanical operation is possible. However, there was little resistance to the withdrawal of percutaneous cardiopulmonary support and artificial liver support when their continuation was mechanically or physiologically impossible. The physicians shared a desire for a "soft landing" of the patient, that is, a slow and gradual death without drastic and immediate changes, which serves the psychosocial needs of the people surrounding the patient. For that purpose, vasopressors were often withheld and withdrawn. The findings suggest what the Japanese physicians avoid is not what they call a life-shortening act but an act that would not lead to a soft landing, or a slow death that looks 'natural' in the eyes of those surrounding the patient. The purpose of constructing such a final scene is believed to fulfill the psychosocial needs of the patient's family and the physicians, who emphasize on how death feels to those surrounding the patient. Unless withdrawing LST would lead to a soft landing, Japanese clinicians, who recognize that the results of withdrawing LST affect not only the patient but those around the patient, are likely to feel that there is an ethically relevant difference between withholding and withdrawing LST.
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Affiliation(s)
- Kaoruko Aita
- The University of Tokyo, Graduate School of Humanities and Sociology, Global COE Programme Death and Life Studies, 7-3-1 Hongo, Bunkyo-ku, Tokyo113-0033, Japan.
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