Do-not-attempt-resuscitation orders, end-of-life care discussions, and advance care planning for deteriorating patients in Japan

We appreciate the interest and comments of Ogata et al. on our recently published article in Acute Medicine and Surgery.^{1, 2} We share the view of Ogata et al. that advance care planning (ACP) should be promoted in acute care hospitals. However, because data on patients with clinical deterioration are still lacking in Japan, we hope that similar research will continue to be shared among medical facilities. Therefore, we would like to highlight several issues that need to be addressed in future studies.

First, while our study provided a quantitative evaluation of the existence of DNAR orders for deteriorating patients, the quality of EOLC and the process of shared decision-making (SDM) could not be evaluated. Therefore, we could not provide deeper interpretations of the content of SDM with patients and their families regarding DNAR orders, EOLC, limitations of medical treatment, time-limited trials, or ACP.

Second, DNAR orders can change depending on the situation; perspectives; and values of patients, their families, and healthcare providers. We would like to highlight that an RRS resulted in not only new DNAR orders for patients without pre-existing DNAR orders but also the withdrawal of pre-existing DNAR orders.¹ However, the current database includes outcomes at the point of deterioration or 1 month later and does not allow for long-term follow-up. As Ogata et al. pointed out,² the appropriate timing of SDM among patients and their families and the interpretation and handover of SDM among facilities are key considerations.

Third, we investigated the limitations of the medical treatment for pediatric patients with clinical deterioration in Japan.³ Although cases in children were fewer than those in adults, we have demonstrated that the limitation of medical treatment was present in 6% of deteriorating children. This pediatric study underlines the potential utility of including healthcare providers in treatment teams as targets for training in pediatric ACP.

Fourth, the 2023 guidelines published by the Society of Critical Care Medicine recommend that responding healthcare providers should have expertise in facilitating the achievement of patients' goals of care and establishing treatment plans that best reflect their wishes and prognoses.⁴ In the field of acute care medicine in Japan, many statements and guidelines have been published regarding EOLC, DNAR orders, and ACP, including the “Advice on Do Not Attempt Resuscitation (DNAR) order” by the “Japanese Society of Intensive Care Medicine in 2017 and the Guidelines for decision making with end-of-life care” by the Ministry of Health, Labour and Welfare in 2018. However, the contents of these guidelines have not been fully disseminated to the medical field and also proven to be clinically effective in encouraging SDM. Therefore, the outcomes before and after these guidelines should be compared based on annual trends.⁵

Finally, caution should be exercised when interpreting our series of study findings and discussions as the previously mentioned controversial aspects remain open to debate. We believe that nationwide clinical practice and research on DNAR orders, EOLC, and ACP for deteriorating patients must be addressed from a multidisciplinary perspective.

The authors declare that they have no competing interests.

Approval of the research protocol: N/A.

Informed Consent: N/A.

Registry and the Registration No. of the study/Trial: N/A.

Animal Studies: N/A.