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End-of-Life Care in ICUs in East Asia

A Comparison Among China, Korea, and Japan

Park, So Young, MD1; Phua, Jason, MD, PhD, MRCP2; Nishimura, Masaji, MD, PhD3; Deng, Yiyun, MD4; Kang, Yan, MD, PhD4; Tada, Keiichi, MD, PhD5; Koh, Younsuck, MD, PhD, FCCM6 on behalf of the Asian Collaboration for Medical Ethics (ACME) Study Collaborators and the Asian Critical Care Clinical Trials (ACCCT) Group

doi: 10.1097/CCM.0000000000003138
Clinical Investigations
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Objectives: To compare physicians’ perceptions and practice of end-of-life care in the ICU in three East Asian countries cultures similarly rooted in Confucianism.

Design: A structured and scenario-based survey of physicians who managed ICU patients from May 2012 to December 2012.

Setting: ICUs in China, Korea, and Japan.

Subjects: Specialists who are either intensivists or nonintensivist primary attending physicians in charge of patients (195 in China, 186 in Korea, 224 in Japan).

Interventions: None.

Measurements and Main Results: Country was independently associated with differences in the practice of limiting multiple forms of life-sustaining treatments on multivariable generalized linear model analysis. Chinese respondents were least likely to apply do-not-resuscitate orders, even if they existed (p < 0.001). Japanese respondents were most likely to practice do not resuscitate for terminally ill patients during cardiac arrest, even when no such prior order existed (p < 0.001). Korean respondents’ attitudes were in between those of Chinese and Japanese respondents as far as withdrawing total parenteral nutrition, antibiotics, dialysis, and suctioning was concerned. Chinese respondents were most uncomfortable discussing end-of-life care issues with patients, while Japanese respondents were least uncomfortable (p < 0.001). Chinese respondents were more likely to consider financial burden when deciding on limiting life-sustaining treatment (p < 0.001). Japanese respondents felt least exposed to personal legal risks when limiting life-sustaining treatment (p < 0.001), and the Korean respondents most wanted legislation to guide this issue (p < 0.001). The respondents’ gender, religion, clinical experience, and primary specialty were also independently associated with the different perceptions of end-of-life care.

Conclusions: Despite similarities in cultures and a common emphasis on the role of family, differences exist in physician perceptions and practices of end-of-life ICU care in China, Korea, and Japan. These findings may be due to differences in the degree of Westernization, national healthcare systems, economic status, and legal climate.

1Department of Pulmonary and Critical Care Medicine, Kyung Hee University Medical Center, Seoul, Korea.

2Division of Respiratory and Critical Care Medicine, Department of Medicine, University Medicine Cluster, National University Hospital, National University Health System, Singapore, Singapore.

3Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan.

4Department of Intensive Care, West China Hospital of Sichuan University, Chengudu, China.

5Department of Medicine for Longtime Care of Diseased Elderly, Hiroshima Sea Side Hospital, Hiroshima, Japan.

6Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

New address: Current address for Dr. Park: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Medical Center, Daejeon, Korea.

The collaborator list of the Asian Collaboration for Medical Ethics (ACME) Study in China, Korea, and Japan is listed in Appendix 1.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: yskoh@amc.seoul.kr

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