9th Asia/Oceania Regional Congress of Gerontology and Geriatrics
Melbourne, Oct. 23-28. 2011.

IHEP

Between Ideal and Realistic Practice of Terminal Situations:
An International Comparison among Physicians, Nurses, and other Caregivers††††††
Daisuke Watanabe, Ph.D. , Taeko Nakashima, Ph.D. , Kanao Tsuji, M.D.
†Seikei University††Institute for Health Economics and Policy†††Life Care System.

Purpose:To improve terminal care, particularly home-based care, professionals have to require collaboration of people with variousoccupations. Through international comparing among three professionals, the purpose of this study was to investigate the awareness ofvarious professionals in terminal care in order to compare with long-term care experiences, occupations, and views of life and death.
Table1: overviews of countries of this study

Data:

79.3
83.9

79.7
83.5

74.2
80.5

Old age social
spending**,
2007

8.8%

1.6%

4.3%

4.3%

6.9%

Length ofstay***:2008/2009

18.5

－

5.8

4.0

7.1

QOD score,
2010

4.7

3.7

7.9

－－Sources:
Eiu.com, 2010, The Quality of Death: Ranking end-of-life care across the world.
IMF, 2011, World Economic Outlook Database.
OECD, 2010, Key Tables from OECD.
OECD, 2011, Health Statistics.
real principle

67.6%

67.5%

60.3%

0.5

-1

1.0

Israel

48.0%

17.6%

59.1%
50.0%

20.0%
0.0%
IsraelAustralia Chzeck

IsraelAustralia Chzeck

Total

57.0%

23.5%

South
Korea

SouthKorea

Figure 3(center): ratio of artificial nutrition as
ideal and real principle of response

40.0%JapanJapan

Total

Figure 1(left upper):gap between ideal and realistic final place
Figure 2(left lower):
gap between ideal and realistic principle ofresponse

Czech

KeepingCzechA.Nutrition Do Nothing
LongerRehab
KoreaLife
Australia
Dignity

JapanFamily
Recover

Australia
QOL
Recover
Dignity
Keeping
Rehab
LongerLife
A.Nutrition
Guideline

FamilyJapanDo Nothing
-0.5

0.0

0.5

1.0

Figure 4: CA of ideal choice and thereasons

Results:
31.3% respondents gave different answers between ideal and realistic practices about aplace to spend the patient’s final days (final place), and 57.0% respondents gave different ones
about a basic principle in working with the case (principle of response) (figure 1, 2). In Japan,Israel, Korea and Czech, more than 40 % respondents chose “Artificial nutrition” as ideal
principle, whereas Australians who chose that were 13.6% (figure 3). As the result of CA, thepositions of the points of ideal choice and the reasons of principle of response indicate that
Australians were associated with respect for Mr. B’s dignity, and Japanese were associated with
Family’s wish and possible recover fully (figure 4) . The positions of the points of realistic ones
indicate that countries grew in diversity .
As the result of logistic regression , the gap of final place was significant associated withcountry, age, experiences of home-based long-term care, patient’s death experience atworkplace, and one view of ideal death about cost. The gap of principle of response wassignificant associated with country, job, case judgments about whether the case was terminal
phase or not, and one view of ideal terminal care about communication (table 2).

Implications:Two gaps have different structures which have only one common factor, country. Thesevarious gaps may cause the communication gaps between occupations or between such views. In
terminal situation, professionals require collaboration of people with various occupations. In
order to make good collaboration, this implication enhances mutual understanding, and will
support new policy-making for public support system for terminal care and death education.
Acknowledgement: This study was supported by a grant from the Health and Welfare Bureau for the Elderly, the Ministry ofHealth, Labor and Welfare, Japan.

options
principles of response
1. artificial nutrition
2. rehabilitation
3. keeping current
treatment
4. do nothing

Israel-0.2

89.5%

67.2%

60.0%

Total0.0

Australia Chzeck-0.5

80.0%

Israel0.0

100.0%SouthKorea-0.5Japan32
0.5

13.6%

0.0%

0.0%

20.5

QOL

20.0%

10.6

40.0%

20.0%

01

44.1%

45.5% 47.4%

0.0

0

48.3%

-0.5

3

73.7%

-0.2

0.0

0.2

0.4

Korea
0.6

-1

31.3%

76.8
83.8

0.8

31.7%

60.0%

LE. at birth*, M: 79.6
2009 male /F: 86.4
female

0.4

40.9%

67.6%

10.2%

0.2

40.0%

38.2%

69.4%

15.4%

1.0

80.0%

14.3%

* Life Expectancy at birth, ** Old age social spending: public social
expenditure as a percentage of GDP*** Average length of stay: acute care, Days

ideal principle

52.6%

11.0%

Mr. B Mr. B (80 yrs. old) lives with his wife at home.
It has been 10 years since he was diagnosed withdementia (Alzheimer’s disease). Although hisconsciousness is not impaired, he only responds tofamilies and direct care workers with eye movements. In
general, it is extremely difficult for him to communicate
with others. About a half month ago, he had high feverand cough, so he went to hospital and was diagnosed
with pneumonia. Currently, he is unable to swallow foods,
and he takes medicine and nutrition through IV(intravenous drip). Because he cannot receive nutrition
by mouth, he may need artificial nutrition (e.g. tubefeeding) shortly. His wife (80 yrs. old) hopes to have him
stay and spend last days at home. She also hopes tospend as long a time with him as possible. Their financial
condition is stable because they own a house and receive
employee’s pension. Yet, her caregiving capacity is low,
and there is no relative nearby. Therefore, she is very
worried about her additional caregiving burden.

1.0

60.0%

23.1%

Ageing rate(65+), 2010

Methods:
Correspondence analysis (CA) was used to show
graphically associations between differences in country andideal and realistic choice and the reasons of Mr. B’s case
Logistic regression was used to determine therelationship between ideal and realistic practices’ gaps as
outcome variables and occupation, job experiences, views oflife and death, and other variables (i.e. sex, age, years ofeducation, and country) as explanatory variables.

JapanSouthCzech
Australia Israel
Republic
Korea

0.0

Data were drawn from a sample of 323 physicians, nurses,and caregivers from 5 countries (Japan, South Korea, Australia,Czech Republic, and Israel) in October to December 2010. To
clarify the ideal terminal approach and realistic one, thequestionnaire included a fictitious case of person withdementia who was diagnosed as pneumonia and was unableto swallow foods. Investigation centered care facilities andclinics which had experienced terminal care service, andwhich were chosen by convenient sampling.

Fictitious Case of Mr. B.

0.8

Figure 5: CA of realistic choice
and the reasons

Table 2: results of logistic regression

reasons of the principle
1. possible recover fully
2. possibility for longerlife
3. improvement of QOL
4. respect for Mr. B’s
dignity
5. family’s wish
6*. set by national orfacility guideline* CA of Figure 4 did not use theitem, because of very small case
(4 case)gap between ideal and realistic gap between ideal and realistic
place of final days
principle of response
variab le (reference)value
95% CI
95% CIORORcountry (Czech)
Japan.208 ( .038 - 1.147 ).346 ( .102 - 1.172 ) †South Korea.026 ( .004 .161 ) **.205 ( .052 .815 ) *Israel.101 ( .017 .588 ) *.651 ( .169 - 2.502 )Australia.227 ( .035 - 1.451 ).576 ( .135 - 2.457 )sex (female)man
1.694 ( .869 - 3.305 )1.611 ( .841 - 3.085 )age.961 ( .930 .994 ) †.987 ( .955 - 1.020 )years of education
1.112 ( .916 - 1.351 )
1.118 ( .929 - 1.345 )
professionals (physicians) nurse.657 ( .195 - 2.218 )6.261 ( 1.822 - 21.512 ) **care worker
1.128 ( .331 - 3.847 )
9.136 ( 2.713 - 30.768 ) ***years of long-term care
1.030 ( .990 - 1.072 )1.002 ( .960 - 1.046 )years of home-based long-term care
.950 ( .900 - 1.003 ) † 1.002 ( .943 - 1.065 )Yes
1.364 ( .746 - 2.492 )exp.1 of care for families
exp. of family's deathYes.981 ( .539 - 1.785 )exp. of patient's death at w ork Yes.551 ( .310 .981 ) *is the case in the terminal ? Yes
1.160 ( .677 - 1.987 ).317 ( .183 .548 ) ***2

f.s. (ideal death: death in a short time thatcauses no problems)
f.s. (ideal death: prepared deathsurrounded by family)
3
f.s. (ideal EOL care : spending as muchtime as possible together)f.s. (ideal EOL care: Short term and low
cost end-of-life care)f.s. (ideal EOL care: End-of-life careallowing communication)
Intercept.
Model fit
-2LL
Nagelkerke's R squareN

1.553 ( 1.127 -2.138 ).918 (.683 -1.234 )1.207 (.804 -1.811 ).879 (.585 -1.319 ).796 (.558 -1.136 )

1.175 (.822 -1.678 )

1.130 (.807 -1.582 )1.052 (.754 -1.467 )

1.194 (.843 -1.690 )1.459 (.969 -2.198 )

3.786

.159

360.314.318
323

346.734.219
323† p<.10, * p<.05, ** p<.01, *** p<.001
1exp.: experience, 2 f.s.: factor score, 3 EOL care: end of life care†