Abstract
Background and Objectives: The question of whether to withdraw mechanical ventilation from dying patients remains nearly unexplored in Japan. In late 2007, the Japanese Association for Acute Medicine compiled a set of guidelines for the withdrawal of life-sustaining treatment that include some specific circumstances under which physicians are allowed to withdraw treatment from dying patients, the first of its kind in the nation. This study was conducted to investigate whether physicians withdraw mechanical ventilation from dying patients, and to identify and analyze factors influencing their decisions.
Methods: In 2006-2007, 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.
Results: Data analysis revealed that none of the informants chose to withdraw mechanical ventilation from dying patients in ordinary clinical settings, and four factors related to the practice were identified: (1) problems involving police and mass media, which the informants believe have resulted in inappropriate accusations against some physicians who have recently made the headlines after withdrawing mechanical ventilation from dying patients, (2) cultural values that promote family-oriented end-of-life care, (3) emotional barriers that prevent physicians from withdrawing care, centering on the physicians' notion that they would be shortening their patients' lives by their own hands if they were to withdraw the treatment, and (4) medical reasons including physicians' fear that the withdrawal of mechanical ventilation may cause patient distress. However, data showed that other artificial measures such as artificial liver support and percutaneous cardiopulmonary support have been terminated. In addition, some of the physicians said that maintaining mechanical ventilation on end-stage patients has caused unfair distribution of limited medical resources.
Discussion and Conclusions: During a period that was void of any guidelines, police investigation and media reports have made physicians interpret that Japanese society does not allow medical staff to withdraw mechanical ventilation from dying patients, although police investigation has not led to any indictments and several media reports were found to be faulty. The medical association's guidelines may serve to fill the void partly related to the police and mass media problems, but the guidelines may leave unanswered the problems related to the emotional barriers that prevent physicians from withdrawing care, and their fear that the withdrawal of mechanical ventilation may cause patient distress.
