論文紹介著者

リー・アンドリュー・キセイン（博士課程 2年）
GCOE　RA
医療政策・管理学教室

第一著者名・掲載雑誌・号・掲載年月

Sakiko Fukui／Journal of Pain and Symptom Management Volume 42 No 6 page 882-892 December 2011

文献の英文表記：著者名・論文の表題・雑誌名・巻・号・ページ・発行年（西暦）

Sakiko Fukui, Kazuhiro Yoshiuchi, Junko Fujita, Minako Sawai, and Minako Watanabe.
Japanese People's Preference for Place of End-of-Life Care and Death: A Population-Based Nationwide Survey. Journal of Pain and Symptom Management 42 6:882-892,2011

論文解説

Where people wish to spend their End-of-Life and die is an important question when developing inpatient and community services. Although the Japanese Ministry of Welfare has conducted 4 national surveys investigating the views of the general public about End-of-Life care over the last 20 years, there is a paucity of published studies in the international literature attempting to determine the preferences of the Japanese population with regard to End-of-Life care. This paper by Fukui et al represents an important addition to the evidence in this field. Fukui et al undertook an anonymous, national postal survey in March 2010 of 2000 Japanese people of 40-79 years of age using a random sampling method. The survey questionnaire asked about people`s preferences for their place of End-of-Life care and their place of death, assuming they had a remaining life expectancy of one to two months, no physical distress, and needed care-assistance in their daily activities. The options for place of End-of-Life care and place of death were hospital, palliative care unit, home, or different types of nursing home. The survey questionnaire also asked questions to assess how people`s preferences varied with their experience, perceptions and knowledge. 1042 completed questionnaires were returned and analyzed (55%.) The results for preferences for place of End-of-Life care and preferences for place of death were very similar, with 65% of respondents choosing the same place to both receive End-of-Life care and to die. For End-of-Life care, 43.7% preferred home, 14.8% preferred an acute hospital, 19.2% preferred a palliative care unit, 9.9% preferred a Heath Care Facility for the Elderly, and 1.6% preferred a private nursing home with 10.8% being uncertain. For death, 42.9% preferred home, 15.7% preferred an acute hospital, 20% preferred a Palliative Care Unit, 7.4% preferred a Health Care Facility for the Elderly, 0.6% preferred a private nursing home, and 13.4% were uncertain.

In their conclusions, Fukui et al state that the rates of preferred End-of-Life care at home and preferred death at home were 44% and 43% respectively in their study, but Ministry of Welfare data for 2008 report only 15% of deaths in Japan occur `at home` (ie out of hospital.) Further, they state that only 15% and 16% respectively of the respondents in their survey wish to receive End-of-Life care in an acute hospital and wish to die in an acute hospital, in contrast to the fact that 85% of Japanese deaths were reported in the 2008 data to occur in hospital.

There are 2 problems with this conclusion. Firstly, the design of this study limits to what extent its results are generalizable. In Japan, only patients with diagnoses of cancer or HIV can be admitted to Palliative Care Units, and so the inclusion of the option of a Palliative Care Unit implies to the responder that in the survey the End-of-Life scenario is a cancer scenario. Indeed, for non-cancer patients the option of a Palliative Care Unit is a meaningless one. Further, it is quite possible preferences for place of End-of-Life care and for place of death are influenced by illness diagnosis. Given the scenario and the options presented, it might be more accurate to consider these survey results specific to respondents` preferences in terminal cancer care rather than generalizing to all End-of-Life care.

The second problem with this conclusion is that the categories are not comparable. Fukui et al ask about `acute hospital` as a place of End-of-Life care or place of death. But the national data to which they make comparisons above report all hospital deaths which will include acute hospital deaths as well as deaths in Long Term Care beds, Rehabilitation beds, Psychiatric beds and of course palliative care beds too. Those expressing a preference to die in acute hospital and those expressing a preference to die in a Palliative Care Unit would both experience a hospital death. Furthermore, the survey allowed an `uncertain` response selected by 13.4% of respondents whereas such a category defies comparison.

Preferences for place of End-of-Life care and for place of death need to be investigated for not just cancer but for all common End-of-Life conditions to best inform policy in this area, and questionnaire tools need to be designed with consideration for the inpatient services for which putative patients would be eligible.