Research article

Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study

Kaoruko Aita¹ , Miyako Takahashi¹ , Hiroaki Miyata² , Ichiro Kai¹ and Thomas E Finucane³

¹Department of Social Gerontology, School of Health Sciences and Nursing, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan

²Department of Healthcare Quality Assessment, School of Medicine, The University of Tokyo, Japan

³Division of Gerontology and Geriatric Medicine, School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA

author email corresponding author email

BMC Geriatrics 2007, 7:22doi:10.1186/1471-2318-7-22

Published:	17 August 2007

Abstract

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.

Conclusion

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.