Photo/IllutrationAn ambulance used by a fire department in the Tohoku region (Hajime Mikami)

A quandary is spreading among emergency medical workers on whether to save lives at all costs or grant the wishes of terminally ill patients and let them die with dignity.

Twenty-five percent of fire departments in 52 major cities in Japan allow ambulance crew members to suspend resuscitation measures under certain conditions, particularly if the patient’s request to be allowed to die is known, according to an Asahi Shimbun survey.

Some other fire departments are also considering accepting suspensions of life-saving procedures.

But ambulance crews may feel that doing nothing would run counter to their mission to save lives and could possibly violate the law.

Calls are growing for the central government to set up rules for such cases.

The guidelines of the internal affairs ministry’s Fire and Disaster Management Agency (FDMA) stipulate that ambulance crews must implement life-saving measures if people are at risk of death.

The Fire Services Law does not take into account situations in which ambulance attendants are asked by the patient’s family members or doctors to suspend the life-saving measures.

In Japan’s rapidly graying society, an increasing number of elderly people are being found unresponsive at their homes or in nursing care facilities. The natural response of family members who see the sudden change in the patients’ conditions is to call for an ambulance, especially if they are unable to contact their family doctors.

These calls are made even by people who have confirmed the patients’ wishes not to receive life-prolonging treatment.

The ambulance crews’ responses to requests to let the patient die depend on the area.

The Asahi Shimbun survey conducted in May found that 39 fire departments, representing 75 percent of the 52 major cities, including the 47 prefectural capitals, have decided on how rescue workers should deal with such requests.

Of the 39 fire departments, 26 order emergency crews to implement resuscitation measures while providing explanations to the families or trying to convince them on the need for the life-saving steps.

However, the remaining 13 fire departments, or 25 percent of the 52, allow ambulance crews to suspend resuscitation measures if they receive such instructions from the family doctors.

SEEKING GOVERNMENT RULES

The moves to allow a suspension of resuscitation measures were triggered by a proposal compiled in 2017 by the Japanese Society for Emergency Medicine (JSEM), which consists of emergency physicians, ambulance crew members and others in the medical field.

The society’s proposal contains a job flow chart in which ambulance crews can halt resuscitation measures if they receive instructions directly from the family doctors.

The Tokyo Fire Department as early as this year is expected to adopt a policy that reflects the society’s proposal.

The Yokohama City Fire Bureau this month started discussions on a similar plan. A city examination committee had asked the bureau to conduct activities based on the JSEM’s proposal.

According to The Asahi Shimbun’s survey, 83 percent of the 52 fire departments said central government-set unified standards and views for these cases are necessary.

“Differences depending on the area are not desirable concerning issues about human dignity, including how to die,” said an official of one of the fire departments.

PRETENDING TO BE SAVING LIFE

On one night, a fire department in the Tohoku region received an emergency call: “An elderly patient with terminal-stage cancer has stopped breathing.”

After an ambulance arrived at the scene, the crew tried to resuscitate the patient. But a woman who was apparently a family member of the patient said, “Please stop it.”

The patient had told the family doctor that life-prolonging measures were unwanted.

But the patient was not specific, including on what measures could be performed if breathing stopped at night.

Although the woman was aware of the patient’s wishes, she called the fire department because she was surprised by the patient’s condition.

The chief of the ambulance crew called a hospital and explained the patient’s condition to the family doctor.

“Life-saving is not necessary,” the doctor said. “I want you to bring the patient to my hospital without taking any measures.”

The fire department’s rules state that ambulance crews are forbidden from suspending resuscitation measures if there is even a slight possibility that the patient’s life can be saved.

The crew chief explained the rules to the doctor, who responded, “Carry the patient by pretending that you are implementing resuscitation measures.”

The crew chief rejected the request.

So the doctor conceded, “Carry the patient while doing your best to implement life-saving measures.”

To perform a heart massage, the crew chief used his palms to push the center of the breast of the patient’s thin body. But he felt that if he pushed down by 5 centimeters in accordance with the rules, the patient’s ribs could become dislodged from the sternum.

Eventually, the crew chief pretended to push down on the patient’s chest.

But he wrote in his activity report, “We carried the patient while doing our best to take life-saving measures.”

That incident occurred about five years ago, but the crew chief clearly remembers it even now.