Kaoruko Aita

Japan approves brain death to increase donors: will it work?

On July 13, 2009, Japan’s legislature passed a bill to revise the Organ Transplant Law to discard the law’s unique double standard on brain death, in which brain death constitutes death only when the patient has given previous written consent to be an organ donor and the family does not oppose the donation. The revised law, which does not stipulate that brain death constitutes death but is designed for uniform recognition of people who are brain dead as legally dead, will take eff ect in a year. The legal revision seems to have fi nally made Japan like many other countries on this issue. However, the time lag has clarifi ed that the majority understanding of brain death is not appropriate. With the advancement of intensive medical technology in the past few decades, in consistencies inherent in the concept of whole-brain death, which has been adopted by the USA and many other countries including Japan, have become evident. Even James Bernat, the world’s leading defender of the idea of whole-brain death, has admitted that it is a social construct rather than a scientifi c concept. In December, 2008, the US President’s Council on Bioethics issued a White Paper titled Controversies in the determination of death that examined many questions about the clinical and ethical validity of the whole-brain concept of death. Although the Council concluded that the neurological standard is defensible, they say that the term brain death is highly problematic and should be replaced by total brain failure. The report also emphasises that to maintain a distinction between naming the cology and disease management, health-ser vices research, sur veillance, and public health); and devel opment of ex change pro grammes for leaders and administrators. This bringing together of academic health centres worldwide provides unprecedented opportunities for con structive collaboration. In research, for example, large clinical trials across academic health centres will be possible, with the sharing of research materials and expertise, the generation of large databases, and evalua tion of important areas such as outcomes, patients’ safety, and cost–effi cacy. Clinically, the new organisation could mobilise the international academic community to combat the threat of, for example, an H1N1 pandemic. AAHC International could help facili tate threatmodelling to advise on issues such as school closures and clinical trials, search for important bio markers, examine cytokine profi les and organ dys function in diverse popu lations, and study societal and bio ethical issues to advise governments and international health organisations. The association will also enable the academic com munity to explore the potential for harmonisation of education and training programmes to prepare students and trainees for work in a global society. A key challenge for the new organisation will be to address the problem of health inequality, particularly in countries with under developed health-care systems. This new international organisation of academic health centres will serve to mobilise and speak on behalf of their enormous collective strengths and resources, while helping to ensure that they can eff ectively contribute in international matters that aff ect health, research, and the economy. In so doing, AAHC International will help to foster an international community of academic health centres, a community driven by the ideal of improving the public good.

What has become more acceptable? Continuity and changes in older adults' attitudes toward end-of-life care in Japan

In Japan, with a rapid increase in the aging population, end-of-life care has received growing societal attention. To gain an understanding of the changes in Japanese older adults’ attitudes toward end-of-life care, we compared two sets of comparable survey data, both of which were collected in the same geriatric hospital in Tokyo. These surveys were carried out in 1996 (n = 562) and in 2012 (n = 968), asking outpatients who visited the hospital about their preferences regarding end-of-life care. This research procedure was approved by the institutional review board at Tokyo Metropolitan Institute of Gerontology. Comparing participants’ responses in these surveys can yield at least some insight into how Japanese older adults’ attitudes toward end-of-life care changed under the marked shifts in circumstances surrounding elder care between 1996 and 2012 (e.g. implementation of the public long-term care insurance started in 2000). In both surveys, more women than men participated; women accounted for more than 60% of the participants (63.0% in 1996; 69.3% in 2012). Although mean ages of participants were similar between the 1996 and 2012 surveys, 73.4 (SD = 8.6) and 76.5 (SD = 9.3), respectively, there was a significant difference between the two (P < 0.01). Comparative analyses showed both consistency and differences in participants’ preferences regarding endof-life care across surveys (Table 1). In both surveys, the majority of participants agreed that one’s home was the desirable place to spend the end of life. Also, there was no difference in responses about the use of narcotic drugs to palliate aching pain; less than a half wished to receive this treatment if they were in such a condition. Statistically significant differences were found in participants’ wishes about notification of diagnosis and other types of medical treatment. Compared with those in 1996 survey, 2012 participants were more likely to wish to be notified if and when they had an incurable disease. Regarding medical treatment, a greater proportion of participants preferred the use of antibiotics for pneumonia and a mechanical ventilator for respiratory discomfort in the 2012 surveys than in the 1996 surveys. Furthermore, the 2012 survey participants were more likely than their 1996 counterparts to prefer the use of narcotic drugs to palliate respiratory discomfort despite no difference across surveys in responses regarding the use of such drugs for pain. In contrast, in the 2012 surveys, a greater proportion of participants wished for no artificial nutrition. Also, fewer participants showed preferences for life-sustaining medical treatment in 2012 than 1996 surveys. The results suggest prevailing negative attitudes toward artificially prolonging life among Japanese older adults. At the same time, they do not necessarily hold a consistent, unfavorable opinion of end-of-life medical treatment as a whole. As suggested by cross-survey differences in responses about the use of antibiotics and

Guidelines from the Japan Geriatrics Society for the decision-making processes in medical and long-term care for the elderly: Focusing on the use of artificial hydration and nutrition

Geriatr Gerontol Int 2018; 18: 823–827.