To the Editor: Dr Piers and colleagues1 reported that many European and Israeli clinicians in intensive care units (ICUs) perceived that some patients were provided inappropriate care, and the most common reason was the provision of too much care. However, providing excessive care for patients with little hope for survival could be considered appropriate in certain situations. In Japan, for example, care in the ICU is affordable for citizens, with a maximum of approximately $1000 per month in co-payments under universal health care coverage. In addition, many citizens believe that providing all possible care works as karma for their family members. Furthermore, the Japanese Supreme Court handed down a guilty sentence to a physician who withdrew care from a comatose patient in 2009.2 As a consequence of such legal precedents, withdrawing care is extremely rare in Japan. Although some physicians do so secretly, risking the psychological burden that such actions entail, other physicians believe continuing care despite minimum hope for survival is appropriate, even knowing health care resources are scarce.3
Nagamatsu S, Yamashita K. Perceptions of Appropriateness of Care in the Intensive Care Unit. JAMA. 2012;307(13):1370–1372. doi:10.1001/jama.2012.393
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