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      End-of-life considerations in the ICU in Japan: ethical and legal perspectives

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          Abstract

          In Japan, the continuation of critical care at the end of life is a common practice due to the threat of legal action against physicians that may choose a palliative care approach. This is beginning to change due to public debate related to a series of controversial incidents concerning end-of-life care over the last decade. In this review we contrast and compare the history and evolution of end-of-life care in Japan vs. the USA and other Asian countries. Efforts by the Japanese Society of Intensive Care Medicine (JSICM) to establish better end-of-life care systems, as well as future directions in palliative care in Japan, are discussed.

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          Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.

          Robert Truog, Margaret Campbell, J Randall Curtis … (2008)
          These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
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            International differences in end-of-life attitudes in the intensive care unit: results of a survey.

            M Luce, M. Levy, Arino Yaguchi … (2005)
            Important international differences exist in attitudes toward end-of-life issues in the intensive care unit. A simple questionnaire survey was sent by e-mail to participants at an international meeting on intensive care medicine. Respondents were asked to choose 1 of 3 to 5 possible answers for each of 4 questions related to the treatment of a hypothetical patient in a vegetative state due to anoxic encephalopathy after cardiac arrest with no family and no advance directives. From 3494 valid addresses, 1961 complete questionnaires (56%) were received from 21 countries. Sixty-two percent of physicians from Northern and Central Europe said they involved nurses in end-of-life discussions compared with only 32% of physicians in Southern Europe, 38% in Brazil, 39% in Japan, and 29% in the United States (P<.001 for all comparisons). Written do-not-resuscitate orders were preferred in Northern and Central Europe, whereas oral orders took preference in Southern Europe, Turkey, and Brazil. One third of Japanese physicians said that they would not apply do-not-resuscitate orders. Most participants from Japan, Turkey, the United States, Southern Europe, and Brazil chose to treat the hypothetical patient with antibiotics if he/she developed septic shock, whereas in Northern Europe, Central Europe, Canada, and Australia, terminal withdrawal of mechanical ventilation and extubation were the more commonly chosen responses. In countries where intensive care medicine is relatively well developed, considerable differences remain in physicians' attitudes toward end-of-life care in the intensive care unit. Substantial work remains if an international consensus on these issues is to be reached.
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              Ethnicity and attitudes towards life sustaining technology.

              L Blackhall, G. Frank Gerberick, Peter Murphy … (1999)
              The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.
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                Author and article information

                Contributors
                Jun Makino: drjunmakino@gmail.com
                Shigeki Fujitani: shigekifujitani@gmail.com
                Bridget Twohig: bridget.twohig@mountsinai.org
                Steven Krasnica: steven.krasnica@mountsinai.org
                John Oropello: john.oropello@mountsinai.org
                Journal
                Journal ID (nlm-ta): J Intensive Care
                Journal ID (iso-abbrev): J Intensive Care
                Title: Journal of Intensive Care
                Publisher: BioMed Central (London )
                ISSN (Electronic): 2052-0492
                Publication date (Electronic): 18 February 2014
                Publication date PMC-release: 18 February 2014
                Publication date Collection: 2014
                Volume: 2
                Issue: 1
                Electronic Location Identifier: 9
                Affiliations
                [ ]Department of Critical Care Medicine, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1264, New York, NY 10029 USA
                [ ]Clinical Professor of Emergency/Critical Care Medicine Department, St. Marianna Medical School, 2-16-1 Sugao Miyamae-ku, 216-8511 Kawasaki City, Kanagawa, Prefecture, Japan
                Article
                Publisher ID: 18
                DOI: 10.1186/2052-0492-2-9
                PMC ID: 4267582
                PubMed ID: 25520825
                SO-VID: f71e01f0-b7c0-4987-875c-3c533f809e11
                Copyright © © Makino et al.; licensee BioMed Central Ltd. 2014
                License:

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 10 September 2013
                Date accepted : 21 January 2014
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © BioMed Central Ltd 2014

                Keywords: end-of-life,icu,japan,usa,east,asian countries,palliative care,advance directive,living will
                Data availability:
                Keywords: end-of-life, icu, japan, usa, east, asian countries, palliative care, advance directive, living will

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