Although indication of gastrostomy feeding for the elderly is one of the common issues of clinical ethics in nursing homes, nursing home workers’ practice and attitude regarding shared decision making with patients and their families about starting gastrostomy feeding have not been elucidated. Thus, we conducted a self-completed questionnaire survey of 4 intensive care homes for the elderly and 1 long-term care health facility in Japan. Sixty-seven nursing home workers participated in the survey. Most Japanese nursing home workers did not have experience to discuss with patients and their families in decision making about starting gastrostomy feeding and were not willing to play a role in the process. The workers’ thought that the decision should be made by medical staffs and families, and the workers’ negative impression about gastrostomy feeding seemed to underlie the results. On the other hand, some of the workers recognized that they should confirm the patients’ own preference. These findings suggest that ethical support and education may be necessary in nursing homes in Japan.

  The health insurance systems in Japan include a substitutional mechanism of payment to a victim on behalf of an individual at fault. The patient must submit a notification of third-party infringement if he/she wants to use this optional mechanism. As this notification plays the role of a trigger for a claim for compensation, patients and physicians’opinions regarding this notification may often be in disagreement. In particular, an ethical dilemma may arise if a victim was negative toward the claim for compensation and demanded the usual Medical Treatment Benefits from the physician instead. Ethical matters concerning physicians have not been studied in Japan in relation to this substitutional payment mechanism or notification of third-party infringement.

  Herein, we report two cases in which an ethical dilemma arose concerning this notification. In these cases, the contribution of third-party infringement to the hospitalization was not conclusive. The one submitted the notification affected by physicians’persuasion, but the other did not. Problems on the substitutional payment mechanism are also discussed using the cases. Management of treatment expense claims in cases whose sickness or injury is partially attributed to third-party infringement should be discussed further and better organized in the future.

   [Case] A 69-years-old man was suffering from end-stage renal failure and had received hemodialysis for 10 years. His past medical history included successful resuscitation after cardiopulmonary arrest that occurred at home in October, X year. [Present History] The patient lost consciousness before hemodialysis and was taken to the emergency center of our hospital by ambulance in March, X+2 year. He was in a state of cardiopulmonary arrest on arrival, was resuscitated by critical care, and was started on continuous hemodiafiltration with a circulation assist device after coronary intervention. Consequently, his cardio dynamics became partially stable but clinical signs predicted poor outcomes due to hypoxic encephalopathy, electroencephalogram and head computed tomography.

   [Course/Discussion] Specialists of emergency medicine, cardiovascular medicine and blood purification conferred to adapt the “Guidelines for End-of-Life Care in Emergency/Intensive Care Medicine (JAAM, JSCIM & JCS, 2014)” and the “Proposal for the Shared Decision-Making Process Regarding Initiation and Continuation of Maintenance Hemodialysis (JSDT, 2014)”. After deciding the treatment policy with his family and ceasing renal replacement therapy, the patient died. This case reveals the difference between emergency/intensive care physicians and blood purification professionals in terms of ceasing renal replacement therapy and the basic stance toward end-of-life treatment.

  The purpose of this report is to describe the characteristics of the dilemmas experienced by Speech-Language-Hearing Therapists (ST) during treatment for swallowing disorders. The responses of 8 ST to semi-structured interviews were analyzed based on the grounded theory approach of Strauss and Corbin. Ten categories and one core category were identified. Four of these categories involved situations in which the ST were faced with dilemmas ; i. e., forcing the patient to participate in futile training, ending feeding rehabilitation, continuing with hazardous feeding, and feeling guilty about feeding. Three of these categories involved ethical dilemmas. The results of this study also suggest that ST are at increased risk of suffering compassion fatigue.

  Jehovah’s Witness patients do not accept allogenic blood transfusion. It is important to know medical situations for Witness patients who refuse blood transfusion to solve problems. We had interview with Witnesses. There are many problems that we cannot solve using patients’ Rights, medicines and laws. It is necessary to understand each other using clinical ethics-based correspond that the Witnesses of patients should be respected as much as possible.