Respecting autonomy in difficult medical settings: a questionnaire study 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.

Fragilising clients: A positioning analysis of identity construction during clinical psychology trainees' supervision

CONTEXT

Western mental healthcare system reforms prioritise person-centred care and require clinicians to adjust their professional positions. Realising these reforms will necessitate clinicians-including clinical psychologists-acquiring professional identities that align with them. Learners develop professional identities through socialisation activities: within interactional spaces such as supervision learners come to understand the self (clinician) and, by extension, the other (client). A clinician's understanding of who I am is intertwined with an understanding of who they are. Our study offers a moment-by-moment examination of supervision interactions of clinical psychology trainees to illuminate processes through which the identities of therapists and clients are constructed.

AIM

We examined how clinical psychology trainees and supervisors construct identities for themselves and clients in supervision.

METHODS

We used positioning analysis to explore identity construction during interactions between supervisors (n = 4) and trainees (n = 12) in a clinical psychology training clinic. Positioning analysis focuses on the linguistic choices participants make as they position themselves (and others) in certain social spaces during everyday interactions. Twelve supervision sessions were audio recorded and transcribed. We found that clients were frequently positioned as fragile and subsequently analysed these sequences (n = 12).

RESULTS

Clients' identities were constructed as fragile, which co-occurred with clinical psychologists' claiming positions as responsible for managing their distress. Supervisors played an active role in linguistically positioning clients and trainees in this way. Trainees rarely contested the identities made available to them by supervisors.

DISCUSSION AND CONCLUSION

We suggest that linguistically positioning clients as fragile perpetuates paternalistic clinical discourses that do not align with mental healthcare reform priorities. We make visible how this is achieved interactionally through language and influenced by organisational power relations. Intentional efforts are required to support the professional identity construction of clinical psychologists in ways that do not perpetuate paternalism. We offer recommendations for education and clinical practice to support these efforts.

Genetic testing decision-making experiences within families of colorectal cancer patients: A qualitative study

PURPOSE

Genetic testing is the gold standard for the diagnosis of hereditary colorectal cancer syndromes but is currently inadequate and nonideal. The decision-making processes regarding genetic testing are even less well known. The present study aims to explore the decision-making experience of genetic testing for colorectal cancer patients and their family members.

METHOD

A descriptive qualitative study was employed. Data were collected using individual semi-structured interviews with 5 colorectal cancer patients and 20 family members from November 2020 to April 2021. Interviews were transcribed and analysed using inductive content analysis.

RESULTS

Four categories were identified: 1) the source of information for genetic testing, 2) the differentiated attitudes towards genetic testing, 3) genetic testing decisional needs, and 4) the factors influencing genetic testing decision-making. Colorectal cancer patients and their families engaged in two distinct pathways to genetic testing decisions: direct decision-making and indirect decision-making. Throughout these processes, due to the limited source of information, they had information needs that were met and facilitated genetic testing decision-making.

CONCLUSIONS

Colorectal cancer patients and family members need knowledge related to genetic testing, but they have limited access to information, which prevents them from making informed decisions. Providing decision aid interventions and informational support are significant steps towards addressing the support needs of this population.

Key components of the mental capacity assessment of patients with anorexia nervosa: a study of three countries

BACKGROUND

Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment.

METHODS

A questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders.

RESULTS

A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference.

CONCLUSIONS

It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.

International comparison of physicians' attitudes toward refusal of treatment by patients with anorexia nervosa: a case-based vignette study

BACKGROUND

This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa.

METHODS

A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa.

RESULTS

For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient.

CONCLUSIONS

Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment.

Challenges and solutions in the continuity of home care for rural older people: A thematic analysis

Home care is essential for the continuity of care, but rural communities struggle to procure these services regularly. As rural populations age, these difficulties may be exacerbated. This study examines the challenges and solutions for offering home care in rural areas. Healthcare professionals held focus groups and one-on-one interviews in rural communities, and these interviews were recorded and analyzed using thematic analysis. Changing rural contexts, stakeholder relationships, and sustainable communities were the primary themes. Increasing knowledge, sharing information, and dialogue among stakeholders were also crucial. Collaboration between professions may also create more sustainable home care in rural communities.

Attitudes Towards Prenatal Genetic Counseling, Prenatal Genetic Testing, and Termination of Pregnancy among Southeast and East Asian Women in the United States

Recognizing the heterogeneity of the Asian population with regards to acculturation, education, health awareness, and cultural values is vital for tailoring culturally sensitive and appropriate care. Prior studies show that cultural values influence perceptions of genetics within Asian populations. The reputation of the family unit factors into decisions such as pregnancy termination and disclosure of family medical history, and the nondirective model of American genetic counseling may conflict with the historical Asian model of paternalistic health care. Previous studies also provide conflicting evidence regarding correlations between education, acculturation, age, and awareness and perceptions of genetic testing. The aims of this study were to describe attitudes towards prenatal genetics among Southeast and East Asian women living in the United States for varying amounts of time and to explore sociocultural factors influencing those attitudes. Twenty-three Asian women who were members of Asian cultural organizations in the United States were interviewed via telephone about their attitudes towards prenatal genetic counseling, prenatal genetic testing, and termination of pregnancy. Responses were transcribed and coded for common themes using a thematic analysis approach. Four major themes emerged. In general, participants: (1) had diverse expectations for genetic counselors; (2) tended to weigh risks and benefits with regards to genetic testing decisions; (3) had mixed views on termination for lethal and non-lethal genetic conditions; and (4) identified cultural factors which influenced testing and termination such as lack of available resources, societal shame and stigma, and family pressure. These findings may allow prenatal genetic counselors to gain a richer, more nuanced understanding of their Asian patients and to offer culturally tailored prenatal genetic counseling.

Shared Decision-Making in Patients With Prostate Cancer in Japan: Patient Preferences Versus Physician Perceptions

This article adds the Japanese perspective to our knowledge of shared decision-making (SDM) preferences by surveying patients with prostate cancer (PCA) and physicians in Japan. In 2015, 103 Japanese patients with PCA were asked about their SDM preferences by using an Internet-based 5-point-scale questionnaire. Concurrently, 127 Japanese physicians were surveyed regarding their perceptions of patient preferences on SDM. Drivers of preferences and perceptions were analyzed using univariable ordinal logistic regression and graphing the fitted response probabilities. Although 41% of both patients and physicians expressed and expected a desire for active involvement in treatment decisions (a higher rate than in a similar study for the United States in 2001), almost half the Japanese patients preferred SDM, but only 33% of physicians assumed this was their choice. That is, 29% of Japanese physicians underestimated patients’ preference for involvement in making treatment decisions. Patients with lower health-related quality of life (as measured by the Functional Assessment of Cancer Therapy-Prostate [FACT-P]) expressed a stronger preference for SDM. The study shows that the worse the medical situation, the more patients with PCA prefer to be involved in the treatment decision, yet physicians tend to underestimate the preferences of their patients. Perhaps in contrast to common assumptions, Japanese patients are as interested in being involved in decision making as are patients in the United States.

Gender differences in the perception of difficulty of self-management in patients with diabetes mellitus: a mixed-methods approach

Aim

The aim of this study was to examine the challenges of self-management of diabetes comparing gender.

Methods

Sixty-four women and 129 men (mean age 63 vs. 60 years) with diabetes mellitus (DM) were interviewed using 12 categories (classification codes b1300, d240, d570, d620, d845, d920, e410 + e414, e420, e425, e465, e560) related to self-care management selected from 99 categories of the International Classification of Functioning, Disability and Health (ICF) Core Set for DM. In a mixed-methods analysis, interviews were analyzed according to the Grounded Theory approach, and gender effects on ICF categories related to self-care management were investigated using logistic models.

Results

In quantitative data, compared with men, women tended to experience greater difficulty obtaining foods/ingredients for well-balanced meals to maintain appropriate glucose level (P = 0.004); handling stress and other psychological demands around diabetes treatment (P = 0.034); and social norms, practices, and ideologies that defined an experience of unpleasant treatment after disclosure of DM diagnosis to close family and friends (P = 0.023). Qualitative data shows that women perceived prejudice against people with DM from close family, friends, and neighbors. In contrast, men reported excessive media information on diabetes treatment, which induced prejudice by family members and at the workplace.

Conclusions

Women were more likely to be sensitive to attention from close family and friends, whereas men were more likely to be occupied by work and daily living concerns. Health professionals should pay attention to such gender differences in a patient-professional relationship.

Young adult preferences for physician decision-making style in Japan and the United States

Studies in Japan and the United States investigate preferences for patient-physician decision-making style among young adults in the context of a primary care clinic visit for an upper respiratory infection. A treatment scenario described 1 of 3 decision-making styles: a young adult and doctor using a passive (physician decides), shared (patient and physician decide together), or autonomous (patient decides from a set of medically appropriate alternatives) decision-making style. Unexpectedly, Japanese respondents evaluated the autonomous interaction most positively. US respondents evaluated the shared decision-making scenario most positively. Overall, despite large cultural differences, both country samples favored higher participation in decision making. These results suggest that passive patient approaches are falling out of favor as patient-centered care expectations diffuse globally, even in traditionally hierarchic societies with high levels of respect for authority. The implications of these findings along with managerial implications and suggestions for future research are presented.

Japanese cancer patient participation in and satisfaction with treatment-related decision-making: A qualitative study

Background

Over the last decade, patient involvement in treatment-related decision-making has been widely advocated in Japan, where patient-physician encounters are still under the influence of the long-standing tradition of paternalism. Despite this profound change in clinical practice, studies investigating the actual preferences of Japanese people regarding involvement in treatment-related decision-making are limited. The main objectives of this study were to (1) reveal the actual level of involvement of Japanese cancer patients in the treatment-related decision-making and their overall satisfaction with the decision-making process, and (2) consider the practical implications of increased satisfaction in cancer patients with regard to the decision-making process.

Methods

We conducted semi-structured interviews with 24 Japanese cancer patients who were recruited from a cancer self-help group in Tokyo. The interviews were qualitatively analysed using the approach described by Lofland and Lofland.

Results

The analyses of the patients' interviews focused on 2 aspects: (1) who made treatment-related decisions (the physician or the patient), and (2) the informants' overall satisfaction with the decision-making process. The analyses revealed the following 5 categories of decision-making: 'patient as the active decision maker', 'doctor selection', 'wilfully entrusting the physician', 'compelled decision-making', and 'surrendering decision-making'. While the informants under the first 3 categories were fairly satisfied with the decision-making process, those under the latter 2 were extremely dissatisfied. Informants' views regarding their preferred role in the decision-making process varied substantially from complete physician control to complete patient control; the key factor for their satisfaction was the relation between their preferred involvement in decision-making and their actual level of involvement, irrespective of who the decision maker was.

Conclusion

In order to increase patient satisfaction with regard to the treatment-related decision-making process, healthcare professionals in Japan must assess individual patient preferences and provide healthcare accordingly. Moreover, a better environment should be created in hospitals and in society to facilitate patients in expressing their preferences and appropriate resources need to be made available to facilitate their decision-making process.

Patient autonomy preferences among hypertensive outpatients in a primary care setting in Japan

OBJECTIVES

To investigate autonomy preferences and the factors to promote active patient participation in a primary care setting in Japan.

PATIENTS

Ninety-two hypertensive outpatients who consecutively visited a Japanese hospital between January and May of 2005 in Tokyo, Japan.

METHODS

This cross-sectional study was conducted by using a self-administered questionnaire. The main outcome measures were patient preferences for autonomy (i.e., decision-making and information-seeking preferences), measured by the Autonomy Preference Index (API). The variables studied were patient sociodemographic characteristics, physician characteristics based on patient preference (i.e., ability to communicate, extent of clinical experience, qualifications, educational background, gender, and age), and the Multidimensional Health Locus of Control.

RESULTS

On the API scale from 0 to 100, the patients had an intermediate desire for decision-making (median: 51) and a greater desire for information (median: 95). A multivariate regression model indicated that decision-making preference increased when patients were woman and decreased as physician age increased, and information-seeking preference was positively associated with good communication skills, more extensive clinical experience, physicians of middle age, and patient beliefs that they were responsible for their own health, and was negatively associated with a preference for man physicians.

CONCLUSIONS

Physicians may need to understand that patient autonomy preferences pertain to physician age and gender, physician communication ability and extent of clinical experience, and patient beliefs about self-responsibility toward health, and could use the information to promote reliable patient-physician relationships.

Why are physicians not persuaded by scientific evidence? A grounded theory interview study

Background

The government-led "evidence-based guidelines for cataract treatment" labelled pirenoxine and glutathione eye drops, which have been regarded as the standard care for cataracts in Japan, as lacking evidence of effectiveness, causing great upset among ophthalmologists and professional ophthalmology societies. This study investigated the reasons why such "scientific evidence of treatment effectiveness" is not easily accepted by physicians, and thus, why they do not change their clinical practices to reflect such evidence.

Methods

We conducted a qualitative study based on grounded theory to explore physicians' awareness of "scientific evidence" and evidence-supported treatment in relation to pirenoxine and glutathione eye drops, and to identify current barriers to the implementation of evidence-based policies in clinical practice. Interviews were conducted with 35 ophthalmologists and 3 general practitioners on their prescribing behaviours, perceptions of eye drop effectiveness, attitudes toward the eye drop guideline recommendations, and their perceptions of "scientific evidence."

Results

Although few physicians believed that eye drops are remarkably effective, the majority of participants reported that they prescribed eye drops to patients who asked for them, and that such patients accounted for a considerable proportion of those with cataracts. Physicians seldom attempted to explain to patients the limitations of effectiveness or to encourage them to stop taking the eye drops. Physicians also acknowledged the benefits of prescribing such drugs, which ultimately outweighed any uncertainty of their effectiveness. These benefits included economic incentives and a desire to be appreciated by patients. Changes in clinical practice were considered to bring little benefit to physicians or patients. Government approval, rarity of side effects, and low cost of the drops also encouraged prescription.

Conclusion

Physicians occasionally provide treatment without expecting remarkable therapeutic effectiveness, as exemplified by the use of eye drops. This finding highlights that scientific evidence alone cannot easily change physicians' clinical practices, unless evidence-based practices are accepted by the general public and supported by health policy.

Acceptance, motivators, and barriers in attending breast cancer genetic counseling in Asians

AIM

Cancer genetic risk assessment clinics represent the primary prevention arm in oncology in identifying high-risk patients for screening and prevention, but deals with the taboo subject of cancer risk prediction. Low knowledge level and traditional beliefs may pose significant barriers to its acceptance in Asia.

METHODS

We conducted a questionnaire survey to evaluate the acceptance of breast cancer genetic counseling.

RESULTS

More than 70% of the 438 respondents indicated interest and perceived potential benefits. Higher education level and use of English were associated with greater acceptance. Learning about cancer risk and cancer detection, helping the family, and the doctor's recommendation, were important motivators, while misperception that cancer patients could not gain personally, concerns of not understanding the information, cost issues, and fears of bad news, were important barriers.

CONCLUSIONS

Singaporean women were receptive to cancer genetics counseling. Education to correct misperceptions may optimize utilization of a cancer genetics service.

Decision-making models in Japanese psychiatry: transitions from passive to active patterns

This study deconstructs the current dynamics of the physician-patient relationship in the treatment of minor mood disorders including depression in Japan. An in-depth qualitative investigation was conducted on psychiatrists employed at mental health clinics, university hospitals, and psychiatric hospitals. Triangulation was conducted concurrently using key informant interviews and periodic non-structured interviews with additional physicians and patients. Results revealed two patterns of omakase (entrusting) (Omakase Model) and an emerging pattern of patient participation in decision making (Participatory Model). The pattern traditionally denoted by the Omakase Model encompasses an active and passive entrusting model. The phenomenon of an emerging Participatory Model was uncovered whereby an in-depth analysis led to an understanding behind the associative physician-patient relationship, communication patterns, and a patient's level of awareness. It was found that while active participation in medical decision making is capable of raising the level of treatment efficacy, it is not only active participation in medical decision making, but also active participation in medical treatment that is valued in the physician-patient relationship. Ultimately, a patient actively participates in his or her medical treatment under either the active Omakase Model or Participatory Model, be it entrusting or participatory. Consequently, the active Omakase Model will continue to remain functional alongside the Participatory Model while the passive Omakase Model is likely to fade away in time.

Patients' preferences for involvement in treatment decision making in Japan

BACKGROUND

A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.

METHODS

The subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement.

RESULTS

134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physician's recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physician's opinion, while few respondents would give the family's preference primary importance.

CONCLUSIONS

Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

The importance of paternal family history in hereditary breast cancer is underappreciated by health care professionals

OBJECTIVES

Cancer genetics clinics have been established in many major oncology centers worldwide in recent years. For such specialized clinics to fulfill their function, primary care physicians need to identify high-risk patients for referral.

METHODS

We conducted a survey to evaluate the level of awareness of breast cancer risk factors and hereditary breast cancer among health care providers and patients.

RESULTS

284 health care professionals, 221 medical students, 104 breast cancer patients and 177 cancer-free women participated in the study. Less than half of the patients with breast cancer were aware of their risk for another breast cancer or of the increased breast cancer risk of their sisters and daughters. Less than one quarter of the health care professionals and medical students knew the importance of paternal family history in the evaluation for hereditary breast cancer. Only about half of the health care professionals and medical students and less than one third of the breast cancer patients and cancer-free women knew about genetic testing and prophylactic mastectomy as options for women at risk for hereditary breast cancer.

CONCLUSIONS

Health care providers and medical students lack basic genetic knowledge and are not aware of emerging diagnostic and preventive options for hereditary breast cancer. Inclusion of cancer genetics in the continuing medical education of health care providers is important to promote such awareness.