Ethical decision making and patient autonomy: a comparison of physicians and patients in Japan and the United States

Preferences of bereaved family members on communication with physicians when discontinuing anticancer treatment: referring to the concept of nudges

BACKGROUND

This study aimed to clarify the situation and evaluate the communication on anticancer treatment discontinuation from the viewpoint of a bereaved family, in reference to the concept of nudges.

METHODS

A multi-center questionnaire survey was conducted involving 350 bereaved families of patients with cancer admitted to palliative care units in Japan.

RESULTS

The following explanations were rated as essential or very useful: (i) treatment would be a physical burden to the patient (42.9%), (ii) providing anticancer treatment was impossible (40.5%), (iii) specific disadvantages of receiving treatment (40.5%), (iv) not receiving treatment would be better for the patient (39.9%) and (v) specific advantages of not receiving treatment (39.6%). The factors associated with a high need for improvement of the physician's explanation included lack of explanation on specific advantages of not receiving treatment (β = 0.228, P = 0.001), and lack of explanation of 'If the patient's condition improves, you may consider receiving the treatment again at that time.' (β = 0.189, P = 0.008).

CONCLUSIONS

Explaining the disadvantages of receiving treatment and the advantages of not receiving treatment, and presenting treatment discontinuation as the default option were effective in helping patients' families in making the decision to discontinue treatment. In particular, explanation regarding specific advantages of not receiving treatment was considered useful, as they caused a lower need for improvement of the physicians' explanation.

Shared decision-making with athletes: a survey study of healthcare professionals' perspectives

Objectives

Shared decision-making (SDM) is a trending topic in athlete health care; however, little is known about its use in a sports context. This study aimed to measure knowledge and self-perceived practice of SDM among healthcare professionals working with athletes. This study evaluates SDM attitudes and preferences and explores how healthcare professionals perceive the factors influencing SDM.

Methods

A web-based cross-sectional survey with open-ended and closed-ended questions.

Results

Our survey was completed by 131 healthcare professionals. The majority (63.6%) reported to prefer SDM and to be confident in their SDM skills (81.1%). Despite this inclination and confidence, only one in four clinicians reported consistent practice of SDM when feasible. Additionally, most clinicians lacked SDM knowledge. The barriers perceived by healthcare professionals included time constraints (17.6%), limited patient knowledge (17.6%), limited patient motivation (13.5%) and language barriers (16.2%). Importantly, two-thirds of the participants believed that SDM in athlete health care differs from SDM in non-athletes due to the high-pressure environment, the tension between performance and health, and the involvement of multiple stakeholders with potentially conflicting interests.

Conclusions

Although healthcare professionals preferred SDM, they did not fully understand nor routinely practice it. Most healthcare professionals perceive SDM in athlete health care to differ from SDM in the general population. Therefore, to inform the implementation of SDM in athlete health care, future research is crucial to understand better what makes practising SDM unique in this setting.

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.

Family roles in informed consent from the perspective of young Chinese doctors: a questionnaire study

BACKGROUND

Based on the principle of informed consent, doctors are required to fully inform patients and respect their medical decisions. In China, however, family members usually play a special role in the patient's informed consent, which creates a unique "doctor-family-patient" model of the physician-patient relationship. Our study targets young doctors to investigate the ethical dilemmas they may encounter in such a model, as well as their attitudes to the family roles in informed consent.

METHODS

A questionnaire was developed including general demographic characteristics, the fulfillment of the obligation to fully inform, who will be informed, and the ethical dilemmas in decision-making. We recruited a total of 421 doctors to complete this questionnaire, of which 368 met the age requirements for this study. Cross tabulation and Pearson's chi-squared test were used to analyze the differences between types of patients for categorical variables, and a p-value < 0.05 was considered statistically significant.

RESULTS

Our data shows that only 20 doctors (5.40%) stated "informing the patient alone is sufficient" when it comes to informing patients of their serious conditions. The rest of the participants would ensure that the family was informed. When facing elderly patients with decision-making capacity, the data was statistically different (3.8%; P < 0.001) The primary reason for ensuring that family members be informed differs among the participants. In addition, when family members asked doctors to conceal the patient's medical condition for the best interests of patients, 270 doctors (73.4%) would agree and cooperate with the family. A similar proportion (79.6%) would do so when it comes to elderly patients.

CONCLUSIONS

(1) Chinese doctors pay extra attention to informing the patient's family, which may not be in the patient's best interests. (2) Chinese doctors treat adult (but not elderly) patients and elderly patients differently when it comes to informing family members. (3) When family members request that doctors withhold information from patients "in the best interest of the patient," the majority choose to comply with the request, although this may cause them distress.

Perspectives of hospitalized heart failure patients: preferred and perceived participation roles in treatment decisions

Shared decision-making (SDM) is a pivotal process in seeking optimal individual treatment and incorporating clinical evidence and patients' autonomous preferences. However, patients' actual attitudes toward participation in decision-making for state-of-the-art heart failure (HF) treatment remain unclear. We conducted a questionnaire-based survey distributed by nurses and physicians specializing in HF care to assess patients' preferred and perceived participation roles in treatment decision-making during the index hospitalization, rated on five scales (from extremely passive to purely autonomous attitudes). Simultaneously, we investigated the important factors underlying treatment decision-making from the perspective of hospitalized HF patients. Of the 202 patients who were approached by our multidisciplinary HF team between 2017 and 2020, 166 (82.2%) completed the survey. Logistic regression analyses were conducted to identify the clinical determinants of patients who reported that they left all decisions to physicians (i.e., extremely passive attitude). Of the 166 participants (male 67.5%, median age 73 years), 32.5% preferred an extremely passive attitude, while 61.4% reported that they actually chose an extremely passive attitude. A sole determinant of choosing an extremely passive decision-making role was lower educational status (odds ratio: 2.11, 95% confidence interval 1.11-4.00). The most important factor underlying the decision-making was "Physician recommendation" (89.2%). Notably, less than 50% considered "In alignment with my values and preferences" as an important factor underlying treatment decision-making. The majority of HF patients reported that they chose an extremely passive approach, and patients prioritized physician recommendation over their own values and preferences.

Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing

BACKGROUND

Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner.

METHODS

Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction.

DISCUSSION

In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful.

TRIAL REGISTRATION

The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.

Impact of value similarity on social trust in medical students: a cross-sectional web survey

BACKGROUND

Social trust in medical students is trust in the cluster of medical students and not individual medical students. Social trust in medical students seems critical in clinical practice since citizens often face unknown medical students for the first time. However, most previous research has focused on interpersonal trust in particular medical professions, and social trust in medical students has not been addressed sufficiently. In social science, the Salient Value Similarity model has demonstrated that the value similarity between professionals and citizens is associated with social trust. This research aimed to explore the relationship between social trust in medical students and the perception of value similarity. This study also aimed to determine whether the information of medical students strengthens social trust in them.

METHODS

We conducted a cross-sectional study to investigate how the perception of value similarity affects social trust. The participants answered the social trust questionnaires before and after reading a brief summary of the medical education curriculum and certification via the internet in Japan. The model structure of social trust in medical students, including the perception of value similarity, was investigated using SEM. A paired t-test was used to examine the effect of informing citizens about the knowledge, skills, and professionalism requirements of students attending medical school on social trust by reading the brief summary.

RESULTS

The study included 658 participants, who all answered a web questionnaire. Social trust in medical students was associated with the perception of ability and value similarity. Social trust in medical students, the perception of ability, and value similarity were improved by information about medical students.

CONCLUSIONS

The perception of ability and value similarity seem to affect social trust in medical students. Information on medical education regarding the knowledge, skills, and professionalism of medical students may improve social trust in these students. Further research is required to sophisticate the model of social trust in medical students by exploring social trust in the medical students' supervisors in clinical settings.

Factors Impacting Advance Decision Making and Health Care Agent Appointment among Taiwanese Urban Residents after the Passage of Patient Right to Autonomy Act

In recent years, advance care planning (ACP) promotion in Taiwan has expanded beyond clinical practice to the broader population. This study aims to investigate people's attitudes toward ACP and to identify factors influencing their signing of advance directives (ADs) and appointment of health care agents (HCAs).

METHODS

We identified 2337 ACP participants from consultation records between 2019 and 2020. The relationships among the participants' characteristics, AD completion, and HCA appointment were investigated.

RESULTS

Of 2337 cases, 94.1% completed ADs and 87.8% were appointed HCAs. Welfare entitlement (OR = 0.47, p < 0.001), the place ACP progressed (OR = 0.08, p < 0.001), the participation of second-degree relatives (OR = 2.50, p < 0.001), and the intention of not being a family burden (OR = 1.65, p = 0.010) were significantly correlated with AD completion. The probability of appointing HCAs was higher in participants with family caregiving experience (OR = 1.42, p < 0.05), who were single (OR = 1.49, p < 0.05), and who expected a good death with dignity (OR = 1.65, p < 0.01).

CONCLUSIONS

Our research shows that adopting ACP discussion in Taiwan is feasible, which encourages ACP conversation and facilitates AD completion.

IMPLICATIONS

Male and younger adults may need extra encouragement to discuss ACP matters with their families.

LIMITATIONS

due to sampling restrictions, our data were chosen from an urban district to ensure the integrity of the results. Furthermore, interview data could be collected in future research to supplement the quantitative results.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND

In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.

METHODS

Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.

RESULTS

Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.

CONCLUSIONS

In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

Indications for involuntary hospitalization for refusal of treatment in severe anorexia nervosa: a survey of physicians and mental health care review board members in Japan

BACKGROUND

When a patient with anorexia nervosa refuses treatment despite a physically critical condition, the therapist considers involuntary inpatient treatment under the Mental Health Law. However, ethical and practical problems arise from its application. In this study, a survey of treatment providers for eating disorders and psychiatric review board members was conducted regarding indications for involuntary hospitalization under the Mental Health Act for refusal of treatment for anorexia nervosa.

METHODS

A survey of 212 physicians affiliated with the Japanese Society for Eating Disorders and 180 members of Mental Health Care Review Boards across Japan was conducted using six vignette cases of patients with anorexia nervosa refusing treatment.

RESULTS

Regardless of the duration of illness or age of the patient, few physicians chose compulsory hospitalization with or without the consent of the family, while the largest number of physicians chose hospitalization for medical care and protection when there was family consent. Among committee members, only hospitalization for medical care and protection was determined to be appropriate when there was family consent. Both hospitalization for medical care and protection, and compulsory hospitalization were deemed appropriate in the absence of family consent. Committee members who adjudged refusal of treatment for anorexia nervosa as self-injurious behavior suggested that compulsory hospitalization was indicated.

CONCLUSIONS

When a patient with life-threatening anorexia nervosa refuses inpatient treatment, hospitalization for medical care and protection is actively chosen if the patient's family consents. Mental Health Care Review Board members considered this acceptable. However, if the family does not consent, the physicians did not choose compulsory hospitalization, and the psychiatric review board was divided on this. Consensus was not achieved in this regard.

Facts and Recommendations regarding When Medical Institutions Report Potential Abuse to Child Guidance Centers: A Cross-Sectional Study

BACKGROUND

Medical institutions are required to report suspected cases of child abuse to administrative agencies, such as child guidance centers in Japan. It is left to the discretion of the medical institutions whether to notify the family of the child or the center. However, it is unclear what kinds of measures are being taken to ensure a robust policy of notification versus non-notification and how notifying the family will affect the child.

METHODS

An unregistered questionnaire survey on reporting suspected child abuse cases to child consultation centers and notifying families was conducted by mail across 518 pediatric specialist training facility hospitals designated by the Japanese Pediatric Society.

RESULTS

Responses were received from 323 facilities (62.4% response rate), of which 5 facilities were excluded because of incomplete responses. Therefore, in all, 318 facilities were included in the analysis. The results showed that 59.8% of the facilities had a policy of notifying the family, 33.7% said the decision varies from case to case, and 6.6% did not have a policy of notifying the family. The facilities that had a policy of either notifying or not notifying the family were less likely to experience problems than those with a policy of deciding on a case-by-case basis. The proportion of cases in which some problems occurred was higher in the cases where families were notified than in the cases where they were not, with 51.4% of the children experiencing worsening of relationships with family members. In the cases where the families were not notified, the children were twice as likely to experience further abuse than in cases where the families were notified.

CONCLUSION

Problems arise in the case of both notification and non-notification. It is necessary to examine background factors and specific methods of notification in the cases where problems arise.

Implementation of advance care planning decision aids for patients undergoing high-risk surgery: a field-testing study

BACKGROUND

Patients undergoing high-risk surgery are at a risk of sudden deterioration of their health. This study aimed to examine the feasibility of the development of two patient decision aids (PtDAs) to assist patients undergoing high-risk surgeries in informed decision-making about their medical care in a crisis.

METHODS

This field testing implemented two PtDAs that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families. The study used a mixed-methods approach. The primary outcome was patients' decision satisfaction evaluated by the SURE test. Secondary outcomes were the perception of the need to discuss advance care planning (ACP) before surgery and mental health status. The families were also surveyed on their confidence in proxy decision-making (NRS: 0-10, quantitative data). In addition, interviews were conducted after discharge to assess the acceptability of PtDAs. Data were collected before (preoperative outpatients, baseline: T0) and after providing PtDAs (in the hospital: T1) and following discharge (T2, T3).

RESULTS

Nine patients were enrolled, of whom seven agreed to participate (including their families). The SURE test scores (mean ± SD) were 2.1 ± 1.2 (T0), 3.4 ± 0.8 (T2), and 3.9 ± 0.4 (T3). The need to discuss ACP before surgery was 8.7 ± 1.3 (T1) and 9.1 ± 0.9 (T2). The degree of confidence in family surrogate decision-making was 6.1 ± 2.5 (T0), 7.7 ± 1.4 (T1), and 8.1 ± 1.5 (T2). The patients reported that using PtDAs provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans. Additionally, patients wanted to share and discuss their decision-making process with medical professionals after the surgery.

CONCLUSIONS

PtDAs supporting ACP in patients undergoing high-risk surgery were developed, evaluated, and accepted. However, they did not involve any discussion of patients' ACP treatment wishes with their families. Medical providers should be coached to provide adequate support to patients. In the future, larger studies evaluating the effectiveness of PtDAs are necessary.

Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse

Background

Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self–other differences in the intention to withhold LSTs between genders.

Methods

Between March and October 2019, a structured questionnaire was distributed to hospitalized patients’ family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia.

Results

Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios.

Conclusion

Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.

Translating and validating a Japanese version of the instrument for patient assessment of medical professionalism (J-IPAMP): a cross-sectional survey

BACKGROUND

Although there are many tools to assess medical professionalism, they rarely address patients' perspectives. The instrument for patient assessment of medical professionalism (IPAMP) comprises 11 items and has been established and validated as a valuable tool for assessing trainees' professionalism from the patient's perspective. However, there is no instrument to assess professionalism from the patient's perspective in Japan. The purpose of the present study was to develop a Japanese version of the IPAMP (J-IPAMP) and test its validity and reliability.

METHODS

We conducted a cross-sectional survey to examine the reliability and validity of the J-IPAMP in two hospitals (one each in an urban and rural area) in Japan. Receptionists or surveyors distributed the anonymous questionnaire to 276 inpatients; all participants were aged above 20 years and assigned to medical trainees. We evaluated its structural and criterion-related validity, as well as internal consistency reliability.

RESULTS

Data of 235 (85.1%) patients were analyzed. Using the split-half validation technique, we performed an exploratory factor analysis (EFA) along with a confirmatory factor analysis (CFA). The EFA showed a one-factor solution. Then, to compare the model fitness between two models (the two-factor model from the original English version vs. unidimensional model suggested by the EFA), the CFA was performed. The CFA showed that almost all of the fit indices met their respective criteria and were approximately the same for the two models. Thus, we adopted a single-factor model. The Pearson correlation coefficients between the total J-IPAMP scores and the global ratings were 0.738, indicating adequate criterion-related validity. The Cronbach's alpha of the 11 items of the instrument was 0.96 (95% confidence interval: 0.96-0.97) and the omega value was 0.96, demonstrating acceptable internal consistency reliability.

CONCLUSIONS

We developed the Japanese version of the IPAMP. Its validity and reliability were verified through analysis. This instrument can be utilized for professionalism education in the postgraduate training setting.

Psychosocial and Ethical Behaviors and Attitudes of Health Care Professionals in the Clinical Setting of Living Kidney Donors: A Qualitative Study

BACKGROUND

There are several psychosocial and ethical issues surrounding the decision making of living kidney transplant donors. This study aimed to determine what health care professionals (HPs) consider in their clinical practice and their attitudes toward donors' decision-making processes.

METHODS

Face-to-face semistructured interviews were conducted with 15 HPs. A thematic analysis was performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board and conducted in accordance with the Declaration of Helsinki.

RESULTS

Six main categories-maintaining family relationships, improving donor understanding, supporting voluntary decision making, setting the environment for the examination, having different attitudes toward the donor's intentions, and resisting confirmation of intent-were identified. The HPs provided diverse considerations to respect the donors' autonomy.

CONCLUSION

In clinical practice, there is a lack of practical methods to confirm living donors' levels of understanding and spontaneity, suggesting that these methods need to be established. Factors related to family functioning may reflect the unique culture of Japan, and this may be indicative of the need to consider treatment based on cultural values.

Autonomy in Japan: What does it Look Like?

This paper analysed the nature of autonomy, in particular respect for autonomy in medical ethics/bioethics in Japan. We have undertaken a literature survey in Japanese and English and begin with the historical background and explanation of the Japanese word Jiritsu (autonomy). We go on to identify patterns of meaning that researchers use in medical ethics / bioethics discussions in Japan, namely, Beauchamp and Childress’s individual autonomy, relational autonomy, and O’Neill’s principled autonomy as the three major ways that autonomy is understood. We examine papers discussing these interpretations. We propose using the term ‘a form of autonomy’ first used by Edmund Pellegrino in 1992 and examine the nature of ‘a form of autonomy.’ We finally conclude that the crux of what Pellegrino calls ‘something close to autonomy,’ or ‘a form of autonomy' might best be understood as the minimization of physician paternalism and the maximization of respect for patient preference. Simultaneously, we introduce a family-facilitated approach to informed consent and respond to criticism by Laura Sullivan. Finally, we discuss cross-cultural approaches and global bioethics. Furthermore, we use the term ‘Bioethics across the Globe’ instead of ‘Global Bioethics’, calling for international scholars to write works to provide an in-depth understanding of each country. We conclude that deep understanding of others is pivotal for dialogue to be of value. We hope this article will deepen the reader’s understanding of Japan and will contribute to the progress of bioethics worldwide.

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.

Definition and Recommended Cultural Considerations for Advance Care Planning in Japan: A Systematic Review

Although Delphi studies in Western countries have provided a consensus for practices pertaining to advance care planning (ACP), their findings may not be applicable to Asian countries with distinct, family-oriented cultures. This systematic review aimed to synthesize the definitions of and evidence for ACP and analyze recommended practices in Japan. We conducted a systematic review using narrative synthesis in December 2018. Key words were searched from Ichushi-Web by NPO Japan Medical Abstracts Society, Citation Information by the National Institute of Informatics, and Japanese Institutional Repositories Online databases. In addition, in August 2019, we conducted hand searching using Google Scholar and Google. We included original Japanese articles that addressed factors regarding ACP (e.g. definitions, elements, roles and tasks, and timing of ACP). Data were synthesized using thematic analysis. The study protocol was registered prospectively (PROSPERO: CRD42020152391). Of the 3,512 studies screened, 27 were included: 22 quantitative and 5 qualitative. Five-position statements/guidelines were added by hand searching. Definitions and several distinct practice patterns of ACP and the importance of families' roles were identified. Unique recommendations addressed the importance of properly eliciting patients' preferences that are the best for both patients and families, engaging the public to raise awareness of ACP, and developing policies and guidelines for ACP. We identified the definition of and unique recommendations for ACP based on Japanese cultural values and norms. Further research is needed to evaluate the recommendations provided in this systematic review.

Japanese women's reasons for accompaniment status to hereditary breast and ovarian cancer-focused genetic counseling

Genetic counselors routinely assess and understand clients' needs at the beginning of a session. Attending a genetic counseling session with or without companions is an objective sign that genetic counselors can easily notice. This study focused on clients' reasons for their accompaniment status for genetic counseling, which we categorize into attending with or without a companion(s). A questionnaire survey and interviews were conducted using snowball sampling, starting with the chief executive officer (CEO) of the Japanese hereditary breast and ovarian cancer (HBOC) support group. Of 32 participants, 19 continued with an in-depth interview after answering the questionnaire. Five themes were identified from the interview: (1) personal confidence, (2) decision-making style, (3) family members' habits and time availability, (4) considerations and conflicts with family members, and (5) healthcare provider's suggestion. Our data suggested that the clients expected their companion(s) to play certain roles. This indicates that the reasons of accompaniment status will be helpful for genetic counselors to understand both clients' and their families' motivations, personalities, habits, and psychosocial backgrounds. In a high-context culture such as that of Japan, accompaniment status may be a helpful sign to understand clients' true worries. In addition, some companions may be future clients in genetic counseling, due to the genetic nature of the disease. In conclusion, our study indicated that it is important for genetic counselors to record accompaniment status before the initial genetic counseling and to pay attention to its reasons at the beginning of the session, which may lead them to understand the client's psychosocial background to facilitate better client-centered genetic counseling.

Practices and perspectives of primary care physicians in Japan and the United States about diagnosing dementia: a qualitative study

BACKGROUND

While dementia is a common problem in Japan and the US, primary care physicians' practices and perspectives about diagnosing dementia in these different healthcare systems are unknown.

METHODS

Qualitative research was conducted in an ethnographic tradition using semi-structured interviews and thematic analysis in primary care settings across Japan and in the Midwest State of Michigan, US. Participants were a total of 48 primary care physicians, 24 each from Japan and the US participated. Both groups contained a mixture of geographic areas (rural/urban), gender, age, and years of experience as primary care physicians.

RESULTS

Participants in Japan and the US voiced similar practices for making the diagnosis of dementia and held similar views about the desired benefits of diagnosing dementia. Differences were found in attitudes about the appropriate timing of formally diagnosing dementia. Japanese physicians tended to make a formal diagnosis when problems that would benefit from long-term care services emerged for family members. US physicians were more proactive in diagnosing dementia in the early stages by screening for dementia in health check-ups and promoting advance directives when the patients were still capable of decision-making. Views about appropriate timing of diagnostic testing for dementia in the two systems reflect what medical or nursing care services physicians can use to support dementia patients and caregivers.

CONCLUSIONS

Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US. Testing to establish an early diagnosis of dementia by primary care physicians only partly relates to testing and treatment options available. Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US.

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

BACKGROUND

Instances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan.

METHODS

A cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process.

RESULTS

Of the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates' considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings.

CONCLUSIONS

Surrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning.

The survival time of end-of-life home care patients in Fukui prefecture, Japan: A retrospective observational study

ABSTRACT

End-of-life advance care planning (ACP) has become increasingly important in home care setting. In facilitating ACP discussion in home care setting, accurate understanding of patients' survival would be beneficial because it would facilitate healthcare professionals to individualize ACP discussion. However, little is known about survival outcome of home care patients. This study aimed to clarify the outcome of patients and identify factors to better predict the survival outcome of home care patients with the focus on patients' primary diseases.We conducted a retrospective analysis using data from 277 patients managed at a home care clinic in Japan and first treated in 2017 or 2018. Data regarding sociodemographic and clinical characteristics, and clinical outcome on December 31, 2019 were extracted. Using Kaplan-Meier product-limit method, we estimated the overall 30 days, 90 days, 1 year, and 3 year survival probabilities among the entire patients and their differences according to their primary disease. We also evaluated whether outcomes differed based on the primary disease or other factors using the hazard ratio and Cox proportional hazards regression.The overall survival probability was 82.5% at 30 days, 67.8% at 90 days, 52.7% at 1 year, and 39.1% at 3 years. The survival rates at 30 days, 90 days, 1 year, and 3 years were 64.6%, 33.4%, 9.5%, and 4.1% among cancer patients; 91.9%, 86.4%, 78.1%, and 47.0% among dementia patients; and 91.9%, 86.4%, 78.1%, and 47.0% among patients with other nervous and cerebrovascular diseases, respectively. Cox proportional hazard regression clarified that cancer patients (hazard ratio 6.53 [95% CI 4.16-10.28]) and older adults (hazard ratio 1.01 [95% CI 1.00-1.02]) were significantly more likely to die than dementia patients and young patients, respectively.Primary disease had a significant influence on the prediction of survival time and could be a useful indicator to individualize ACP in home care setting.

Characterising end-of-life decision-making of life-sustaining treatment among Japanese nurses

BACKGROUND

Often, nurses are closer to end-of-life (EOL) patients than other medical professionals, due to the time they spend with them at their bedside, which leads them to understand patients' care goals.

AIMS

To investigate the importance of EOL preferences by examining nurses' EOL decision-making regarding life-sustaining treatment (LST).

METHODS

In this cross-sectional study, 559 self-reported questionnaires of Japanese nurses were examined. Marital status, age and decision-making regarding LST for themselves were investigated.

FINDINGS

Unmarried participants from all age groups had a higher percentage of 'no preference for LST' than married groups. Differences between the percentages were higher in the 20s age group. Married participants increasingly preferred to receive no LST as their age increased, unlike single participants.

CONCLUSION

Marital status influences Japanese nurses' EOL decision-making regarding LST. Therefore, it is necessary to consider a patient's marital status to facilitate better decision-making.

Factors associated with the accomplishment of home death among patients receiving physician-led home healthcare

AIM

To evaluate unique factors associated with home death in older Asian individuals who received physician-led home healthcare.

METHODS

We carried out a case-control study at a single hospital in Japan from February 2018 to December 2019. We included patients who had started receiving physician-led home healthcare and died at home as cases, and those receiving the same type of care but died in the hospital as controls. Multivariable logistic regression was used to evaluate factors associated with home death.

RESULTS

A total of 152 patients (mean age 70.3 years [SD 11.2 years]; 86 [56.6%] men) were included, of whom 89 (58.6%) died at home and 63 (41.4%) died in the hospital. Comparing the two groups, the presence of family psychological problems related to care was significantly more common in the hospital death group (home death 49.4%; hospital death 32.3%, P = 0.036). Home death was related to patients aged >85 years compared with patients aged <75 years (adjusted odds ratio 6.47, 95% CI 1.52-27.48) and patients who were in the highest quartile of the number of symptoms (adjusted odds ratio 5.45, 95% CI 1.15-25.95) compared with the lowest. Family members' willingness for the patient to die at home was associated with home death (adjusted odds ratio 7.47, 95% CI 2.13-26.19).

CONCLUSIONS

Older age and multiple symptoms were related to accomplishing home death. Patient preference was not associated with the place of death, but family member preference was. These results might reflect family concepts particular to Asia. Geriatr Gerontol Int 2021; 21: 525-531.

Experiences of Patient-Centered Care Among Japanese and Australian Cancer Outpatients: Results of a Cross-Sectional Study

There have been few international comparisons of patient-centered cancer care delivery. This study aimed to compare the experiences of patient-centered care (PCC) of Japanese and Australian radiation oncology patients. Participants were adults with cancer attending a radiotherapy appointment at a Japanese or Australian clinic. Participants completed a survey asking about 10 indicators of PCC. Overall, 259 Japanese and 285 Australian patients participated. Compared with Japanese participants, Australian participants were significantly more likely to report receiving information about: what the treatment is, and the short-term and long-term side effects of treatment. A higher proportion of Australian participants reported being asked whether they wanted a friend or family member present at the consultation. There were no differences in the frequency with which Japanese and Australian participants were asked by their clinicians about whether they were experiencing physical side effects or emotional distress. International differences highlight the (1) need to exercise caution when generalizing from one country to another; and (2) the importance of context in understanding PCC delivery and the subsequent design of quality improvement interventions.

How do healthcare professionals respond to ethical challenges regarding information management? A review of empirical studies

Aim

This study is a systematic review that aims to assess how healthcare professionals manage ethical challenges regarding information within the clinical context.

Method and Materials

We carried out searches in PubMed, Google Scholar and Embase, using two search strings; searches generated 665 hits. After screening, 47 articles relevant to the study aim were selected for review. Seven articles were identified through snowballing, and 18 others were included following a system update in PubMed, bringing the total number of articles reviewed to 72. We used a Q-sort technique for the analysis of identified articles.

Findings

This study reveals that healthcare professionals around the world generally employ (to varying degrees) four broad strategies to manage different types of challenges regarding information, which can be categorized as challenges related to confidentiality, communication, professional duty, and decision-making. The strategies employed for managing these challenges include resolution, consultation, stalling, and disclosure/concealment.

Conclusion

There are a variety of strategies which health professionals can adopt to address challenges regarding information management within the clinical context. This insight complements current efforts aimed at enhancing health professional-patient communication. Very few studies have researched the results of employing these various strategies. Future empirical studies are required to address this.

Abbreviations

CIOMS: Council of International Organization of Medical Sciences; WHO: World Health Organization; AMA: American Medical Association; WMA: World Medical Association; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis; ISCO: International Standard Classification of Occupations; ILO: International Labour Office; SPSS: The Statistical Package for the Social Sciences

Investigation of users' experiences for online access to their electronic health records in Japan

The solution of sharing electronic health records (EHR) with patients has the potential to improve patients' understanding and remembering of their health information. We call this solution the patient open-EHR. In Japan, this solution is not yet widespread, and experiences of actual users are not known. Our aim is to explore the needs and satisfaction of patients who are actually using one patient open-EHR system in Japan that allows registered patients online access to part of their EHR. A cross-sectional study was done using an online questionnaire. Patients registered with our patient open-EHR system were invited to participate by posting an invitation message on the system login page and sending them invitation emails. We investigated their needs regarding the system and their views regarding the system's ability to improve their understanding, remembering, and other perspectives. Answers from 95 patients, collected between August 10 and October 20, 2019 were analyzed. The need to further understand and remember the information received from the doctor was among the top four reasons behind using the system. However, only 48% of patients agreed that the system improved their remembering and 68% agreed that it improved their understanding. Thirty-seven percent of respondents expressed dissatisfaction with access to only blood test results and prescriptions. Despite this dissatisfaction, respondents were positive about the future of the system. Hospitals need to recognize the needs of patients and to consider them when providing patient open-EHR service. The EHR has potential not only for hospitals but also for patients.

Palliative Care for Idiopathic Pulmonary Fibrosis Patients: Pulmonary Physicians' View

CONTEXT

Although idiopathic pulmonary fibrosis (IPF) has worse outcomes compared with most malignancies, patients with IPF receive poor access to optimal palliative care.

OBJECTIVES

This study aimed to characterize the practice of pulmonologists regarding palliative care and end-of-life communication for patients with IPF and identify perceived difficulties and barriers thereto.

METHODS

Self-administered questionnaires were sent by mail to representative pulmonologists from Shizuoka prefecture, Japan. Physician-reported practice, difficulties, timing of end-of-life communication, and barriers related to palliative care were investigated.

RESULTS

Among the 135 participants, 130 (96%) completed the questionnaire. Most of the participants reported that patients with IPF complained of dyspnea and cough. However, less morphine was prescribed for IPF than for lung cancer. The participants experienced greater difficulty in providing palliative care for IPF than for lung cancer. Moreover, actual end-of-life discussions in patients with IPF were conducted later than the physician-perceived ideal timing. Among the barriers identified, few established treatment and difficulty in predicting prognosis (odds ratio [OR] 2.0; P = 0.04), discrepancies in understanding and care goals among patients, family, and medical staff (OR 2.2; P = 0.03), and inadequate communication about goal of care (OR 2.3; P = 0.003) were significantly associated with the physician-perceived difficulties in providing palliative care for patients with IPF.

CONCLUSION

Pulmonologists experienced greater difficulty in providing palliative care to patients with IPF than to those with lung cancer. Clinical studies on the optimal palliative care for patients with IPF are urgently required.

Radiation Oncologist Perceptions and Utilization of Digital Patient Assessment Platforms

BACKGROUND

Patient engagement is increasing in the presence of digital patient assessment platforms, or physician rating websites. Despite this rapid growth, data remains insufficient regarding how these evaluations impact radiation oncologists.

OBJECTIVES

The purpose of this study was to assess radiation oncologists worldwide on their awareness and noted effects of digital patient assessment platforms.

METHODS

An electronic survey was delivered to 6,199 members of the American Society of Radiation Oncology. Subjects were radiation oncologists practicing throughout the world. The survey consisted of 14 questions focused on demographics, practice details, patient volume, institutional utilization of patient reviews, and perceptions of radiation oncologists on health care reviews provided by patients.

RESULTS

There were 447 responses from practicing radiation oncologists in total, 321 (72%) of which are in the US. Most respondents (228; 51%) either agreed or strongly agreed that patients consider online reviews when deciding which physician to visit. Of all respondents, 188 (42%) reported that their institution checks their online feedback, whereas 157 (36%) and 99 (22%) respectively reported not knowing, or to their knowledge their institution does not check their online feedback. Respondents who saw more than the average number of consults per week were significantly more likely to receive negative feedback (P = 0.005). Forty-five percent of respondents agreed or strongly agreed that online virtual assessment tools contribute to physician burnout. Respondents (100; 22%) who received inappropriate or misdirected feedback were significantly more likely to report that virtual reviews contribute to burnout (P = 0.001).

CONCLUSIONS

Radiation oncologists need to be aware that self-reported patient assessments are a data point in the quality of a physician and health care establishment. To best ensure appropriate feedback of a physician's capabilities as a doctor, leadership and employee alignment for patient experience are now more important than ever.

Examining persuasive message type to encourage staying at home during the COVID-19 pandemic and social lockdown: A randomized controlled study in Japan

OBJECTIVE

Behavioral change is the only prevention against the COVID-19 pandemic until vaccines become available. This is the first study to examine the most persuasive message type in terms of narrator difference in encouraging people to stay at home during the COVID-19 pandemic and social lockdown.

METHODS

Participants (n = 1,980) were randomly assigned to five intervention messages (from a governor, a public health expert, a physician, a patient, and a resident of an outbreak area) and a control message. Intention to stay at home before and after reading messages was assessed. A one-way ANOVA with Tukey's or Games-Howell test was conducted.

RESULTS

Compared with other messages, the message from a physician significantly increased participants' intention to stay at home in areas with high numbers of people infected (versus a governor, p = .002; an expert, p = .023; a resident, p = .004).

CONCLUSION

The message from a physician-which conveyed the crisis of overwhelmed hospitals and consequent risk of people being unable to receive treatment-increased the intent to stay at home the most.

PRACTICE IMPLICATIONS

Health professionals and media operatives may be able to encourage people to stay at home by disseminating the physicians' messages through media and the internet.

Association between early informed diagnosis and survival time in patients with lung cancer

OBJECTIVE

As a malignant tumor with high mortality, lung cancer (LC) often causes great trauma to patients, and a series of negative emotions and a heavy psychological burden accompanies poor prognosis. Whether or not to inform the patients of their condition has always been a controversial topic in the medical community. This retrospective cohort study investigated the association between early informed diagnosis and survival time in patients with LC.

METHODS

A total of 29 825 patients with LC were enrolled between October 2002 and December 2016. The potential factors influencing LC survival were registered, including knowing their cancer diagnosis status, age, gender, pathological type, clinical stage, surgical history, hospital grade, and patient occupation. All participants were followed up every 6 months until June 2017.

RESULTS

In June 2017, 23.1% of the participants still survived. Their median survival time (MST) was 11.20 months (95% confidence interval [CI], 10.98-11.43). Generally, patients that knew their cancer diagnosis had longer MST than those who did not (18.33 months vs 8.77 months, P < .001). By stratified analysis, patients that knew their cancer diagnosis had longer survival time in each subgroup (P < .001, all subgroups). Cox regression analysis showed that knowing their cancer diagnosis was an independent influencing factor for survival in patients with LC (hazard ratio, 0.826; 95% CI, 0.802-0.851; P < .001).

CONCLUSIONS

Knowing their cancer diagnosis contributed to longer survival time in patients with LC, providing clear evidence that medical staff and patients' families should fully disclose cancer diagnoses to patients.

Nephrologists Should Voluntarily Divulge Survival Data to Potential Dialysis Patients: A Questionnaire Study

Background

For many dialysis patients, survival is no different than with certain cancers. Yet, it appears that most nephrologists do not give detailed information about survival prior to obtaining informed consent for chronic dialysis. There are no published data on whether patients wish to be so informed.

Objective

To assess whether patients would want voluntary disclosure by their physician of their survival should they need dialysis, and if so, why?

Method

A questionnaire was completed by 100 general nephrology patients during their first visit to a nephrologist.

Results

The vast majority of patients (97%) would want to be given life-expectancy information, and for the physician to do so without having to be prompted. Furthermore, the majority of patients would want as much information as possible, both good and bad.

Conclusions

Virtually all patients want, and therefore should receive from their physician, prognostic information about dialysis to facilitate informed decision-making. This is in accordance with current practice guidelines.

Octogenarian preferences and expectations for acute coronary syndrome treatment

Background:

The number of elderly persons with cardiovascular disease is increasing. In Sweden, the incidence of acute myocardial infarction is the highest among individuals aged 85 years and over. However, there is still little evidence about whether this population benefits from established treatments. Furthermore, the values and preferences of octogenarians (age ⩾80 years), as well as how they could be involved in treatment decisions, have been largely overlooked in research. Overall, increased knowledge about the preferences and expectations of octogenarians is needed to incorporate their treatment expectations into the decision-making process.

Aims:

This study aimed to describe the treatment choice preferences and post-treatment life expectations of octogenarians with acute coronary syndrome.

Methods:

A total of 19 patients (eight women, 11 men) aged 80 years and older and diagnosed with non-ST-elevation myocardial infarction or unstable angina were enrolled in this qualitative study. Data were collected between May 2011 and June 2013 through semistructured interviews. The data were analysed using qualitative content analysis.

Results:

We identified two main categories: Wanting the best and Hope for increased wellbeing. Participant preferences were influenced by their own and others’ previous experiences and their confidence in healthcare professionals. With respect to treatment outcomes, the participants hoped to get well, stay active, experience fewer symptoms and regain vitality.

Conclusion:

The studied octogenarians desired the best treatment option and trusted that their healthcare providers will make appropriate recommendations. These patients expected their treatment to result in increased wellbeing and fewer symptoms.

Factors Relating to Caregivers' Preference for Advance Care Planning of Patients in Japan: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to examine the preferences of home caregivers on patient advance care planning (ACP), including life-sustaining treatment (LST) and the factors relating to these preferences.

BACKGROUND

Personalized ACP aims to respect the autonomy and choices of terminally ill patients regarding end-of-life care. However, there have been cases wherein doctors must instead discuss ACP with surrogates (including caregivers) for various reasons such as dementia, intractable neurologic diseases, and cerebrovascular accident.

METHODS

In this cross-sectional study, self-written questionnaires (filled by individuals themselves) were distributed to 506 in-home caregivers in 6 Japanese prefectures; the questionnaires contained items on caregiver and patient demographics, number of people living together in a caregiver's home (aside from patients), care duration, comprehension level of doctors' explanations regarding their patient's condition, patient diseases, whether caregivers have or have not told patients about their disease, level of nursing care, and caregiver LST preference (preferred or not preferred). The questionnaire package also contained the Burden Index of Caregiver-11, Patient Health Questionnaire-9, and Short Form-8 Health Survey.

RESULTS

Valid responses were obtained from 309 caregivers. More than half of them were not sure of their patient's LST preference. Sex, number of people living together in a care home, comprehension level of doctors' explanations, and care duration were found to be the significant factors relating to caregivers' LST preference (P < .05).

CONCLUSION

Health providers should be cognizant of the background factors relating to caregiver ACP preference when deciding on LST for terminal patients.

Patients’ and Caregivers’ Attitudes Toward Deprescribing in Singapore

Background

Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs.

Method

A cross-sectional survey of two groups of participants was conducted using the Revised Patients’ Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants’ characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed.

Results

A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively.

Conclusions

Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

An integrated knowledge translation approach to develop a shared decision-making strategy for use by Inuit in cancer care: a qualitative study

Background

In relation to the general Canadian population, Inuit face increased cancer risks and barriers to health services use. In shared decision-making (sdm), health care providers and patients make health care decisions together. Enhanced participation in cancer care decisions is a need for Inuit. Integrated knowledge translation (kt) supports the development of research evidence that is likely to be patient-centred and applied in practice.

Objective

Using an integrated kt approach, we set out to promote the use of sdm by Inuit in cancer care.

Methods

An integrated kt study involving researchers with a Steering Committee of cancer care system partners who support Inuit in cancer care ("the team") consisted of 2 theory-driven phases:■ using consensus-building methods to tailor a previously developed sdm strategy and developing training in the sdm strategy; and■ training community support workers (csws) in the sdm strategy and testing the sdm strategy with community members.

Results

The team developed a sdm strategy that included a workshop and a booklet with 6 questions for use by csws with patients. The sdm strategy (training and booklet) was finalized based on feedback from 5 urban-based Inuit csws who were recruited and trained in using the strategy. Trained csws were matched with 8 community members, and use of the sdm strategy was assessed during interviews, reported as 6 themes. Participants found the sdm strategy to be useful and feasible for use.

Conclusions

An integrated kt approach of structured research processes with partners developed a sdm strategy for use by Inuit in cancer care. Further work is needed to test the sdm strategy.

Disclosure of Cancer Diagnosis: an Individualized and Non-paternalistic Approach Is Preferred

There is no consensus among healthcare providers on a unified disclosure practice with regard to cancer diagnosis, whether to tell or not. This issue is complicated by the absence of a clear policy for healthcare practitioners, who face this dilemma every day in their clinical practice. This study uniquely aims to explore Jordanian public preference on cancer diagnosis disclosure and the type of information they need. A descriptive cross-sectional survey design was used in this study. The sample consisted of 485 participants who were conveniently selected from the Jordanian public, and data was collected using the Arabic-Cancer Patients Information Needs Questionnaire. The majority of participants were females (56.1%) and most of them (62.1%) were aged between 18 and 29 years. It was found that 421 (86.8%) participants wanted to be informed of the diagnosis if they developed cancer. Participants show high needs of information with mean of total score of 4.2 SD 0.7 out of 5. They mainly demanded to know the things that participants could do to help their cure (mean = 4.47, SD 0.77). Also, they wanted to know whether their cancer was under control or not (item no. 4, mean = 4.42, SD 0.81). This study marks a point of change in public thinking about health issues. Jordanian public preferred to be fully informed of their cancer diagnosis. They wanted information about their prognosis, treatment and the available supportive services, which are of great interest to the Jordanian public.

Psycho-oncology: History, Current Status, and Future Directions in Japan

One of the most relevant risk factors for cancer is aging; thus, the number of patients who develop cancer and die is increasing in Japan. Cancer has been a leading cause of death since 1981, and more than one-fourth of Japanese people die of cancer. More than 1,000,000 and 37,000 Japanese people develop cancer and die every year, respectively, making it a major health problem in Japan.

Psycho-oncology is a relatively new medical field that was established in the 1970s in Western countries and introduced in Japan in the 1980s. Psycho-oncology was developed for investigating two issues neglected in previous medical research: the impact of behavioral and psychosocial factors on cancer morbidity and mortality and the psychological influence of cancer on patients, their families, and medical staff.

Because of progress made in cancer treatment, cancer diagnosis is not necessarily equivalent to a death sentence. However, approximately half of patients with cancer die, and many patients with cancer and their families need appropriate care for psychological distress. The most common psychiatric problems patients with cancer experience are adjustment disorders, major depression, and/or delirium. In addition, the suicide rate in Japan for individuals within 1 year of a cancer diagnosis is more than 20 times higher than that for individuals without cancer. Physical symptoms, such as pain and nausea/vomiting, can be closely associated with psychological function. Mental health professionals, particularly psycho-oncologists, are expected to work with other cancer professionals to manage patients' distress.

The present review focuses on patients with cancer' psychological distress and physical symptoms that are closely associated with psychological function and provides an overview of the current status of psycho-oncology in Japan. The future perspective of psycho-oncology is also discussed.

Sex differences in surrogate decision-maker preferences for life-sustaining treatments of Japanese patients with heart failure

AIMS

Patients with end-stage heart failure (HF) often require surrogate decision making for end-of-life care owing to a lack of decision-making capacity. However, the clinical characteristics of surrogate decision making for life-sustaining treatments in Japan remain to be investigated.

METHODS AND RESULTS

Among 934 patients admitted to our hospital for HF from January 2004 to December 2015, we retrospectively reviewed the medical records of consecutive 106 patients who died in hospital (mean age 73 ± 13 years; male, 52.6%). During hospitalization, attending physicians conducted an average of 2.1 ± 1.4 end-of-life conversations with patients and/or their families. Only 4.7% of patients participated in the conversations and declared their preferences; surrogates made medical care decisions in 95.3% of cases. Most decisions by surrogates (98.1%) were made without the patient's advance directive. During initial end-of-life conversations, 49.4% of surrogates requested cardiopulmonary resuscitation (CPR). However, 72.0% of CPR preferences were changed to do not attempt resuscitation (DNAR) orders in the final conversation. Female surrogates were more likely to change the preference from CPR to DNAR than were male surrogates (47.1% vs. 25.0%, P = 0.023).

CONCLUSIONS

Compared with male surrogates, female surrogates wavered more often in their decisions regarding life-sustaining treatments of Japanese patients with end-stage HF.

Islamic Considerations on the Application of Patient's Autonomy in End-of-Life Decision

In end-of-life situation, the need for patient's preference comes into the picture with the intention of guiding physicians in the direction of patient care. Preference in medical directive is made by a person with full mental capacity outlining what actions should be taken for his health should he loses his competency. This is based on the reality of universal paradigm in medical practice that emphasises patient's autonomy. A specific directive is produced according to a patient's wish that might include some ethically and religiously controversial directives such as mercy killing, physician-assisted suicide, forgoing life-supporting treatments and do-not-resuscitate. In the future, patient autonomy is expected to become prevalent. The extent of patient autonomy has not been widely discussed among Muslim scholars. In Islam, there are certain considerations that must be adhered to.

Disclosure of cancer diagnosis in China: the incidence, patients' situation, and different preferences between patients and their family members and related influence factors

Purpose

The purpose of this study was to investigate the disclosure incidence of cancer diagnosis to patients before chemotherapy, to survey the attitudes of the patients and their families and related influencing factors toward disclosure of cancer diagnosis, and to compare the anxiety and depression levels between the disclosure and non-disclosure patients.

Participants and methods

A prospective cohort study was conducted at a tertiary hospital in China. A consecutive series of patients who had been diagnosed with malignancy by pathology and their family member were included in our study from March 2017 to December 2017. Patients’ situation, preferences, and their family members’ preferences were investigated by a self-designed questionnaire following a semi-structured interview. The Chinese version of HADS for anxiety and depression was used to test the patients’ psychological distress. Binary logistic regression was used to analyze the related influencing factors of patients’ disclosure of their diagnosis.

Results

A total of 124 pairs of patients and their family members were analyzed. Of the 124 patients, 47 (37.90%) patients knew about their cancer diagnosis and 77 (62.10%) patients did not know about their cancer diagnosis before chemotherapy. There were more patients than family members who wanted the patients to be informed about the diagnosis of terminal illness (91.9% vs 53.2%, P<0.01). Binary logistic regression analysis showed that patients with university education (odds ratio [OR], 15.322; 95% confidence interval [CI], 1.781–131.781; P<0.05), patients having equal or above average annual income (OR, 5.170; 95% CI, 1.842–14.514; P<0.01) were more likely informed about cancer diagnosis before chemotherapy. Higher anxiety level was found in diagnosis non-disclosure group (P<0.05) and no significant difference in depression score between two groups (P>0.05).

Conclusion

More than half of the patients did not know their exact diagnosis before chemotherapy in China. Educational level and economic status may be influencing factors for the disclosure of cancer diagnosis. Patients and their family members had different preferences toward diagnosis disclosure.

Physicians' Experience of Communication with Nurses related to Patient Safety: A Phenomenological Study Using the Colaizzi Method

PURPOSE

This study attempted to understand the core experiences of physicians related to communicating with nurses in Korea.

METHODS

Ten physicians who worked at four tertiary university hospitals were interviewed. Data were analyzed using the phenomenological method developed by Colaizzi.

RESULTS

The following six categories of participants' experience of communication with nurses were extracted from the analysis: (a) "Complex situations and heavy roles that cannot afford safety," (b) "Forcing a superior position in an authoritative environment," (c) "Different perspectives on patient care and difficulties in establishing relationships," (d) "Communicating key clues and receiving feedback from each other," (e) "Apathetic agreements rather than improvements," and (f) "Gradually developing mutually complementary communication."

CONCLUSION

The present findings revealed that physicians lacked an understanding about the roles and tasks of nurses. The participants engaged in mutually complementary communication with experienced nurses, obtaining desirable patient outcomes and perceived order filtering by nurses as a safety mechanism. It is important for managers to act as proactive change agents to improve communication. Furthermore, the importance and different forms of complementary communication between physicians and nurses need to be described and taught in depth with practical cases.