Japanese physicians’ practice of withholding and withdrawing mechanical ventilation and artificial nutrition and hydration from older adults with very severe stroke

Amid the lack of legislation or guidelines regarding withholding and withdrawing care in Japan, some physicians who have withdrawn mechanical ventilation from dying patients have recently been subjected to police investigations on suspicion of murder. Under the circumstances, we examined Japanese physicians’ attitudes towards mechanical ventilation and artificial nutrition and hydration (ANH) as life-sustaining treatments (LST) to find out if they withhold or withdraw the LST when treating older adults with stroke-caused profound impairment with no hope for recovery. Face-to-face, in-depth interviews were conducted with 27 physicians ranging in age from 26 to 70 in 2004 mainly in the Tokyo metropolitan area. The study findings show that the informants held different views towards the two LST because most doctors considered ANH to be indispensable, while they did not think so for mechanical ventilation. Regarding the reasons that lead physicians to consider ANH is indispensable while mechanical ventilation is not, the following factors were identified: ANH's special status as food and water, ordinary/extraordinary, the level of technology, and sense of unnaturalness. Because of its indispensability, ANH is automatically provided, while mechanical ventilation could be withheld in some patients that the physicians have diagnosed to have no hope for recovery. The current legal framework in Japan, which poses legal risks for physicians when withdrawing care, have led some of the physicians to withdraw care in a secret manner, thus causing an unnecessary psychological burden on the physicians. This study indicated that the legal framework has possibly caused troubles in two ways: routinely providing patients with possibly unwanted mechanical ventilation and ANH, and conversely, prompting some doctors to withhold mechanical ventilation in some cases, thereby potentially depriving some patients of a chance to recover. The introduction of the practice of a trial treatment period may be more cogent, considering the inherent uncertainty of diagnoses. The findings of the study also indicated that the physician informants tended to view the value of maintaining the lives of non-communicative patients in terms of the relationships of such patients with others. The vulnerability of patients without strong relationships with others needs to be taken into consideration when compiling guidelines regarding withholding and withdrawing care in Japan.