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November 27, 1996

Advance Directives and Withdrawal of Dialysis in the United States, Germany, and Japan

Author Affiliations

From the Division of Nephrology (Dr Sehgal) and the Department of Medicine (Drs Sehgal and Butzlaff and Mr Weisheit), MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; Center for Biomedical Ethics and Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland (Dr Sehgal); Department of Internal Medicine, Sakura National Hospital, Chiba, Japan (Dr Miura); Division of Nephrology, Department of Internal Medicine, Otto-von-Guericke University, Magdeburg, Germany (Dr Kielstein); and the International Student Center, Tohoku University, Sendai, Japan (Dr Taguchi).

JAMA. 1996;276(20):1652-1656. doi:10.1001/jama.1996.03540200038028

Objective.  —To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan.

Design.  —Survey by questionnaire.

Participants.  —Seventy-two American, 87 German, and 73 Japanese nephrologists.

Main Outcome Measures.  —Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases.

Results.  —American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about 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 supported by a patient advance directive.

Conclusions.  —There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.