Clinical Ethics Consultation in Japan: What does it Mean to have a Functioning Ethics Consultation?

This research examines the current status of clinical ethics consultation (CEC) in Japan through a nationwide study conducted with chairs of ethics committees and clinical ethics committees among 1028 post-graduate clinical teaching hospitals. We also qualitatively analyzed their viewpoints of the CEC's benefits and problems related to hospital consultation services to identify the critical points for CEC and inform the development of a correctly functioning system. The questionnaire included structured questions about hospital CEC organization and service purpose and operation and open-ended questions about the benefits and problems of initiating CEC. The questionnaire comprised the presence/absence of an ethics committee, CEC services and membership when services were implemented, users, and the number of cases handled since inception. In addition, the respondents also provided their impressions of the CEC system's impact on their hospital by describing (a) the benefits of CEC services and (b) the ineffectual or harmful aspects of the CEC system. Qualitative data were examined using qualitative content analysis to determine the impact of establishing a CEC and the difficulties of practice. One hundred twenty-five questionnaires were returned from either the chair of the ethics committee or clinical ethics committee in teaching hospitals. Of these, 90 (72%) reported they provided CEC services. Additionally, 36 respondents (34.6%) reported that their existing research and clinical ethics committees had conducted CEC services, and 35 (33.7%) reported having a newly established clinical ethics committee conducting CEC services. Three positive effects of establishing and four challenges in managing CEC were also identified.

Psychometric properties of the Japanese version of the Self-Care of Heart Failure Index version 7.2.

AIMS: It is more important for patients with heart failure (HF) to objectively identify their self-care status. The Self-Care of Heart Failure Index (SCHFI) version 7.2 is a reliable and valid instrument comprising three scales: self-care maintenance, symptom perception, and self-care management. We aimed to translate the SCHFI v.7.2 into Japanese and test its validity and reliability. METHODS AND RESULTS: This was a cross-sectional study. Two translators performed forward and backward translations between English and Japanese. To assess structural validity, confirmatory factor analyses were performed using the structure of the original version. To assess convergent validity, the associations between each scale and self-care self-efficacy were evaluated. To assess internal consistency, model-based internal consistency coefficients were calculated. Participants were 314 Japanese outpatients with HF (mean age: 72.8 ± 12.8 years). Regarding structural validity, all scales showed adequate model fit indices, supporting a two-factor structure with items similar to those in the original version. However, to improve the model fit indices, it was necessary to add error correlations for the self-care maintenance and symptom perception scales. Regarding convergent validity, all scales showed significant associations with self-care self-efficacy. Regarding internal consistency, the model-based internal consistency coefficients were sufficient for all scales (0.739, 0.908, and 0.783 for the self-care maintenance, symptom perception, and self-care management scales, respectively). CONCLUSION: The Japanese version of the SCHFI v.7.2 had adequate validity and reliability. This instrument is useful for assessing self-care in Japanese HF patients. However, factors influencing self-care should be considered when interpreting results.

Ethical Issues faced by Home Care Physicians and Nurses in Japan and their Ethics Support Needs: a Nationwide Survey.

This study aimed to identify the ethical issues faced by home care physicians and nurses, and the support they require. It was conducted in collaboration with the Japanese Association for Home Care Medicine from November to December 2020. An e-mail was sent to 2785 physicians and 582 nurses who are members of the society, requesting their participation in a web-based survey targeting physicians and nurses with practical experience in home care; 152 physicians and 53 nurses responded. Home care physicians and nurses face ethical issues, some of which are that "the patient's wishes cannot be reliably understood owing to their impaired decision-making capacity" and "there is disagreement between the patient and their family members over the necessary healthcare." The respondents sought "experience with, and insight into, healthcare ethics" and "home care" from people with whom they would consult on ethical issues, but at the time of the actual consultation, those individuals were the main healthcare professionals involved with the patient. In addition, the respondents desired to have "multidisciplinary discussions in the community," "participation of healthcare ethics experts at meetings," and "meetings held by healthcare ethics experts" to discuss specific cases. Given these results and the history of healthcare ethics education in Japan-which has been implemented mostly for healthcare providers-we conclude that it is important for academic societies that offer healthcare ethics education to healthcare providers and regional core hospitals with ethics support resources to collaborate to provide ethics consultation services in the community.

Somatic Changes Perceived by Patients With Heart Failure During Acute Exacerbation: A Qualitative Study Using Text Mining.

BACKGROUND: Patients with heart failure (HF) often inadequately perceive their symptoms. This may be because the medical terms do not match the somatic changes experienced by patients. To improve symptom perception, healthcare professionals must understand the somatic changes as perceived by patients. OBJECTIVE: This study aims to analyze patients' narratives about somatic changes in patients with HF by text mining and to clarify the overall description of somatic changes using patients' expressions. METHODS: Semistructured interviews were conducted on 21 patients hospitalized for acute exacerbation of HF. Qualitative data obtained from the interviews were analyzed by content analysis through text mining. RESULTS: Among the 21 patients, 76.2% were men. The mean (SD) age was 71.3 (13.7) years. The most frequently used terms were "breath," "distressed," "feet," and " ha-ha (gasping sound)" (46, 40, 29, and 28 times, respectively). The somatic changes noticed by patients could be categorized into medical jargon such as "dyspnea on exertion," "exercise intolerance," "fatigue," "paroxysmal nocturnal dyspnea," "frequent urination," "increased sputum," "weight gain," "feet and face edema," "abdominal edema," and "ankle edema." However, the expressions of somatic changes used by the patients were diverse. CONCLUSIONS: The findings of patient-specific expressions of symptoms suggest that there is a need to assess symptoms not only using medical jargon but also by focusing on patient-specific expressions.

Report on the Establishment of the Consortium for Hospital Ethics Committees in Japan and the First Collaboration Conference of Hospital Ethics Committees.

Hospital ethics committees (HECs) are expected to play extremely broad and pivotal roles such as case consultation, education of staffs on healthcare ethics, and institutional policy formation. Despite the growing importance of HECs, there are no standards for setup and operation of HECs, and composition and activities of HECs at each institution are rarely disclosed in Japan. In addition, there is also a lack of information sharing and collaboration among HECs. Therefore, the authors established the Consortium of Hospital Ethics Committees (CHEC) in October 2020, which has been regularly hosting a couple of core activities. One is the Healthcare Ethics Forum, held monthly online for CHEC members to freely discuss HECs and healthcare ethics consultation. The other is the Collaboration Conference of Hospital Ethics Committees, intended to provide a place for HEC members and administrative officers from across Japan to exchange information of their HECs, learn from each other, and cooperate to operate HECs appropriately. In this paper, the authors introduced CHEC as well as reported the results of a questionnaire survey conducted at the first conference among participating facilities, suggesting the diverse structures and activities of HECs in Japan.

The relationship between perceived difficulty and reflection in the practice of discharge planning nurses in acute care hospitals: A nationwide observational study.

AIMS AND OBJECTIVES: To clarify the characteristics and practice of discharge planning nurses in acute care hospitals and to elucidate the relationship between subjective difficulty perceived in practice and reflection. BACKGROUND: The importance of discharge planning for an effective transition from the hospital to a care facility is increasing. In acute care hospitals, however, it is not clear what discharge planning nurses are doing for patients who are highly dependent on medical treatment, the subjective difficulties they perceive in practical activities, and whether reflection by nurses can be expected to mitigate those difficulties. DESIGN: Cross-sectional survey. METHODS: This survey was conducted in 2,379 acute care hospitals in Japan from 1 June-30 June 2018. The survey of discharge planning practice activities examined nine factors. A nurse who answered that he/she did reflect on his/her practices was defined as a self-reflecting nurse. The STROBE statement checklists were completed. RESULTS: Questionnaires were collected from 760 respondents (response rate = 32.1%). The discharge planning nurses had fewer than 36 months of experience with discharge planning. Among the nurses who had been involved in hospital discharge support for 13 months or more, the self-reflecting nurses had fewer perceived difficulties in their practice activities than the non-self-reflecting nurses did. CONCLUSIONS: It was shown that discharge planning nurses with 13 months or more of experience and who practiced reflection on their practical activities perceived less subjective difficulty. Reflection in daily practice may mitigate the subjective difficulty of practical activities experienced by discharge planning nurses, and the establishment of an effective training method that promotes such reflection is required. RELEVANCE TO CLINICAL PRACTICE: In the future, it will be necessary to construct and evaluate an effective education programme for discharge planning nurses that includes self-reflection on practice cases.

Histone demethylase JMJD1A coordinates acute and chronic adaptation to cold stress via thermogenic phospho-switch.

In acute cold stress in mammals, JMJD1A, a histone H3 lysine 9 (H3K9) demethylase, upregulates thermogenic gene expressions through ß-adrenergic signaling in brown adipose tissue (BAT). Aside BAT-driven thermogenesis, mammals have another mechanism to cope with long-term cold stress by inducing the browning of the subcutaneous white adipose tissue (scWAT). Here, we show that this occurs through a two-step process that requires both ß-adrenergic-dependent phosphorylation of S265 and demethylation of H3K9me2 by JMJD1A. The histone demethylation-independent acute Ucp1 induction in BAT and demethylation-dependent chronic Ucp1 expression in beige scWAT provides complementary molecular mechanisms to ensure an ordered transition between acute and chronic adaptation to cold stress. JMJD1A mediates two major signaling pathways, namely, ß-adrenergic receptor and peroxisome proliferator-activated receptor-γ (PPARγ) activation, via PRDM16-PPARγ-P-JMJD1A complex for beige adipogenesis. S265 phosphorylation of JMJD1A, and the following demethylation of H3K9me2 might prove to be a novel molecular target for the treatment of metabolic disorders, via promoting beige adipogenesis.

The Psychosocial Influences of Waiting Periods on Patients Undergoing Endoscopic Submucosal Dissection.

This study aimed to clarify psychosocial influences of waiting periods on patients undergoing endoscopic submucosal dissection for cancer at an advanced medical care facility in Japan. Subjects were consenting patients hospitalized from 2009 to 2010. Qualitative and quantitative data were gathered about patients' characteristics, disease and stage, and waiting period. Qualitative content analysis was used to analyze free statements and interview data. Subjects included 154 patients with an average wait period of 46.28 days for admission. Qualitative analysis revealed the following wait period perceptions. For calmness, results indicated (1) no anxiety, (2) relief based on doctors' positive judgment, (3) whatever happens/no choice, and (4) trust in doctor. For uneasiness, perceptions included (1) the sooner, the better/eagerly waiting, (2) anxiety and concern, and (3) emotional instability. Four waiting period coping types were identified: (1) making phone inquiries, (2) busy and forgot about the medical procedure, (3) relief from anxiety, and (4) unable to function well in daily life. Patients need to be educated about cancer progression and provided an estimated wait time. They also require more information about how to manage daily life such as monitoring factors from the nursing domain including physical condition, digestive symptoms, diet, and exercise.

Comparison of ethical judgments exhibited by clients and ethics consultants in Japan.

BACKGROUND: Healthcare professionals must make decisions for patients based on ethical considerations. However, they rely on clinical ethics consultations (CEC) to review ethical justifications of their decisions. CEC consultants support the cases reviewed and guide medical care. When both healthcare professionals and CEC consultants face ethical problems in medical care, how is their judgment derived? How do medical judgments differ from the ethical considerations of CECs? This study examines CECs in Japan to identify differences in the ethical judgment of clients and CEC consultants. METHODS: The CEC request and response documents of all 60 cases reviewed across Japan between October 2006 and the end of October 2011 were classified in terms of the presence of decisional capacity in the patient. We conducted a qualitative content analysis of the differences in reasoning between client and CEC consultants. Reasoned judgments were verified in individual cases to classify the similarities or differences of opinion between CEC clients and teams. RESULTS: As the result of classification of the decisional capacity and the difference of opinion regarding medical care, the most frequent category was 25 cases (41.7%) of "uncertain decisional capacity," and 23 cases (38.3%) of "withholding of decision-making." A chi-square analysis was performed on presence of decisional capacity and agreement in decision-making, yielding a statistically significant difference (p < 0.05). The CEC consultants' reasoning was based on "patient's preference was ambiguous," "validity of family as a surrogate," "estimation of patient preference," and "patient's best interest," whereas the CEC client's reasoning was based on "consistent family preference was shown/not shown" and "appropriate therapeutic methods to manage patient safety." CONCLUSION: Differences in opinions were found in cases classified according to decisional capacity. Furthermore, the reasoning behind judgments differed between CEC clients and CEC consultants. The reasoning of CEC consultants was critical and reflective, while for clients it was situational and pragmatic.

Clinical ethics consultation: examining how American and Japanese experts analyze an Alzheimer's case.

BACKGROUND: Few comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimer's case regarding ethics consultation. METHODS: We presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews. RESULTS: Establishing a consensus was a common goal among American and Japanese participants. In attempting to achieve consensus, the most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an "ethics facilitation" approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate. CONCLUSION: Our findings suggest that consensus building through an "ethics facilitation" approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country.

An eight-year follow-up national study of medical school and general hospital ethics committees in Japan.

BACKGROUND: Ethics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nation's ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan. METHODS: This study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovah's Witnesses. RESULTS: Committee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovah's Witnesses, among both medical school and hospital ethics committees. CONCLUSION: Overall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.