Tsuda Kenji, Higuchi Asaka, Yokoyama Emi, Kosugi Kazuhiro, Komatsu Tsunehiko, Kami Masahiro, Tanimoto Tetsuya
Medical Governance Research Institute, Minatoku, Japan.
Graduate School of Education, Seisa University, Yokohama, Japan.
Interact J Med Res. 2019 Sep 6;8(3):e12781. doi: 10.2196/12781.
Due to a low birth rate and an aging population, Japan faces an increase in the number of elderly people without children living in single households. These elderly without a spouse and/or children encounter a lack of caregivers because most sources of care for the elderly in Japan are not provided by private agencies but by family members. However, family caregivers not only help with daily living but are also key participants in treatment decision making. The effect of family absence on treatment decision making has not been elucidated, although more elderly people will not have family members to make surrogate decisions on their behalf.
The aim is to understand the influence of family absence on treatment decision making by physicians through a cross-sectional online survey with three hypothetical vignettes of patients.
We conducted a cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second was about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned to either of the two versions of the questionnaires-with family or without family-but methods were identical otherwise. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures.
Among 1112 physicians, 454 (40.8%) completed the survey; there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR] 0.55, 95% CI 0.34-0.80; P=.002) and artificial ventilation (OR 0.51, 95% CI 0.35-0.75; P<.001) for a patient from vignette 1 without family. In vignette 2, fewer physicians were willing to perform artificial ventilation (OR 0.59, 95% CI 0.39-0.90; P=.02). In vignette 3, significantly fewer physicians showed willingness to perform wound treatment (OR 0.51, 95% CI 0.31-0.84; P=.007), surgery (OR 0.35, 95% CI 0.22-0.57; P<.001), blood transfusion (OR 0.45, 95% CI 0.31-0.66; P<.001), vasopressor (OR 0.49, 95% CI 0.34-0.72; P<.001), dialysis (OR 0.38, 95% CI 0.24-0.59; P<.001), artificial ventilation (OR 0.25, 95% CI 0.15-0.40; P<.001), and chest compression (OR 0.29, 95% CI 0.18-0.47; P<.001) for a patient without family.
Elderly patients may have treatments withheld because of the absence of family, highlighting the potential importance of advance care planning in the era of an aging society with a declining birth rate.
由于出生率低和人口老龄化，日本面临着独居无子女老年人数量的增加。这些无配偶和/或子女的老年人缺乏照料者，因为在日本，大多数老年人的照料并非由私人机构提供，而是由家庭成员提供。然而，家庭照料者不仅协助日常生活，还是治疗决策的关键参与者。尽管越来越多的老年人将没有家庭成员代表他们做出替代决策，但家庭缺失对治疗决策的影响尚未阐明。
旨在通过一项包含三个患者假设案例的横断面在线调查，了解家庭缺失对医生治疗决策的影响。
我们使用三个假设案例对日本医生进行了横断面在线调查。第一个案例是关于一名65岁患有酒精性肝硬化的男性，第二个案例是关于一名78岁患有痴呆症的女性，两人均因肺炎出现意识障碍。第三个案例是关于一名70岁下肢坏死的女性。参与者被随机分配到问卷的两个版本之一——有家庭或无家庭——但其他方法相同。参与者对关于是否会实施所呈现医疗程序的问题选择“是”或“否”的回答。
在1112名医生中，454名（40.8%）完成了调查；两组之间的基线特征无显著差异。对于案例1中无家庭的患者，愿意进行透析的医生明显更少（优势比[OR]0.55，95%置信区间0.34 - 0.80；P = 0.002）以及进行人工通气的医生明显更少（OR 0.51，95%置信区间0.35 - 0.75；P < 0.001）。在案例2中，愿意进行人工通气的医生更少（OR 0.59，95%置信区间0.39 - 0.90；P = 0.其二，2）。在案例3中，对于无家庭的患者，愿意进行伤口治疗的医生明显更少（OR 0.51，95%置信区间0.31 - 0.84；P = 0.007）、进行手术的医生明显更少（OR 0.35，95%置信区间0.22 - 0.57；P < 0.001）、进行输血的医生明显更少（OR 0.45，95%置信区间0.31 - 0.66；P < 0.001）、使用血管加压药的医生明显更少（OR 0.49，95%置信区间0.34 - 以下是原文剩余部分的翻译：
72；P < 0.001）、进行透析的医生明显更少（OR 0.38，95%置信区间0.24 - 0.59；P < 0.001）、进行人工通气的医生明显更少（OR 0.25，95%置信区间0.15 - 0.40；P < 0.001）以及进行胸外按压的医生明显更少（OR 0.29其二，95%置信区间0.18 - 0.47；P < 0.001）。
老年患者可能因家庭缺失而得不到治疗，这凸显了在出生率下降的老龄化社会中，预先护理计划的潜在重要性。
