Care of the terminally ill

Seven patients died between 2000 and 2005 at a hospital in Imizu, Toyama Prefecture, because doctors removed their respirators. Police have started an investigation. A 50-year-old chief surgeon responsible for taking the respirators from six of the patients said he acted on the will of the patients’ family members. The incident points to the confusion and difficulty doctors and nurses experience due to the lack of clear guidelines on life-prolonging measures for terminally ill patients. Such guidelines are in order, but their formulation must be carefully discussed to ensure they are acceptable to all parties involved, including doctors, nurses, patients and their family members.

The seven patients — four men and three women — at the Imizu City Hospital were in their 50s to 90s and five of them were suffering from cancer. The deaths came to light after a nurse told the deputy director of the hospital in mid-October 2005 that the surgeon had ordered the removal of a patient’s respirator. The hospital director rejected the surgeon’s call to remove the respirator. The patient, suffering from a cerebral infarction, died nine days later with the respirator still attached. The hospital launched an in-house investigation committee and learned about the deaths of the seven patients. It notified police, thinking that there was something “unnatural” about the process leading to their deaths.

A statement by the hospital’s director shows that the hospital was not well-prepared concerning a possible decision on whether to continue or terminate treatment designed to prolong the life of terminally ill patients. He said that his hospital does not have rules concerning treatment of terminal cases, including rules concerning termination of life-prolonging measures.

In five cases the surgeon consulted with a doctor he pairs with in deciding to remove respirators, and in one case he made the decision alone. Another doctor made the decision to remove the respirator from the seventh patient.

The biggest problem is that the surgeon did not obtain consent for removal of the respirators from the patients themselves. Nor did he inform the hospital director of his decisions. The surgeon only received verbal consent from the patients’ family members and mentioned the consent in the patients’ medical reports. “Rather than getting written consent, I removed the respirators on the strength of trustful relationship with family members of the patients,” the surgeon said. He also said, “Because I felt so sorry, I could not ask the family members to sign a written consent.” But at the same time, the surgeon’s action appears to be based on a strong personal conviction. “There are meaningless life-prolonging measures. If family members want removal of a respirator, I remove it. Since my action came out of myself in a natural way, what I did is nothing I should be ashamed of.”

In 1995, the Yokohama District Court said that the following conditions must be met to allow passive euthanasia — a patient is terminally ill with no prospect for recovery; the patient expresses agreement to passive euthanasia (when this is impossible, family members can guess the patient’s will) and life-prolonging measures such as a respirator and instillation of nutriments are judged to be medically meaningless. A doctor at Tokai University Hospital was accused of killing a terminally ill patient suffering from multiple myeloma by injecting potassium chloride at the request of the patient’s eldest son. The doctor was found guilty.

Questions arise when the case of the surgeon at the Imizu hospital is considered in light of the conditions set down by the Yokohama court. The surgeon says his patients were brain dead. But did the doctor fully explain the patients’ conditions to their families? How did he go about obtaining the consent from family members to remove the terminally ill patients’ respirators? The surgeon himself admits that in making his decisions he did not meet all the conditions necessary for passive euthanasia. Police will determine whether his actions were illegal. But various factors, including progress in life-prolonging measures and patients’ awareness of their right to make their own decisions, make it urgent that guidelines concerning the care of terminally ill patients, and passive euthanasia, be worked out.

A study group at the Health, Welfare and Labor Ministry said in its 2004 report that doctors and nurses often have a difficult time because there are no clear rules on what procedures to follow concerning decisions on the withholding or termination of life-prolonging measures. They also face a division in opinion between patients and their family members concerning terminal-stage treatment. Lawyers, medical and bioethics experts, lawmakers and government officials are urged to engage the people in a public debate on the issue while taking Japan’s historical, religious and cultural factors into full consideration.