Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study.
BACKGROUND
The question of whether to withhold artificial nutrition and hydration (ANH) from severely cognitively impaired older adults has remained nearly unexplored in Japan, where provision of ANH is considered standard care. The objective of this study was to identify and analyze factors related to the decision to provide ANH through percutaneous endoscopic gastrostomy (PEG) in older Japanese adults with severe cognitive impairment.


METHODS
Retrospective, in-depth interviews with thirty physicians experienced in the care of older, bed-ridden, non-communicative patients with severe cognitive impairment. Interview content included questions about factors influencing the decision to provide or withhold ANH, concerns and dilemmas concerning ANH and the choice of PEG feeding as an ANH method. The process of data collection and analysis followed the Grounded Theory approach.


RESULTS
Data analysis identified five factors that influence Japanese physicians' decision to provide ANH through PEG tubes: (1) the national health insurance system that allows elderly patients to become long-term hospital in-patients; (2) legal barriers with regard to limiting treatment, including the risk of prosecution; (3) emotional barriers, especially abhorrence of death by 'starvation'; (4) cultural values that promote family-oriented end-of-life decision making; and (5) reimbursement-related factors involved in the choice of PEG. However, a small number of physicians did offer patients' families the option of withholding ANH. These physicians shared certain characteristics, such as a different perception of ANH and repeated communication with families concerning end-of-life care. These qualities were found to reduce some of the effects of the factors that favor provision of ANH.


CONCLUSIONS
The framework of Japan's medical-legal system unintentionally provides many physicians an incentive to routinely offer ANH for this patient group through PEG tubes. It seems apparent that end-of-life education should be provided to medical providers in Japan to change the automatic assumption that ANH must be provided.
Aita
Kaoruko
K
Department of Social Gerontology, School of Health Sciences and Nursing, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. aitak-tky@umin.ac.jp
Takahashi
Miyako
M
Miyata
Hiroaki
H
Kai
Ichiro
I
Finucane
Thomas E
TE
D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D003072:Cognition Disorders / Q000178:diet therapy* / Q000191:economics; D003362:Cost-Benefit Analysis; D004644:Emotions; D004750:Enteral Nutrition / Q000191:economics; D005066:Euthanasia, Passive / Q000941:ethics; D005260:Female; D005853:Geriatrics / Q000191:economics; D006801:Humans; D007407:Interviews as Topic; D007564:Japan; D016365:Liability, Legal; D008297:Male; D008875:Middle Aged; D028681:Moral Obligations; D009313:National Health Programs; D011368:Professional-Family Relations; D036301:Qualitative Research; D012189:Retrospective Studies; D012945:Social Values
Soc Sci Med. 1993 May;36(9):1151-9
8511644
Arch Intern Med. 1992 Apr;152(4):697-700
1373053
Arch Intern Med. 1997 Feb 10;157(3):327-32
9040301
Nihon Ronen Igakkai Zasshi. 1997 Jan;34(1):12-6
9077099
Nihon Ronen Igakkai Zasshi. 1999 Jan;36(1):45-51
10332194
J Am Geriatr Soc. 1999 Sep;47(9):1105-9
10484254
JAMA. 1999 Oct 13;282(14):1365-70
10527184
Age Ageing. 2005 Jul;34(4):320-1
15955754
Arch Intern Med. 2005 Aug 8-22;165(15):1729-35
16087820
Clin Nutr. 2005 Oct;24(5):848-61
16261664
Geriatrics. 2006 Jun;61(6):12-3
16768539
Geriatrics. 2006 Jun;61(6):30-5
16768542
J Gerontol A Biol Sci Med Sci. 2006 Jun;61(6):621-7
16799146
Lancet. 2006 Jul 1;368(9529):12-4
16815362
N Engl J Med. 2000 Jan 20;342(3):206-10
10639550
Hastings Cent Rep. 2001 Jan-Feb;31(1):36-42
11478092
Nihon Ronen Igakkai Zasshi. 2002 Nov;39(6):639-42
12518416
J Am Geriatr Soc. 2003 Jan;51(1):129-31
12534858
Arch Intern Med. 2003 Jun 9;163(11):1351-3
12796072
JAMA. 2003 Jul 2;290(1):73-80
12837714
N Engl J Med. 2003 Jul 24;349(4):359-65
12878744
Nihon Ronen Igakkai Zasshi. 2003 Sep;40(5):504-8
14579722
Nihon Ronen Igakkai Zasshi. 2003 Nov;40(6):607-9
14689852
Health Aff (Millwood). 2004 May-Jun;23(3):26-36
15160800
Clin Nutr. 2004 Oct;23(5):1248-9
15380920
Lancet. 1990 Feb 3;335(8684):278-9
1967733
N Engl J Med. 1995 Nov 9;333(19):1295-9
7566019