ADVANCE DIRECTIVES AND WITHDRAWAL OF DIALYSIS IN THE UNITED-STATES, GERMANY, AND JAPAN

Objective.-To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan. D esign.-Survey by questionnaire. Participants.-Seventy-two American, 87 German, and 73 Japanese nephrologists. Main Outcome Measures.-Each ne phrologist's total number of (1) dialysis patients, (2) cases of withd rawal of dialysis, (3) patients with advance directives, and (4) uses of such directives, Nephrologists also stated whether they would conti nue or stop dialysis in 8 hypothetical cases. Results.-American, Germa n, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirt y percent of American patients had advance directives, and such direct ives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such direc tives were used in decision making for 0.09% of patients. When asked a bout a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists, However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was su pported by a patient advance directive. Conclusions-There is a high pr evalence of advance directives among American dialysis patients, and s uch directives frequently play a role in decision making. German and J apanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their u se.