Withdrawal of care in Japan

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens

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.

Advance directives in Japanese nursing homes

CONTEXT

Advance directives are poorly understood in Japanese nursing homes. In April 2006, additional funding for end-of-life care became available as the first support for terminal care at Japanese nursing homes.

OBJECTIVES

The objectives of this study were to investigate the adoption of advance directives by Japanese nursing homes, the effect of additional funding for end-of-life care in nursing homes from long-term care insurance on the use of advance directives, and the types of directives used.

METHODS

A nationwide questionnaire survey of nursing homes was performed in Japan. The participants were 913 nursing homes. We investigated the prevalence of advance directives, details of the directives, and demographic data of the responders.

RESULTS

Advance directives were used in 58.4% of nursing homes. The timing of introduction of the directives and the results of multivariate analysis at the facility level suggested a relation between the availability of additional funding for end-of-life care and the adoption of advance directives. Most nursing homes used instructional directives, especially directives providing an explanation and informed consent for end-of-life care in the nursing home.

CONCLUSION

More than half of Japanese nursing homes have introduced advance directives, and additional funding for end-of-life care is related to their introduction. Most nursing homes have adopted instructional directives, especially those providing an explanation and informed consent regarding end-of-life care at the nursing home.

Can physicians' judgments of futility be accepted by patients? A comparative survey of Japanese physicians and laypeople

Back ground

Empirical surveys about medical futility are scarce relative to its theoretical assumptions. We aimed to evaluate the difference of attitudes between laypeople and physicians towards the issue.

Methods

A questionnaire survey was designed. Japanese laypeople (via Internet) and physicians with various specialties (via paper-and-pencil questionnaire) were asked about whether they would provide potentially futile treatments for end-of-life patients in vignettes, important factors for judging a certain treatment futile, and threshold of quantitative futility which reflects the numerical probability that an act will produce the desired physiological effect. Also, the physicians were asked about their practical frequency and important reasons for futile treatments.

Results

1134 laypeople and 401 (80%) physicians responded. In all vignettes, the laypeople were more affirmative in providing treatments in question significantly. As the factors for judging futility, medical information and quality of life (QOL) of the patient were rather stressed by the physicians. Treatment wish of the family of the patient and psychological impact on patient side due to the treatment were rather stressed by laypeople. There were wide variations in the threshold of judging quantitative futility in both groups. 88.3% of the physicians had practical experience of providing futile treatment. Important reasons for it were communication problem with patient side and lack of systems regarding futility or foregoing such treatment.

Conclusion

Laypeople are more supportive of providing potentially futile treatments than physicians. The difference is explained by the importance of medical information, the patient family’s influence to decision-making and QOL of the patient. The threshold of qualitative futility is suggested to be arbitrary.

Physicians' psychosocial barriers to different modes of withdrawal of life support in critical care: A qualitative study in Japan

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.

Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study

Background

The question of whether to withhold artificial nutrition and hydration (ANH) from severely cognitively impaired older adults has remained nearly unexplored in Japan, where provision of ANH is considered standard care. The objective of this study was to identify and analyze factors related to the decision to provide ANH through percutaneous endoscopic gastrostomy (PEG) in older Japanese adults with severe cognitive impairment.

Methods

Retrospective, in-depth interviews with thirty physicians experienced in the care of older, bed-ridden, non-communicative patients with severe cognitive impairment. Interview content included questions about factors influencing the decision to provide or withhold ANH, concerns and dilemmas concerning ANH and the choice of PEG feeding as an ANH method. The process of data collection and analysis followed the Grounded Theory approach.

Results

Data analysis identified five factors that influence Japanese physicians' decision to provide ANH through PEG tubes: (1) the national health insurance system that allows elderly patients to become long-term hospital in-patients; (2) legal barriers with regard to limiting treatment, including the risk of prosecution; (3) emotional barriers, especially abhorrence of death by 'starvation'; (4) cultural values that promote family-oriented end-of-life decision making; and (5) reimbursement-related factors involved in the choice of PEG. However, a small number of physicians did offer patients' families the option of withholding ANH. These physicians shared certain characteristics, such as a different perception of ANH and repeated communication with families concerning end-of-life care. These qualities were found to reduce some of the effects of the factors that favor provision of ANH.

Conclusion

The framework of Japan's medical-legal system unintentionally provides many physicians an incentive to routinely offer ANH for this patient group through PEG tubes. It seems apparent that end-of-life education should be provided to medical providers in Japan to change the automatic assumption that ANH must be provided.

Japanese physicians' practice of withholding and withdrawing mechanical ventilation and artificial nutrition and hydration from older adults with very severe stroke

Amid the lack of legislation or guidelines regarding withholding and withdrawing care in Japan, some physicians who have withdrawn mechanical ventilation from dying patients have recently been subjected to police investigations on suspicion of murder. Under the circumstances, we examined Japanese physicians' attitudes towards mechanical ventilation and artificial nutrition and hydration (ANH) as life-sustaining treatments (LST) to find out if they withhold or withdraw the LST when treating older adults with stroke-caused profound impairment with no hope for recovery. Face-to-face, in-depth interviews were conducted with 27 physicians ranging in age from 26 to 70 in 2004 mainly in the Tokyo metropolitan area. The study findings show that the informants held different views towards the two LST because most doctors considered ANH to be indispensable, while they did not think so for mechanical ventilation. Regarding the reasons that lead physicians to consider ANH is indispensable while mechanical ventilation is not, the following factors were identified: ANH's special status as food and water, ordinary/extraordinary, the level of technology, and sense of unnaturalness. Because of its indispensability, ANH is automatically provided, while mechanical ventilation could be withheld in some patients that the physicians have diagnosed to have no hope for recovery. The current legal framework in Japan, which poses legal risks for physicians when withdrawing care, have led some of the physicians to withdraw care in a secret manner, thus causing an unnecessary psychological burden on the physicians. This study indicated that the legal framework has possibly caused troubles in two ways: routinely providing patients with possibly unwanted mechanical ventilation and ANH, and conversely, prompting some doctors to withhold mechanical ventilation in some cases, thereby potentially depriving some patients of a chance to recover. The introduction of the practice of a trial treatment period may be more cogent, considering the inherent uncertainty of diagnoses. The findings of the study also indicated that the physician informants tended to view the value of maintaining the lives of non-communicative patients in terms of the relationships of such patients with others. The vulnerability of patients without strong relationships with others needs to be taken into consideration when compiling guidelines regarding withholding and withdrawing care in Japan.