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Originally published as JCO Early Release 10.1200/JCO.2003.10.155 on October 21 2002 © 2002 American Society for Clinical Oncology Attitudes of Japanese Physicians Toward Terminal Dehydration: A Nationwide SurveyByFrom the Seirei Hospice, Seirei Mikatabara Hospital, Hamamatsu, Shizuoka; Department of Palliative Care, National Cancer Center Hospital East, Kashiwa, Chiba; and Department of Medical Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan. This article was published ahead of print at www.jco.org.Address reprint requests to Tatsuya Morita, MD, Seirei Hospice, Seirei Mikatabara Hospital, 3453 Mikatabara-cho, Hamamatsu, Shizuoka 433-8558, Japan; email: inomoteho{at}ma4.justnet.ne.jp
PURPOSE: To clarify physician attitudes toward terminal dehydration and identify the physician-related factors contributing to their attitudes. METHODS: A cross-sectional survey of Japanese physicians with a self-reported questionnaire was used. RESULTS: A total of 584 responses were analyzed (response rate, 53%). In the vignette of a gastric cancer patient with an estimated survival of 1 month and almost impossible oral intake due to intestinal obstruction, 50% chose intravenous hydration of 1,000 mL/d, while 24% selected more than 1,500 mL/d. For a lung cancer patient with cachexia, 58% chose 1,000 mL/d, while 26% selected no hydration or 500 mL. Multivariate analyses revealed that the physicians with more positive attitudes toward intravenous hydration were significantly less involved in end-of-life care, more likely to regard the physiologic requirement of fluid and nutrition as important in initiating intravenous hydration, more likely to believe that intravenous hydration is effective for symptom palliation, and more likely to believe that intravenous hydration is the minimum standard of care. CONCLUSION: Physicians have considerably divergent attitudes toward intravenous hydration for terminally ill cancer patients. To resolve the discrepancy, the priority in hydration research should be to clarify the appropriate physiologic requirements of fluid and nutrition in dying patients, the effects of intravenous hydration on patient symptoms, and the reasons why physicians consider intravenous hydration to be the minimum standard of care.
WHETHER OR NOT a clinician should administer artificial hydration to terminally ill cancer patients has been the focus of active discussion in recent medical literature.1,2 Hospice care practitioners have traditionally stressed that the routine use of artificial hydration does not always contribute to patient comfort,3,4 while many patients receive a large amount of intravenous hydration in cure-oriented hospitals just before death.5,6 However, more recently, some palliative care specialists have emphasized the importance of adequate hydration as a measure of symptom management,7 and there are large discrepancies in the physician practice of artificial hydration therapy for terminally ill cancer patients, not only between oncologists and hospice clinicians but also among palliative care experts.8-10 This large discrepancy could cause serious clinical problems in that terminal patients may suffer unnecessary distress: some patients could develop dehydration-related agitation if rehydration is not appropriately performed despite it being an intrinsically treatable condition,7 or some could experience iatrogenic pulmonary congestion due to excessive hydration if adequate monitoring is lacking.11 As patients generally follow their physicians’ recommendations on artificial hydration12,13 and many studies have revealed that physician-related variables have a significant influence on their end-of-life decisions,14,15 physicians’ divergent attitudes toward terminal dehydration are a major source of the inconsistencies in actual practice. Thus, elucidating the physician-related factors contributing to their medical decisions is important to understand why the discrepancies exist and what we should do to minimize the discrepancy. To our knowledge, however, only a few preliminary studies have been conducted to explore how physician-related factors influence their attitudes toward terminal dehydration.16-20 We hypothesized on the basis of the literature review8-10,16-20 that the medical decisions of physicians on artificial hydration therapy are influenced by what factors physicians regard as important and what they believe about terminal dehydration. In this survey, our primary aim was to clarify physicians’ attitudes toward artificial hydration therapy for terminally ill cancer patients and to identify the determinants of their clinical decisions.
This study was designed as a nationwide cross-sectional survey, in which a self-reported questionnaire was mailed to eligible physicians in December 2000. A second questionnaire was mailed to physicians who had not returned the reply postcard within 4 weeks after the initial mailing. The cover letter explained that this survey was confidential and anonymous. Participation consent was indicated by the completion and return of the questionnaire.
Respondents The representatives of each institution were requested to identify consecutive physicians as potential participants if they were attending physicians whose specialty was primary responsibility for the care of terminally ill cancer patients, such as internal medicine, medical oncology, surgery, and palliative medicine. Physicians involved in this study project were excluded. A total of 1,123 physicians were recruited as a heterogeneous sample of physicians working at cancer centers, general hospitals, or palliative care units (508 from 16 cancer centers and 615 from 74 institutions other than cancer centers).
Questionnaire The questionnaire, a 12-page leaflet, first investigated seven areas in the respondents’ backgrounds: age, sex, years of clinical practice, specialty and practice setting, number of cancer deaths during the previous year, self-perceived ability in symptom control (rated on a 5-point Likert-type scale from 1 = "very insufficient" to 5 = "very sufficient"), and possibility of refusing artificial hydration in their own terminal stage (rated on a 5-point Likert-type scale from 1 = "absolutely not" to 5 = "probably"). The last question was aimed at investigating physicians’ personal preferences in artificial hydration. The respondents were then asked to rate the degree to which they regarded 30 medical-psychosocial factors as important on a 5-point Likert-type scale (1 = "not important at all" to 5 = "very important") in deciding the indication of intravenous hydration for a terminally ill cancer patient with an estimated survival of 1 month. Moreover, they were required to rate the degree of agreement with 25 brief statements about intravenous hydration on a 6-point Likert-type scale (1 = "strongly disagree" to 6 = "strongly agree"). Physicians who (dis)agreed with each statement were defined as those who chose any of "probably (dis)agree," "(dis)agree," or "strongly (dis)agree." The physicians were finally requested to select a recommended treatment for two vignettes in their usual practice. In both cases, a terminally ill cancer patient with an estimated survival of 1 month was bedridden, dependent on others in most daily activities, and almost incapable of oral intake. The underlying etiology for their reduced oral intake was intestinal obstruction from gastric cancer in one case and progressive cachexia due to lung cancer in another case. Prepared treatment options were (1) no hydration or 500 mL/d intravenous hydration, (2) 1,000 mL/d intravenous rehydration, (3) 1,500 to 2,000 mL/d intravenous rehydration, and (4) hyperalimentation.
Statistical Analyses The mean score of three items (required fluid volume, required nutrient quantity, and results of laboratory tests) was labeled as the subscale score of "physiologic requirement" of fluid and nutrition in dying patients (Cronbach’s alpha coefficient, 0.72; mean ± S.D, 2.8 ± 0.68). Five items investigating etiologies that impair oral intake were summarized as an "underlying etiology" subscale (presence of intestinal obstruction, cachexia, dysphasia, neuropsychiatric complications, and treatable conditions such as hypercalcemia; alpha, 0.76; mean, 3.5 ± 0.68). Three questions evaluated the "metabolic function" of patients (hepatorenal function, cardiopulmonary function, and degree of fluid retention; alpha, 0.84; mean, 3.4 ± 0.83), and three items examined "current patient distress" (degree of physical distress, psychologic distress, and quality of life; alpha, 0.88; mean, 4.2 ± 0.74). "Current general conditions" were evaluated by two questions (expected survival and performance status; alpha, 0.74; mean, 3.8 ± 0.92), and four questions addressed "preference of the patient and family" (patient’s wishes and values, wishes and values of the patient’s family, patient’s acceptance of his/her condition, and family’s acceptance of patient condition; alpha, 0.81; mean, 4.2 ± 0.62). The mean score of two items referring to the importance of possibility that intravenous hydration alleviates or deteriorates patient distress was defined as a subscale score of "possibility of symptom alleviation" (alpha, 0.84; mean, 4.2 ± 0.85). "Team opinion" was assessed by two questions (opinions of nurses and opinions of physician colleagues; alpha, 0.82; mean, 3.4 ± 0.76), and two items evaluated "cost" (patient financial burden, and cost and equipment required for intravenous hydration; alpha, 0.80; mean, 3.0 ± 0.84). In addition, the importance of "possibility of survival prolongation," "patient’s age," "effects of intravenous hydration on the patient’s daily activities," and "accessibility of a venous route" was evaluated individually (mean, 2.9 ± 1.1, 3.1 ± 1.0, 3.9 ± 0.78, and 3.6 ± 0.84, respectively). The strength of physician belief that "intravenous hydration is effective for symptom palliation" was evaluated by the mean score of the questions on the effects of intravenous hydration for 11 symptoms (sensation of thirst, general malaise, delirium, burden of urination, nausea/vomiting, cough/sputum/dyspnea, pain, edema, ascites, pleural effusion, and general comfort; alpha, 0.85; mean, 3.3 ± 0.72). The mean score of three items ("intravenous hydration is the minimum standard of care," "reduced oral intake in the terminal stage is a natural process," and "allowing a patient to die under dehydrated conditions is ethically impermissible") was defined as a subscale score of physician belief that "intravenous hydration is the minimum standard of care" (alpha, 0.77; mean, 3.2 ± 1.0). The strength of physicians’ belief that "withholding intravenous hydration can be abused" was assessed by two questions ("withholding intravenous hydration leads to handling lives without respect" and "withholding intravenous hydration leads to the custom of undertreatment for compromised patients"; alpha, 0.78; mean, 2.1 ± 0.88). Two questions examined the intensity of the physicians’ belief that "withholding intravenous hydration shortens patient life" ("withholding intravenous hydration often shortens the patient’s survival" and "withholding intravenous hydration is indistinguishable from an act of intentional acceleration of death"; alpha, 0.79; mean, 2.5 ± 1.0). Belief that "withholding intravenous hydration damages trust in physicians" was assessed by two items ("withholding intravenous hydration leads to loss of patient trust" and "withholding intravenous hydration leads to loss of family trust"; alpha, 0.93; mean, 2.8 ± 1.0), while two items addressed the physicians’ belief that "withholding intravenous hydration is criticized" ("withholding intravenous hydration can be criticized by colleagues" and "withholding intravenous hydration may lead to legal accusation"; alpha, 0.71; mean, 2.1 ± 0.88). Additionally, three beliefs that "maintaining a venous route is a burden on the patient," "it is difficult to adequately determine the medical indication for intravenous hydration," and "patients have the right to refuse intravenous hydration" were assessed individually (mean, 3.8 ± 1.1, 4.1 ± 1.2, and 5.2 ± 0.95, respectively).
To explore the determinants of physicians’ attitudes, potential contributing factors (seven areas of physician characteristics, 13 subscales of the physician-perceived importance of medical-psychosocial factors, and nine subscales of physicians’ beliefs) were screened by univariate analyses. Univariate analyses were performed using the Mann-Whitney U test and the Multiple logistic regression analyses were then performed using all significant predictors identified by univariate analyses as independent variables in a forward elimination fashion. For comparisons, the respondents were classified into two groups: in the gastric cancer scenario, (a) physicians who selected no hydration or 1,000 mL/d intravenous hydration and (b) physicians who selected 1,500 mL/d or hyperalimentation; in the lung cancer scenario, (a) physicians who selected no hydration or 500 mL/d intravenous hydration and (b) physicians who selected 1,000 mL/d or hyperalimentation. We determined this classification based on the actual distribution of the responses, and another classification (physicians who perform intravenous hydration 500 mL/d or more v those who do not) achieved the same results. All analyses were performed using the Statistical Package for the Social Sciences (version 9.0; SPSS Japan Inc, Tokyo, Japan).
Characteristics of Physicians Of the 1,123 physicians to whom questionnaires were mailed, 595 returned the questionnaires (356 returned them within 4 weeks and 239 did so after a reminder). Since 11 responses did not meet the eligibility criteria, 584 responses were finally analyzed (response rate, 53% [584 of 1,112]). The response rates were 44% (222 of 508) in cancer centers and 59% (361 of 615) in other settings. We could not further compare the backgrounds between respondents and nonrespondents because of lack of the original data. The characteristics of the physicians are listed in Table 1.
Physician-Rated Importance of Medical-Psychosocial Factors More than 75% of the respondents ranked patient’s wishes and values, degree of physical distress, and possibility of symptom alleviation by intravenous hydration as important or very important in indicating intravenous hydration: 91% (n = 533), 84% (n = 490), and 77% (n = 451), respectively. On the other hand, required fluid volume, possibility of survival prolongation, and required nutrient quantity were perceived as important or very important in 35% (n = 202), 30% (n = 175), and 9.4% (n = 55), respectively.
Physician Beliefs About Intravenous Hydration Twenty-three percent (n = 134) and 26% (n = 153) agreed that "withholding intravenous hydration leads to loss of patient trust" and "family trust," respectively. Ten percent (n = 59) and 7.7% (n = 45) agreed that "withholding intravenous hydration can be criticized by colleagues" and "withholding intravenous hydration may lead to legal accusation," respectively. In addition, 65% (n = 379) agreed that "maintaining a venous route is a burden on the patient," and 72% (n = 423) agreed that "it is difficult to adequately determine the medical indication for intravenous hydration."
Attitudes Toward Intravenous Hydration in the Vignettes
Factors Contributing to the Physicians’ Decisions Univariate analyses. Univariate analyses (Table 3) showed that physicians with more positive attitudes toward intravenous hydration were significantly less involved in end-of-life care, less likely to refuse artificial hydration in their own cases, more likely to regard the "physiologic requirement" of fluid and nutrition as important, and more likely to believe that "intravenous hydration is effective for symptom palliation," "intravenous hydration is the minimum standard of care," "withholding intravenous hydration can be abused," "withholding intravenous hydration shortens patient life," and "withholding intravenous hydration damages trust in physicians."
They were also significantly more likely to regard "underlying etiology" as important, less likely to regard the "possibility of symptom alleviation" as important, more likely to believe that "withholding intravenous hydration is criticized," and less likely to believe that "patients have the right to refuse intravenous hydration," but the absolute differences in the mean scores were less than 0.30 (data not shown). On the other hand, there were no statistically significant differences between the groups in respondent age, sex, clinical experience, the degree of agreement on difficulty in adequately determining the medical indication for intravenous hydration, and the physicians’ perceived importance of "preference of the patient and family," "current patient distress," "possibility of survival prolongation," "current general condition," "metabolic function," "effects of intravenous hydration on the patient’s daily activities," "accessibility of a venous route," "team opinion," and "cost." Multivariate analyses. Multiple logistic regression analyses (Table 4) revealed that specialty (not palliative medicine), more physician-perceived importance of the "physiologic requirement" of fluid and nutrition, a stronger belief that "intravenous hydration is effective for symptom palliation," and a stronger belief that "intravenous hydration is the minimum standard of care" independently related to more positive attitudes toward intravenous hydration.
The most important finding in this study is the identification of physician-related factors influencing their medical decisions about intravenous hydration for terminally ill cancer patients. The differences in the physician-perceived importance of the "physiologic requirement" of fluid and nutrition, the degree to which they believed that "intravenous hydration is effective for symptom palliation," and the degree to which they perceived intravenous hydration as "the minimum standard of care" were the main origins of discrepancies in physicians’ attitudes, independent of their specialties. On the other hand, the physicians allocated essentially equal levels of importance to "preference of the patient and family," "current patient distress," "possibility of symptom alleviation," and "possibility of survival prolongation" in deciding the indications of intravenous hydration. Physicians who regarded the "physiologic requirement" of fluid and nutrition as more important recommended a higher-level intravenous hydration in the vignettes. This result corresponds to the clinical observation that identified "giving fluid and food" as the main reason for intravenous hydration in an Israeli oncology unit19 and several qualitative or preliminary studies which revealed that many caregivers of terminally ill cancer patients were concerned that the patient would not receive sufficient nutrition without artificial hydration.13,22 Since patients generally follow their physician’s recommendations,12,13 the physician’s comprehension of the physiologic requirements of fluid and nutrition plays an important role in the decision-making process. However, because of a lack of empirical evidence on the appropriate physiologic requirements for dying patients, clinicians often treat terminally ill patients as if they are identical to nonterminal individuals. Thus, physiologic studies designed to clarify the appropriate fluid and nutrition required in the terminal phase will be of great value to resolve this discrepancy. The physicians’ belief in the efficacy of intravenous hydration for symptom palliation was a strong determinant for their medical decisions. Comparable findings have been reported in previous studies. A preliminary survey from Switzerland revealed that a physician’s decision to perform artificial hydration depended on his or her assessment of how distressed a patient was by dehydration.16 Also, in a vignette survey from the United Kingdom, 85% of physicians listed "ensuring the patient’s comfort" as a reason for performing parenteral rehydration.17 This finding, combined with our result that both physicians with positive attitudes toward intravenous hydration and those with negative attitudes equally regarded "current patient distress" and the "possibility of symptom alleviation" as important factors, indicates that clinicians make different decisions in initiating artificial hydration despite their same intention: palliation of patient distress. Among American hospice practitioners, the majority of them support the view that dehydration causes no remarkable distress for terminal patients based on their clinical experiences,3 and several case series stress that terminal dehydration is not always associated with patient discomfort.4,11 To date, although some empirical studies have investigated the associations between hydration status and actual patient experiences,7,23-27 they have focused on only limited physical symptoms; therefore, the findings about the overall effects of intravenous hydration are conflicting or at most preliminary.28 Since this study revealed a lack of conclusive evidence on the benefits and risks of artificial hydration as the main origin of divergence in physician practice, well-designed clinical studies with comprehensive outcome assessments are strongly encouraged to resolve the discrepancies. The physicians’ belief that "intravenous hydration is the minimum standard of care" was a significant determinant of physicians’ attitudes. In Japan, withdrawing and withholding life-support therapy, including artificial hydration, is basically accepted based on the principle of patient autonomy, similar to the case in many Western countries.29,30 In addition, a nationwide opinion survey revealed that 70% of 2,400 Japanese individuals in the general public support the withdrawal of life-sustaining therapy in a painful terminal stage.31 In this study, however, 40% of the physicians regarded intravenous hydration as the minimum standard of care, and 32% considered allowing a patient to die under dehydrated conditions as being ethically impermissible. These results corresponded to the findings of previous surveys that Japanese physicians were more likely to perform life-support therapy for terminal patients than Japanese-American doctors,32 and that 24% of Japanese oncologists regarded the withdrawal of life-support treatment as never being ethically justified.33 This attitude may be related to the physician’s professional role to prolong patient life, their value system of the "sanctity of life," and cultural demands from patients and families in Japanese society.19,34 Some investigators suggest, however, that physicians perform artificial hydration for terminal patients without a clear medical aim as a "symbol of caregiving," and it is motivated by their own insufficient knowledge about clinical ethics, their own difficulty in accepting a patient’s death, which can be seen as a medical failure, and their need for emotional comfort for themselves, acquired by "doing something" and not "standing by."16-18 As it is beyond the scope of this study to address why physicians regarded intravenous hydration as the minimum standard of care, qualitative studies using in-depth interviews are warranted. This study has several limitations. We cannot conclude whether this sample is representative of all physicians in Japan because there is no complete registry system of physicians available. Also, the response rate was relatively low and the results may not apply to the half of the study population that did not reply, and we cannot compare many of the backgrounds of respondents and nonrespondents because of the lack of original data. However, we do not believe that the selection bias seriously influences the conclusion, because the number of subjects studied is large and because the physician backgrounds are basically consistent with another nationwide survey with different selection methods.15 Finally, as the study participants were limited to Japanese physicians, the findings cannot be automatically generalized for other ethnic groups. In conclusion, this study highlights marked divergences in physicians’ attitudes toward intravenous hydration for terminally ill cancer patients. Physicians’ attitudes are not well explained by the differences in the physician-perceived importance of patient and family preference, current patient distress, possibility of symptom alleviation, and possibility of survival prolongation. Physicians’ perceptions about the importance of the "physiologic requirements" of fluid and nutrition, their belief that "intravenous hydration is effective for symptom palliation," and their belief that "intravenous hydration is the minimum standard of care" were independent determinants of physicians’ attitudes. To minimize the existing discrepancy, research emphasis should be placed on (1) physiologic studies to determine the appropriate requirements for fluid and nutrition in dying patients, (2) clinical studies to examine the comprehensive treatment efficacy of intravenous hydration, and (3) qualitative studies to address why physicians think intravenous hydration is the minimum standard of care. These studies will strongly contribute to clarification of appropriate medical management for terminal dehydration.
Appendix
Supported in part by a Grant-in-Aid for Cancer Research (11-2) from the Ministry of Health and Welfare, Japan.
The other members of the Japan Palliative Oncology Study Group involved in this survey are as follows: Toshihiro Matsuura, MD, Department of Gastroenterology, Chubu National Hospital, Aichi, Japan; Yoichiro Tamura, MD, Department of Surgery, Kasumigaura National Hospital, Ibaraki, Japan; and Shunya Uchida, MD, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.
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7. Lawlor PG, Ganon B, Mancini IL, et al: Occurrences, causes, and outcome of delirium in patients with advanced cancer: A prospective study. Arch Intern Med 160: 786-794, 2000 8. Bozzetti F: Guidelines on artificial nutrition versus hydration in terminal cancer patients. Nutrition 12: 163-167, 1996[CrossRef][Medline] 9. National Council for Hospice and Specialist Palliative Care Services: Artificial hydration (AH) for people who are terminally ill. Eur J Palliat Care 4: 124, 1997 10. MacDonald N: Ethical issues in hydration and nutrition, in Portenoy RK, Bruera E (eds): Topics in Palliative Care, vol 2. New York, NY, Oxford University Press, 1998, pp153-163 11. Andrews M, Bell ER, Smith SA, et al: Dehydration in terminally ill patients: Is it appropriate palliative care? Postgrad Med J 93: 201-208, 1993[Medline]
12. Bruera E, MacDonald N: To hydrate or not to hydrate: How should it be? J Clin Oncol 18: 1156-1158, 2000 13. Morita T, Tsunoda J, Inoue S, et al: Perceptions and decision-making on rehydration of terminally ill cancer patients and family members. Am J Hospice Palliat Care 16: 509-516, 1999
14. Emanuel EL, Fairclough D, Clarridge BC, et al: Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med 133: 527-532, 2000
15. Morita T, Akechi T, Sugawara Y, et al: Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: A nationwide survey. J Clin Oncol 20: 758-764, 2002 16. Collaud T, Charles-Henri R: Dehydration in dying patients: Study with physicians in French-speaking Switzerland. J Pain Symptom Manage 6: 230-240, 1991[CrossRef][Medline]
17. Martin PP, Bayer AJ, Tomlinson A, et al: Attitudes of hospital doctors in Wales to use of intravenous fluids and antibiotics in the terminally ill. Postgrad Med J 65: 650-652, 1989
18. Micetich KC, Dteinecker PH, Thomasma DC: Are intravenous fluids morally required for a dying patient? Arch Intern Med 143: 975-978, 1983 19. Musgrave CF, Bartal N, Opstad J: Intravenous hydration for terminal patients: What are the attitudes of Israeli terminal patients, their families, and their health professionals? J Pain Symptom Manage 12: 47-51, 1996[CrossRef][Medline] 20. Penn K: Passive euthanasia in palliative care. Br J Nursing 11: 462-466, 1992 21. Statistics and Information Department, Minister’s Secretariat, Ministry of Health and Welfare: Report on the Socioeconomic Survey of Vital Statistics: The Medical Treatment for the Terminally Ill Patients. Tokyo, Japan, Ministry of Health and Welfare, 1996 22. Parkash R, Burge F: The family’s perspective on issues of hydration in terminal care. J Palliat Care 13: 23-27, 1997[Medline] 23. Burge FI: Dehydration symptoms of palliative care cancer patients. J Pain Symptom Manage 8: 454-464, 1993[CrossRef][Medline] 24. Ellershaw JE, Sutcliffe JM, Saunders CM: Dehydration and the dying patient. J Pain Symptom Manage 10: 192-197, 1995[CrossRef][Medline]
25. McCann RM, Hall WJ, Grith-Juncker A: Comfort care for terminally ill patients: The appropriate use of nutrition and hydration. JAMA 272: 1263-1266, 1994 26. Morita T, Tsunoda J, Inoue S, et al: Determinants of sensation of thirst in terminally ill cancer patients. Support Care Cancer 9: 177-186, 2001[CrossRef][Medline] 27. Vullo-Navich K, Smith S, Andrews M, et al: Comfort and incidence of abdominal serum sodium, BUN, creatinine and osmolality in dehydration of terminal illness. Am J Hospice Palliat Care 15: 77-84, 1995[CrossRef] 28. Viola RA, Wells GA, Peterson J: The effects of fluid status and fluid therapy on the dying: A systemic review. J Palliat Care 13: 41-52, 1997[Medline] 29. The Bioethics Committee for Japanese Medical Association: Special report about "what physicians faced with patients with terminal illness should do?" Nihon Ishikai Zassi 107: 1209-1217, 1992
30. Miller FG, Meier DE: Voluntary death: A comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med 128: 559-562, 1998 31. Miyashita M, Hashimoto S, Kawa M, et al: Attitudes towards terminal care among the general population and medical practitioners in Japan. Nippon Eiseigaku Zasshi 46: 391-401, 1999 32. Asai A, Fukuhara S, Lo B: Attitudes of Japanese and Japanese-American physicians towards life-sustaining treatment. Lancet 346: 356-359, 1995[CrossRef][Medline] 33. Asai A, Miura Y, Tanabe N, et al: Advance directives and other medical decisions concerning the end of life in cancer patients in Japan. Eur J Cancer 34: 1582-1586, 1998[CrossRef][Medline]
34. Norberg A, Hirschfeld M, Davidson B, et al: Ethical reasoning concerning the feeding of severely demented patients: An international perspective. Nurs Ethics 1: 1-13, 1994 Submitted October 30, 2001; accepted September 30, 2002.
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 test, where appropriate. To assess chance results by 29 comparisons, the P value necessary for statistical significance was defined as .0017 (.05/29) using the Bonferroni correction. 
