PhD defence M.M.L. (Monique) Daniels

Below is a brief summary of the dissertation:

Lifelong Mechanical Ventilation in Japan Calls for Greater Scope to Reconsider Treatment

In Japan, unlike in the Netherlands, withdrawing life-sustaining treatment is uncommon, even when continuing treatment no longer reflects the wishes of the patient or their family, or is no longer considered medically appropriate. This also applies to invasive mechanical ventilation, often initiated following an acute, life-threatening event. In this form of treatment, a ventilator supports breathing through a tube inserted into the airway. Some patients subsequently remain dependent on mechanical ventilation and intensive hospital care for years, and often for the rest of their lives, frequently without regaining consciousness. PhD research by Monique Daniels has shed light on this largely understudied patient population. Her findings contributed to new Japanese guidelines that provide greater scope to carefully reconsider and, when appropriate, withdraw life-sustaining treatment.

Daniels, who held senior management positions in Dutch hospitals for many years, lived in Japan for more than four years. She studied this largely overlooked patient population with the aim of understanding Japanese clinical practice, rather than judging it by Dutch standards. Her research included an analysis of data from nearly 400,000 patients who received mechanical ventilation, interviews with family members, and a study of Japanese physicians’ perspectives.

Her findings show that an increasing proportion of patients who receive invasive mechanical ventilation become dependent on it in the long term: now approximately one in fifty. Half of these patients are aged 75 or older, and most are admitted to hospital as emergencies.

For families, the consequences are profound. What begins as a life-saving decision may later turn out to be a path with no way back. Patients’ wishes and treatment preferences are often unknown. Even when they are known, withdrawing treatment is complicated by legal and regulatory uncertainty and cultural attitudes. Family members rarely discuss their loved one’s situation, either with healthcare professionals or within their own social networks. Opportunities to reconsider treatment therefore often remain unexplored.

Physicians differ in their views on whose perspective should carry the greatest weight in treatment decisions: the patient’s wishes, a consensus between the patient and family, or the physician’s clinical judgement. At the same time, physicians call for clearer guidelines on the careful withdrawal of mechanical ventilation when continuing treatment is no longer appropriate or desired.

From Research to Change

A committee representing Japanese medical professional societies used Daniels’ research findings to highlight the need for change. Recently revised guidelines now provide physicians with greater clarity on the circumstances under which life-sustaining treatments may be withdrawn during the acute phase, as well as when such treatments may be initiated on a time-limited basis and subsequently reassessed. These decisions should take into account the patient’s condition and the wishes of the patient and their family.