End-of-life decisions and advance directives in palliative care: a cross-cultural survey of patients and health-care professionals

J Pain Symptom Manage. 1998 Sep;16(3):153-62. doi: 10.1016/s0885-3924(98)00067-0.


In order to explore possible differences in the scope of end-of-life decisions and attitudes toward advance directives (AD) in palliative care, we conducted a survey of 159 patients in palliative care institutions and 93 health-care professionals experienced in palliative care in the United States, Germany, and Japan. Giving an AD in this clinical setting was considered important by patients and professionals. The prevalence of a formal written AD was 79% in the United States, 18% in Germany, and 9% in Japan. In Japan, there was a high prevalence of entrusting all decisions to the family (known as omakase). More than 80% of the patients had negative feelings toward their future decisions in the United States and Germany, in contrast to only 45% in Japan. Although favored by the professionals, there were no specific instruments for obtaining ADs. In Germany and Japan, some patients had given an informal AD. As a pilot content validity step, survey results were used to derive a checklist for content and procedural aspects in end-of-life decision-making. This checklist may provide the basis for developing an instrument to guide physicians, especially non-palliative care specialists, in communication with their patients and their families in this difficult clinical situation.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Advance Directives*
  • Attitude of Health Personnel
  • Cross-Cultural Comparison*
  • Female
  • Germany
  • Humans
  • Japan
  • Male
  • Middle Aged
  • Palliative Care / psychology*
  • Patients / psychology
  • Resuscitation Orders
  • United States