Cross-sectional survey of surrogate decision-making in Japanese medical practice

Palliative Extubation: A Discussion of Practices and Considerations

Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.

“What are the roles and competencies of doctors in the artificial intelligence implementation society?: A qualitative analysis through physician interview” (Preprint)

BACKGROUND

Artificial intelligence (AI) is a term used to describe the use of computers and technology to emulate human intelligence mechanisms. Although AI is known to affect health services, the impact of information provided by AI on the patient-physician relationship in actual practice is unclear.

OBJECTIVE

The purpose of this study is to investigate the effect of introducing AI functions into the medical field on the role of the physician or physician-patient relationship, as well as potential concerns in the AI era.

METHODS

We conducted focus group interviews in Tokyo's suburbs with physicians recruited through snowball sampling. The interviews were conducted in accordance with the questions listed in the interview guide. A verbatim transcript recording of all interviews was qualitatively analyzed using content analysis by all authors. Similarly, extracted code was grouped into subcategories, categories, and then core categories. We continued interviewing, analyzing, and discussing until we reached data saturation. In addition, we shared the results with all interviewees and confirmed the content to ensure the credibility of the analysis results.

RESULTS

A total of 9 participants who belonged to various clinical departments in the 3 groups were interviewed. The same interviewers conducted the interview as the moderator each time. The average group interview time for the 3 groups was 102 minutes. Content saturation and theme development were achieved with the 3 groups. We identified three core categories: (1) functions expected to be replaced by AI, (2) functions still expected of human physicians, and (3) concerns about the medical field in the AI era. We also summarized the roles of physicians and patients, as well as the changes in the clinical environment in the age of AI. Some of the current functions of the physician were primarily replaced by AI functions, while others were inherited as the functions of the physician. In addition, "functions extended by AI" obtained by processing massive amounts of data will emerge, and a new role for physicians will be created to deal with them. Accordingly, the importance of physician functions, such as responsibility and commitment based on values, will increase, which will simultaneously increase the expectations of the patients that physicians will perform these functions.

CONCLUSIONS

We presented our findings on how the medical processes of physicians and patients will change as AI technology is fully implemented. Promoting interdisciplinary discussions on how to overcome the challenges is essential, referring to the discussions being conducted in other fields.

Case report on the legal assurance of Advance Care Planning in collective culture

This case report shows that there is a lack of a legal framework in Japan to protect patients' right during the end‐of‐life period, which hinders the implementation of ACP in medical practice. This report suggests that legal support can contribute to the advancement of ACP while addressing cultural differences.

Advance Care Planning has been widely advocated in Japan, but it has not yet taken root. The collective decision making culture in Japan may unconsciously overpower or ignore the patients' wishes, hence legal support can mitigate its negative impacts on ACP.