Abstract
The question of whether to withdraw mechanical ventilation from brain-dead patients remains nearly unexplored in Japan. This study was conducted to investigate whether physicians withdraw care from brain-dead patients, and to identify and analyze factors influencing their decisions. A retrospective, in-depth interview study was conducted with 35 physicians at emergency and critical care facilities in Japan. The process of data collection and analysis followed the grounded theory approach. Data analysis revealed that withdrawal of mechanical ventilation from brain-dead patients was not common, and four factors related to the practice were identified: (1) legal and institutional barriers that perplex physicians when dealing with brain-dead patients. The barriers include "the double standard of brain death" in Japan, in which brain-dead people are considered legally dead only when they are organ donor candidates; (2) emotional barriers that prevent physicians from withdrawing care; (3) cultural values that promote family-oriented end-of-life care; and (4) medical reasons including physicians' assumption that the patients would have circulatory cessation shortly even with continued mechanical ventilation. Data also showed that families of some brain-dead patients became exhausted waiting for circulatory cessation in the patients when the patients' somatic maintenance lasted for weeks. Meanwhile, 3 of the 35 physicians routinely offered patients' families the option of withdrawing mechanical ventilation. These physicians had certain characteristics in common, such as a different perception of the double standard of brain death. They appreciated the double standard because it allows discretion regarding when to stop providing medical care to brain-dead people. They consider that the discretion is indispensable for medical providers in Japan because currently the understanding of brain death varies according to each individual. The physicians believe that the double standard has helped them in providing better support to the family until the family accepts that the patient is dying. This research suggests that maintaining the double standard of brain death and providing the brain-dead patient's family an option of withdrawing treatment would better serve the family.
