COMMUNICATION BETWEEN PATIENTS AND PHYSICIANS ABOUT TERMINAL CARE - ASURVEY IN JAPAN

We assessed patient-physician communication about terminal care in Jap an by examining the accuracy of physicians' estimation of their patien ts' preferences as regards (1) information about diagnosis and prognos is, (2) the place of death and (3) the therapeutic strategy at termina l stage (life prolongation vs pain control). We conducted a questionna ire survey on inpatients (n = 201) in three hospitals; two in rural ar eas (Nagano and Okinawa) and one in an urban area (Tokyo). Simultaneou sly we asked physicians (n = 40) in charge of the patients to estimate their attitudes. The accuracy of physicians' estimation was assessed by correct estimation rate (CER) and kappa coefficient. (1) Approximat ely 80% of the patients preferred to have candid information about dia gnosis and prognosis, regardless of the nature of their disease. The p hysicians were correct in estimation only in about half of the cases. About one sixth of the physicians' guesses were in opposite direction, while about one third failed to make any estimation at all. Thus, the overall CER was 42%, 57% and 62% in Nagano, Okinawa and Tokyo respect ively. (2) While 70% of the patients wished to meet their death at hom e, the physicians estimated this fact correctly in less than half of t he cases. The physicians frequently could not make any estimation (CER : 21%, 36% and 40% respectively). (3) Two thirds of the patients prefe rred pain control over life prolongation. Again, CER remained in the n eighborhood of 50% (CER: 49%, 49% and 64% respectively). The analysis by kappa coefficients showed that the concordance between patients' pr eferences and physicians' estimation was not far from a figure expecte d by chance alone. Above findings indicate that physicians had practic ally no knowledge of their patients' preferences and strongly suggest absence of effective communications between patients and physicians co ncerning terminal care. This situation inevitably enhances physicians' effort toward prolongation of patients' life at the expense of qualit y of life, and in part accounts for expansion of medical expenditure d uring the least effective stage of therapy.