Preventive medicine is classified into three levels depending on the period and the person in need of medical intervention. First is the primary level, which involves health promotion measures to prevent the occurrence of disease, next is the secondary level, which involves early treatment to prevent the severity of disease, and lastly, the tertiary level, which involves treatment of subsequent complications and to prevent the recurrence of the disease among the seriously ill. Before I started my private practice, I worked at a general hospital in Saitama Prefecture. Of course, since people come to the hospital already sick, all of the cases I was involved in was on the tertiary level. A lot of critically ill patients wanted to go home but they couldn't because they had to be connected to tubes and machines for treatment. As I was working with these people, I had a vision, albeit vague, about implementing a home health care program if I start my own clinic. After 13 years of working as a surgeon, I decided to start a private medical practice. Around that time, I was the primary physician of a patient with terminal esophageal cancer, who happened to live in the same city as mine. That patient was discharged on the same day of my resignation and was about to receive home treatment on the same day that I'll be practicing privately.
On my daily trips to bring new IV drip to the house of that patient, someone from a nearby home nursing station could not help but approach me and taught me how to of home nursing care. From that time onward, the number of patients seeking for home treatment rapidly increased. In addition, I'm currently involved in providing primary preventive care as an occupational health physician to workers of a major electronics manufacturing company. Apart from that, I also provide secondary and tertiary level preventive care in my private practice and to my patients under home treatment, respectively. Although these three levels involve completely different activities that require completely different skills, I wanted to do all of them because I wanted to look at things at a broader prospective. Consequently, I have gained extensive knowledge, as well as a handful of tasks to fulfill even to this day; however, as a doctor, it feels very rewarding to be involved in all stages of medical care.
Doctors like me have been taught in the university to treat humans and save lives. Even if a patient is unconscious and is suffering from a terminal illness, it is possible to apply life-prolonging measures and every other option in the best of our ability if their family wishes to. However, when I was still working in a hospital, I came across a 90-year old patient in comatose, who is also suffering from pneumonia and was severely demented prior to being in that state. Seeing that patient, I suddenly asked myself if a life-prolonging treatment would really serve his best interest. I wondered if that was what he really wanted for himself. I worked in emergency care immediately after my graduation from university, and whenever a patient comes in, I inserted tubes on them for treatment without any second thought. I have regrets from this experience, which still haunts me from time to time. And maybe, like him, there are a lot of them in the world who are receiving unwanted medical treatments. My sentiment became increasingly strong ever since I became involved in an actual home nursing care.
I have examined an elderly who has been bedridden for 15 years after undergoing a gastrostomy. He can no longer eat by mouth due to severe cerebral infarction, but he can continue living as long as he receives nutrition through his gastrostomy feeding device. One day, while I was providing home nursing care for this patient, his daughter, the one taking care of him, had the same sentiment as mine and expressed all the things that I wanted to, but I couldn't. She said, “When is he going to die?”. No one can really blame her. This is Japan's current state, and this is how concerned parties truly feel about their situation. How difficult it is to be unable to die voluntarily. With a desire to convey this reality to the world, I wrote a book "Shinenai Rojin" (an old man who cannot die) in 2017.
Writing this book opened doors to activities that promote the thought of giving people a "dignified death". Death with dignity is basically "natural death". Some people also refer to it as a "peaceful death". Dying patients who choose to die with dignity through natural methods are fundamentally different from those who choose euthanasia, in which they can receive medically-assisted death despite being able to live healthily. And yet, a lot of people still misunderstand this point. Death with dignity is by no means "asking someone to die because their illness can no longer be cured". There are many people in the world who want to live until the end. These are those people whom we want to fight for their lives all the way. What matters is whether one was able to choose their path through their own will. Back in the day, we had a culture that naturally accepts the end of life for those in critical condition.
Nowadays, it has become possible to extend someone's life even if they are not conscious. In spite of that, I believe that a mere life-prolonging treatment is becoming incongruent with modern Japan, which has an aging society at present (and eventually a death-ridden society in the future). It is about time that we change our way of thinking towards death. I really believe that it is crucial to enlighten the public about the importance of keeping a living will, which specifies how one wants to spend their lives and how they want to die, while they are still healthy and able. Furthermore, I believe that it is important to enlighten health care workers beyond this matter, and that we need to establish a medical culture that allows them to wait and observe over one’s passing as part of their education. To those who will pursue a career in medicine, the fundamental principle here is to basically cure disease and to do it with the best of your ability; however, remember that there will always be patients who do not prefer to be treated and patients who have no chance to recover despite receiving treatment. By that time, I hope that there will be more medical professionals with a flexible mindset that will keep a close eye on patients instead of turning a back on them. Humans will inevitably face death, so I think it would be great if we could live in a society where the patient himself (and their family) can choose to die fully satisfied.
