A Cross-Cultural Study on Behaviors When Death Is Approaching in East Asian Countries What Are the Physician-Perceived Common Beliefs and Practices?

The primary aim of this study was to explore common beliefs and practices when death is approaching in East-Asian countries. A cross-sectional survey was performed involving palliative care physicians in Japan, Korea, and Taiwan. Measurement outcomes were physician-perceived frequencies of the following when patient death was approaching: (1) reluctance to take part in end-of-life discussions, (2) role of family members, (3) home death, and (4) circumstances surrounding death. A total of 505, 211, and 207 responses were obtained from Japanese, Korea, and Taiwan physicians, respectively. While 50% of the Japanese physicians reported that they often or very often experienced families as being reluctant to discuss end-of-life issues, the corresponding figures were 59% in Korea and 70% in Taiwan. Two specific reasons to avoid end-of-life discussion, ‘‘bad things happen after you say them out loud’’ and ‘‘a bad life is better than a good death’’ were significantly more frequently observed in Taiwan. Prioritizing the oldest of the family in breaking bad news and having all family members present at the time of death were significantly more frequently observed in Korea and Taiwan. Half of Taiwanese physicians reported they often or very often experienced the patients/family wanted to go back home to die because the soul would not be able to return from the hospital. In all countries, more than 70% of the physicians reported certain family members were expected to care for the patient at home. At the time of death, while no Japanese physicians stated that they often experienced patients wanted a religious person to visit, the corresponding figure in Korean and Taiwan was about 40%. Uncovered expression of emotion was significantly frequently observed in Korean and Taiwan, and 42% of the Japanese physicians reported family members cleaned the dead body of the patient themselves. There seem to be significant intercountry differences in beliefs and practices when death is approaching in East Asian countries. Future studies on direct observations of patients and families are needed. (Medicine 94(39):e1573) Abbreviation: ANOVA = analysis of variance. INTRODUCTION A n understanding of cultural differences is very important for providing patientand family-centered end-of-life care. What patients and families believe is usual or appropriate when death is approaching is heavily influenced by culture, and to provide appropriate care for imminently dying patients, an understanding of the culture of the patients and family members is essential. Nonetheless, to the best of our knowledge, there have been no large-scale studies regarding what is usual when death is approaching, except for review articles based on the experience of clinicians. Existing cross-cultural studies have been focused on patient autonomy, information disclosure, communication, decision-making, hydration, pain management, and withdrawal/withholding of life sustaining treatments. East Asia is traditionally regarded as a typical familycentered region that is based on Confucian culture. Japan, Korea, and Taiwan, however, have considerable differences in cultural traditions, and each country could have unique traditions about death and dying. For example, several studies indicated that, in Taiwan, families believe that the soul will not be able to return from the hospital if patients die in hospitals; this could have a great deal of influence on the patient-preferred place of death, that is, many Taiwanese want to go back home to die even if they are unconscious. In Korea, it is suggested that the concept of filial piety (devotion to and respect for parents) and strong ties among family members heavily influence end-of-life decisions. In Japan, many identify themselves as both Buddhist and Shinto; they do not attend worship services or participate in seasonal rituals for several occasions without religious aims. In these 3 countries, the situation is rapidly changing, and clarification of the common beliefs and practices in East Asian countries when death is approaching is valuable for the provision of culturally suitable end-of-life care. Editor: Wen-Hung Wang. Received: June 25, 2015; revised: July 30, 2015; accepted: August 19, 2015. From the Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan (SYC), Department of Family Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Seoul, South Korea (S-YS), Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Japan (TM), Division of Clinical Psychology, Kyoto University, Kyoto, Japan (YO), Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan (T-YC), Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea (SJK), Department of Social Welfare, Korea National University of Transportation, Chungju City, South Korea (HSK), Department of Family Medicine, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan (SJH), Graduate School of Education, Kyoto University, Kyoto, Japan (TY), Department of Multidisciplinary Cancer Treatment, Graduate School of Medicine, Kyoto University, Kyoto, Japan (ST). Correspondence: Shao-Yi Cheng, Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, 7, Chung Shan S. Rd, Taipei, Taiwan (e-mail: scheng2140@gmail.com). The authors report no conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0, where it is permissible to download, share and reproduce the work in any medium, provided it is properly cited. The work cannot be changed in any way or used commercially. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000001573 Medicine®