title: Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.
abstract: OBJECTIVE
  To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan.
  
  
  METHODS
  Survey by questionnaire.
  
  
  METHODS
  Seventy-two American, 87 German, and 73 Japanese nephrologists.
  
  
  METHODS
  Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases.
  
  
  RESULTS
  American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists. However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was supported by a patient advance directive.
  
  
  CONCLUSIONS
  There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.
authors.affiliation: Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio 44109-1998, USA.
authors.forename: A R
authors.initials: AR
authors.lastname: Sehgal
authors.forename: C
authors.initials: C
authors.lastname: Weisheit
authors.forename: Y
authors.initials: Y
authors.lastname: Miura
authors.forename: M
authors.initials: M
authors.lastname: Butzlaff
authors.forename: R
authors.initials: R
authors.lastname: Kielstein
authors.forename: Y
authors.initials: Y
authors.lastname: Taguchi
mesh_terms: D024362:Advance Directive Adherence; D016223:Advance Directives; D003657:Decision Making; D005858:Germany; D006801:Humans; D007258:Informed Consent; D038622:Internationality; D007564:Japan; D016015:Logistic Models; D016743:Mental Competency; D009398:Nephrology; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D006435:Renal Dialysis; D011795:Surveys and Questionnaires; D014481:United States; D028761:Withholding Treatment