2003 Volume 36 Issue 8 Pages 1315-1326
Very little has been reported in Japan about research into bioethics with respect for the patient's self-determination in withdrawing from stable hemodialysis (HD) treatment during the terminal stage of illness. We, therefore, conducted a survey among nephrologists (n=552) regarding their decisions whether to stop or continue HD for patients in the terminal stage of malignancy. We also surveyed their opinions about advance directive (AD), death with dignity and life with dignity.
Overall, 434 nephrologists (78.6%) returned questionnaires, and effective responses were obtained from 427 (77.4%). Currently AD and death with dignity are not legally permissable in Japan. When the patient has an AD, the number of nephrologists who answered that they would stop HD significantly increased in cases of family request to stop HD (48.0% vs. 78.9%) or to continue HD (0.2% vs. 2.6%). When it was assumed that stopping life-sustaining treatment was not legally prohibited and the patient has an AD, the number of responses indicating to stop HD further increased in cases of family request to stop HD (90.9%) or to continue HD (11.9%). The number of nephrologists who answered that they need an AD totalled 74.0% and those who believed in death with dignity totalled 83.1%, while the number of nephrologists who desired legislation regarding AD (56.4%) and death with dignity (63.7%) decreased. In a comparison of death with dignity and life with dignity, the number of nephrologists who support life with dignity (47.1%) was greater than that supporting death with dignity (15.9%).
Our results suggested that death with dignity may be performed when there is an AD and both the nephrologist and the family respect the patient's self-determination. Furthermore, many nephrologists consider that either AD or death with dignity is required. While, it is supposed that life with dignity is very important for human being, nephrologists were more supportive of life with dignity than death with dignity. Since the right-to-life of all Japanese citizens is guaranteed by the Constitution of Japan, we can start to live with dignity at the terminal stage. Thus, we should recognize that AD for life with dignity is the most important for self-determination within the social consensus.
