Survey of Japanese physicians'' attitudes towards the care of adult patients in persistent vegetative state.

OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.     

How strictly do dialysis patients want their advance directives followed?

OBJECTIVE--The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed. DESIGN--Interview study. SETTING--Seven outpatient chronic dialysis centers. PARTICIPANTS--One hundred fifty mentally competent dialysis patients. INTERVENTION--Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them. RESULTS--Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs. CONCLUSIONS--Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Hospital policies on life-sustaining treatments and advance directives in Canada.

OBJECTIVE: To determine the prevalence and content of hospital policies on life-sustaining treatments (cardiopulmonary resuscitation [CPR], mechanical ventilation, dialysis, artificial nutrition and hydration, and antibiotic therapy for life-threatening infections) and advance directives in Canada. DESIGN: Cross-sectional mailed survey. SETTING: Canada. PARTICIPANTS: Chief executive officers or their designates at public general hospitals. MAIN OUTCOME MEASURES: Information regarding the existence of policies on life-sustaining treatments or advance directives and the content of the policies. RESULTS: Questionnaires were completed for 697 (79.2%) of the 880 hospitals surveyed. Of the 697 respondents 362 (51.9%) sent 388 policies; 355 (50.9%) sent do-not-resuscitate (DNR) policies (i.e., policies that addressed CPR alone or in combination with other life-sustaining treatments). Of the 388 policies 327 (84.3%) addressed CPR alone, 28 (7.2%) addressed CPR plus other life-sustaining treatments, 10 (2.6%) addressed advance directives, and the remaining 23 (5.9%) addressed other life-sustaining treatments. Of the 355 DNR policies 1 (0.3%) stated that routine discussion with patients is required, 315 (88.7%) restricted their scope to terminally or hopelessly ill patients, 187 (52.7%) mentioned futility, 29 (8.2%) mentioned conflict resolution, 9 (2.5%) and 13 (3.7%) required explicit communication of the decision to the competent patient or family of the incompetent patient respectively, 110 (31.0%) authorized the family of an incompetent patient to rescind the DNR order, 224 (63.1%) authorized the nursing staff to do so, and 217 (61.1%) authorized physicians to do so. CONCLUSIONS: Although about half of the public general hospitals surveyed had DNR policies few had policies regarding other life-sustaining treatments or advance directives. Existing policies could be improved if hospitals encouraged routine advance discussions, removed the restriction to terminally or hopelessly ill patients, scrutinized the use of the futility standard, stipulated procedures for conflict resolution, explicitly required communication of the decision to competent patients or substitute decision-makers of incompetent patients and scrutinized the provision allowing families and health care professionals to rescind the wishes of now incompetent patients.     

Seven legal barriers to end-of-life care: myths, realities, and grains of truth

OBJECTIVE: The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. PARTICIPANTS: The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM. EVIDENCE: A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience. CONSENSUS PROCESS: The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process. CONCLUSIONS: Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.     

The legal status of consent obtained from families of adult patients to withhold or withdraw treatment

A review is provided of (1) state legislation on living wills and advance directives and (2) state court decisions and legislation authorizing family members to make the decision to withhold or withdraw life-sustaining treatment from adult patients. Five aspects of the emerging legal standards are summarized: the type of patient eligible; the type of treatment that may be withdrawn or withheld; designation of which family members are empowered to exercise authority; measures intended to prevent abuse of the new power by family members; and provisions empowering physicians to decide. The author suggests that the most prudent course would be to direct health care providers to accept family decisions unless it appears that the family is acting out of ignorance or in bad faith, in which case the decision would be referred to a hospital ethicist or ethics committee and then--only if there were good grounds to suspect ignorance or bad faith--to judicial review.     

Comparison of patients' and health care professionals' attitudes towards advance directives.

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.     

The Medical Directive. A new comprehensive advance care document

Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.     

Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes.

OBJECTIVE: To examine the knowledge of, previous experience with, attitudes toward and perceived barriers to completing advance directives among outpatients at two general medicine clinics. DESIGN: Cross-sectional questionnaire administered in face-to-face structured interviews. SETTING: General internal-medicine outpatient clinics at a university teaching hospital. PATIENTS: One hundred and five adult outpatients who could communicate in spoken English and who consented to be interviewed. RESULTS: Of 167 patients approached, 58 were excluded because they could not communicate in spoken English, and 4 refused to participate. Of the remaining 105 patients, 17 (16%) knew about living wills, 12 (11%) about durable powers of attorney for health care and 4 (4%) about advance directives. Twenty-three (22%) had thought about their preferences for life-sustaining treatment, 20 (19%) had discussed them, none had written them down, and 45 (43%) had thought about choosing a proxy. Sixty-one (58%) wanted to think about their preferences for treatment, 65 (62%) wanted to discuss them, 32 (30%) wanted to write them down, and 80 (76%) wanted to choose a proxy. The perceived barriers to completing an advance directive were inability to write, the belief that an advance directive was unnecessary, a fatalistic attitude, previous discussion of preferences, a desire to leave the decision to doctors, uncertainty about preferences, a desire to discuss preferences rather than document them, a desire to wait until the situation arose, a desire to write down preferences in the future and a desire to avoid thinking about preferences or advance directives. Respondents with more knowledge of life-sustaining treatments were more likely to want to complete an advance directive. CONCLUSIONS: Outpatients have positive attitudes toward advance directives, but their knowledge and experience are limited. These data underscore the need for patient education and for policies to eliminate the barriers to completing advance directives that patients face.     

Autonomy, informed consent and advance directives: a study of physician attitudes

The rights of patients to make decisions concerning their care have been promoted by ethical guidelines under the banner of respect for autonomy, and by legal statutes that address informed consent requirements and advance directives. Given these trends, this study investigated the opinions of 90 physicians specializing in family practice and internal medicine at the Joan C. Edwards Marshall University School of Medicine and the West Virginia University School of Medicine in relation to physician-patient communication. Beliefs and attitudes of these physicians with respect to the participation of patients and family members in medical decisions were explored, using a survey instrument with closed questions. Although physicians surveyed showed respect for the primary elements of informed consent and supported stronger patients' rights, many respondents reported a willingness to override the explicit directives of patients, based on the requests of surrogates. These results reveal a conflict between current ethical and legal standards and the moral intuitions of many practicing physicians. More research focusing explicitly on the role and authority of surrogate decision-makers is warranted.     

Suicide by advance directive?

The medical response to suicide is generally resuscitation, followed by attempts to maximise the patient's recovery. Care is generally withdrawn when it is futile and there is no hope for recovery. Suicidal patients who have completed an advance directive may complicate matters. Should medical providers not resuscitate a patient with an advance directive who has attempted to commit suicide? If stated wishes for care are ignored in the emergency setting, how should decisions be made over time in the event of a successful resuscitation resulting in the need for prolonged therapy counter to the wishes of the advance directive? What are the merits of the stated the wishes of suicidal patient? What if they were depressed at the time of the advance directive? This case highlights the need for consideration of these and other concerns in the care of patients who commit suicide and have an advance directive.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients' instructions, the absence of legal status for directives, the possible interference with a practitioner's clinical judgement, the adequacy and appropriateness of patients' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Ethical dilemmas for house staff physicians. The care of critically ill and dying patients

Winkenwerder describes a disagreement about proper management of a critically ill patient that arose during his tenure as a house staff physician. Despite the attending physician's consideration of the family's wishes and the best interests of the patient, the resident was uneasy with the decision to continue life-prolonging treatment and the role he was to play in implementing such procedures. The author argues that ethical decisions within the group of physicians caring for a patient, especially one who is terminally ill, are not always resolved to everyone's satisfaction. What then are the rights and duties of residents to refuse further participation in care? Winkenwerder suggests dealing with conflicts through recognizing value differences, increasing formal ethics teaching, using consultants, and maximizing communication among members of patient care teams.     

Physicians's reports on the impact of living wills at the end of life in Japan

CONTEXT: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. OBJECTIVES: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. DESIGN: Self administered survey and qualitative study using open question and content analysis. SETTING: Japan. PARTICIPANTS: Physicians known to have cared for a patient who had presented a living will prior to death. MEASUREMENTS: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. MAIN RESULTS: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. CONCLUSIONS: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.     

Attitudes towards and barriers to writing advance directives amongst cancer patients, healthy controls, and medical staff

OBJECTIVES: After years of public discussion too little is still known about willingness to accept the idea of writing an advance directive among various groups of people in EU countries. We investigated knowledge about and willingness to accept such a directive in cancer patients, healthy controls, physicians, and nursing staff in Germany. METHODS: Cancer patients, healthy controls, nursing staff, and physicians (n = 100 in each group) were surveyed by means of a structured questionnaire. RESULTS: Only 18% and 19% of the patients and healthy controls respectively, and 10% of the medical staff had written an advance directive. However, 50-81% of those surveyed indicated that they wished to write one. This intention was associated with deteriorating health (p < 0.001). Only 29% of the healthy controls and 43% of the patients knew about the possibility of appointing a health care proxy. A majority in all groups believed that advance directives may influence the course of treatment (79-85%), yet half of those surveyed in all groups fear that patients could be pressurised into writing an advance directive, and 38-65% thought that relatives could abuse such documents. CONCLUSIONS: Only a minority of the participants had written an advance directive and knew about the possibility of authorizing a health care proxy. Deteriorating health was associated with increasing willingness to make a directive. Despite a majority belief that advance directives may influence treatment at the end of life, other factors limit their employment, such as fear of abuse.     

肿瘤患者预立医疗照护计划的影响因素研究

目的：：研究分析对肿瘤患者实施预立医疗照护计划的影响因素。方法：选取2015年3月至2015年11月在我院诊治的100例肿瘤患者及120例患者家属,经由预立医疗照护计划影响因素问卷进行调查,并对结果进行分析。结果：家属和患者对预立医疗照护计划的认知率比较无明显差异(P>0.05),赞同实施率比较患者组明显高于家属(P<0.05),家属的文化程度、宗教信仰及有无肿瘤丧亲经历不同也有明显的态度差异( P<0.05)家属及患者支持预立医疗照护计划的因素大多是长期病痛折磨、患者有自主权等;家属不支持预立医疗照护计划的原因多为伦理道德因素,患者多是因心愿未完成而不支持。结论：患者对预立医疗照护计划的认可率高于家属,实施时需要考虑两者的不同思考角度。     

终止治疗的讨论和伦理问题

ICU的医护人员必须就许多危重患者生命支持治疗的维持或终止等问题与家属讨论。作者就这种医患交流的重要性、方式、步骤和医学伦理问题进行讨论。     

Patients' knowledge of options at the end of life: ignorance in the face of death

CONTEXT: Effectiveness of legislation promoting advance directives and legalizing physician-assisted suicide depends on patients' understanding their legal options about end-of-life care. However, outpatients' understanding of their legal options at the end of life has not been studied. OBJECTIVES: To estimate the percentage of outpatients who are informed about 4 areas relevant to end-of-life care: refusal and withdrawal of lifesaving treatments, physician-assisted suicide, active euthanasia, and double effect; and to determine whether authoring advance directives, experiencing illness, acting as a proxy for health care decisions, and caring for an ill loved one are associated with better knowledge in end-of-life care. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: One thousand consecutive English-speaking, adult patients attending 1 university-based internal medicine clinic and 3 community-based, university-affiliated, mixed internal medicine and family practice clinics in Oregon during May and June 1999. MAIN OUTCOME MEASURES: Percentage of correct responses in the 4 topic areas and total knowledge score, adjusted for demographic (eg, age, race, educational level, income level, marital status) and experiential (eg, health, proxy decision making, advance directives, and death of a loved one) factors. RESULTS: Of the 1000 patients invited to participate, 728 (73%) consented and completed the questionnaire and were included in the analysis. A total of 69% of respondents answered correctly regarding refusal of treatment, 46% for withdrawal of treatment, 23% for assisted suicide, 32% for active euthanasia, and 41% for double effect. Sixty-two percent of respondents did not distinguish between assisted suicide and euthanasia. After adjustment for other covariates, better knowledge was significantly associated with white race (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.2), having at least a college degree (OR, 3.0; 95% CI, 1.4-6.7), and having been a proxy for health care decisions (OR, 1.8; 95% CI, 1.2-2.6). Personal experience with illness (OR, 1.0; 95% CI, 0.6-1.5), death or illness of a loved one (OR, 1.6; 95% CI, 1.0-2.7), and authoring an advance directive (OR,1.3; 95% CI, 0.9-2.0) were not associated with better knowledge. CONCLUSIONS: A significant proportion of outpatients at university-affiliated clinics in Oregon appear to misunderstand options in end-of-life care. Our results suggest that greater public knowledge about end-of-life care is needed, and advance care planning must be preceded by education about options in end-of-life care. JAMA. 2000;284:2483-2488.     

定性访谈在中医药干预癌症研究中的应用

定性访谈作为定性研究的重要方法,因其突出的人文倾向适用于回答中医药临床诊疗中不可量化的问题.在中医药干预癌症的研究中,通过与医生、患者和家属分别进行一对一个体深度访谈,定性访谈能够用于探索中医药复杂干预,了解医生、患者和家属主观态度、信念、期望等要素,获得来自个体主观的信息,并从中分析特异性和共性,是一种值得探索的研究...     

Doctors' authoritarianism in end-of-life treatment decisions. A comparison between Russia, Sweden and Germany

Objectives—The study was performed in order to investigate how end-of-life decisions are influenced by cultural and sociopolitical circumstances and to explore the compliance of doctors with patient wishes Participants and measurement—Five hundred and thirty-five physicians were surveyed in Sweden (Umeå), Germany (Rostock and Neubrandenburg), and in Russia (Arkhangelsk) by a questionnaire. The participants were recruited according to availability and are not representative. The questionnaire is based on the one developed by Molloy and co-workers in Canada which contains three case vignettes about an 82-year-old Alzheimer patient with an acute life-threatening condition; the questionnaire includes different levels of information about his treatment wishes. We have added various questions about attitudes determining doctors'' decision making process (legal and ethical concerns, patient''s and family wishes, hospital costs, patient''s age and level of dementia and physician''s religion). Results—Swedish physicians chose fewer life-prolonging interventions as compared with the Russian and the German doctors. Swedish physicians would perform cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest less frequently, followed by the German doctors. More than half the Russian physicians decided to perform CPR irrespective of the available information about the patient''s wishes. Level of dementia emerged as the most powerful determining attitude-variable for the decision making in all three countries. Conclusions—The lack of compliance with patient wishes among a substantial number of doctors points to the necessity of emphasising ethical aspects both in medical education and clinical practice. The inconsistency in the treatment decisions of doctors from different countries calls for social consensus in this matter. Key Words: End-of-life decision • DNR order • advance directive • physicians • cross-cultural comparison • survey