Current situation of the hospitalization of persons without family in Japan and related medical challenges

Sayaka Yamazaki; Nanako Tamiya; Kaori Muto; Yuki Hashimoto; Zentaro Yamagata

doi:10.1371/journal.pone.0276090

. 2023 Jun 2;18(6):e0276090. doi: 10.1371/journal.pone.0276090

Current situation of the hospitalization of persons without family in Japan and related medical challenges

Sayaka Yamazaki ^1,^*, Nanako Tamiya ², Kaori Muto ³, Yuki Hashimoto ⁴, Zentaro Yamagata ⁵

Editor: Federica Canzan⁶

PMCID: PMC10237481 PMID: 37267321

Abstract

This study aims to determine the approximate number of hospitalizations of persons without family and the medical challenges they encounter in hospitals across Japan. Self-administered questionnaires were mailed to 4,000 randomly selected hospitals nationwide to investigate the actual conditions and problems, decision-making processes, and use of the government-recommended Guidelines for the hospitalization of, and decision-making support for, persons without family. To identify the characteristics of each region and role of hospitals, chi-square tests were used to make separate group comparisons by hospital location and type. Responses were received from 1,271 hospitals (31.2% response rate), of which 952 hospitals provided information regarding the number of admissions of persons without family. The mean (SD) and median number of hospitalizations (approximate number per year) of patients without family was 16 (79) and 5, respectively. Approximately 70% of the target hospitals had experienced the hospitalization of a person without family, and 30% of the hospitals did not. The most common difficulties encountered during the hospitalization were collecting emergency contact information, decision-making related to medical care, and discharge support. In the absence of family members and surrogates, the medical team undertook the decision-making process, which was commonly performed according to manuals and guidelines and by consulting an ethics committee. Regarding the use of the government-recommended Guidelines, approximately 70% of the hospitals that were aware of these Guidelines responded that they had never taken any action based on these Guidelines, with significant differences by region and hospital type. To solve the problems related to the hospitalization of persons without family, the public should be made aware of these Guidelines, and measures should be undertaken to make clinical ethics consultation a sustainable activity within hospitals.

Introduction

Adults without family members or other surrogate decision makers are known as "unrepresented patients" or "adult orphans," while older adults without family members or other surrogate decision makers are called “elder orphans” [1, 2]. The term "unbefriended" was more commonly used than the other terms to describe these persons in the bioethics, medical, and legal literature [3]. In 2009, a study on the current situation of elder orphans [4] and the impact of the growing number of adult orphans on healthcare providers [5] was conducted. Thereafter, as an emerging topic, research on persons without family has been increasing, mainly in the United States. In particular, many studies have focused on related ethical issues [1, 6–11] and approaches [11–17] to the challenges facing healthcare [7, 8]. While some research in recent years has examined clinical issues [18, 19], studies addressing this problem are limited, and most have been conducted in the United States and other Western countries. The number of extant empirical studies is extremely limited [20].

In the United States, 22.6% of the population is at a high risk of becoming "unbefriended" [2]. In fact, most clinicians encounter an unbefriended individual at least once a quarter [21], and the unbefriended status accounts for 5.5% deaths among intensive care unit patients [22] and 3% of nursing home residents [23]. In the U.S., adults without surrogates are typically white, male, 65 years or older, have nuclear family, and are not socially disconnected [24]. Adults without surrogates experience longer hospital stays and delays in receiving palliative care and treatment [25]. Further, one study in a Canadian long-term care facility found that social support for these individuals was limited, and even basic personal items were difficult to obtain [18]. In 2016, the American Geriatrics Society recommended creating and adapting uniform and legal decision-making standards for unbefriended populations nationwide [13]; however, professional guidelines and laws for addressing issues related to this population have been inconsistent [26].

During admission, approximately 60% of hospitals in Japan require a guarantor, who plays a variety of roles related to the patient’s admission, such as payment of hospitalization expenses, guaranteeing debts, preparing necessary items for hospitalization, and postmortem affairs [27]. A guarantor is not an adult guardian, as stipulated by law, but primarily a patient’s family member who serves as a guarantor without compensation and participates in the patient’s medical decisions, regardless of the degree of decision-making by the patient. However, the increase in the number of single-person households has made the operation of this practice more difficult [27]. In fact, in recent years, persons without dependable family members have been reportedly denied hospitalization in Japan [27, 28]. Against this background, the "Guidelines for the Hospitalization of Persons without Family and Support for Persons with Difficulty in Decision-Making Regarding Medical Care” [29] (hereinafter referred to as the "Guidelines”) were issued in 2019. The Guidelines were compiled by a research group, and The Ministry of Health, Labor, and Welfare recommends following them. The Guidelines specify that the wishes of the patient should be respected regardless of the presence or absence of family members. They also state the specific measures to be taken in the absence of family members (hospitalization planning, discharge support, handling in case of death, etc.), and the role of legally recognized adult guardians in the medical field. However, no studies have quantitatively investigated the hospitalization and medical challenges of persons without family members in Japan.

The aim of this study was to determine the approximate number of hospitalizations of persons without family in Japan and the hospitalization and medical challenges they face. Based on prior research [27, 28], we hypothesized that support for persons without family would vary according to region and hospital size and role of hospitals, and we aimed to test this hypothesis.

Materials and methods

Self-administered hard copy questionnaires (S1 Questionnaire) were mailed to 4,000 hospitals, selected randomly from 7,244 hospitals nationwide that had reported on the function of hospital beds [30] in the 2009 fiscal year. The questionnaires were distributed to nursing managers or medical social workers; we hoped that this group would have the awareness of, and experience with, persons without family. The survey was conducted from September to November 2020.

The questionnaire included questions on the number of hospitalizations of persons without family (approximate number per year), difficulties arising in the hospitalization of these individuals, decision-making processes for medical care when a person’s wishes cannot be confirmed at the point when a decision regarding medical care for a person without family is required, and the use of the Guidelines. According to the Guidelines, "persons without family" include "persons who are unable to contact their families" and "persons who are unable to obtain support from their families”; thus, based on these Guidelines, this study also classified those who are unable to obtain support from their families as "persons without family.”

Based on previous research [27, 28], we organized the roles that family members perform on behalf of patients who are hospitalized. Further, we created eight difficult situations that persons without family may encounter, such as the collection of emergency contact information; matters related to hospitalization plans, supplies needed during hospitalization, hospitalization expenses, discharge support and the retrieval of bodies and belongings and funeral services; as well as decision-making related to medical care and “other,” which was a free-text option. Following previous research [11, 12, 26] on the decision-making process regarding the medical care for persons with no family, and who experience difficulty in making decisions, nine representative processes were created to represent the medical care decision-making process for such individuals. These entailed decisions made according to manuals and guidelines, by medical care teams, at conferences, by the ethics committee, by the attending physician, by patient’s acquaintances and friends, and “other,” which was a free-text option. The questionnaire was reviewed and developed by experts in public health, law, ethics, and nursing.

To clarify the differences and characteristics by region and hospital type, we conducted a survey of hospital locations (Local, Tokyo, Osaka, and Nagoya) and hospital types (general hospitals, hospitals with beds for long-term care, advanced treatment hospitals, and regional medical care support hospitals). The groups were compared using a chi-square test. If the expected value was less than or equal to 5, Fisher’s exact test was performed. We used the locations defined by the Ministry of Land, Infrastructure, Transport, and Tourism [31, 32], with Tokyo, Kanagawa, Saitama, Chiba, and Ibaraki prefectures being classified as the Tokyo area; Kyoto, Osaka, Hyogo, and Nara prefectures as the Osaka area; Aichi and Mie prefectures as the Nagoya area; and other prefectures as local areas. Since advanced treatment hospitals are required to have at least 400 beds, and regional medical care support hospitals are required to have at least 200 beds, group comparisons by hospital type were stratified by the number of beds to adjust for confounding by this number. All analyses were performed using Stata17.

The study was approved by the Ethics Committee of the University of Yamanashi, School of Medicine (Reception No. 2281, July 17, 2020). Survey responses were anonymous, and no identifying patient information was collected. All participants provided written informed consent prior to participation. By returning the questionnaire, participants indicated their consent.

Results

The questionnaire response rate was 31.8% (1,271 collected questionnaires). The respondents comprised 820 (64.5%) medical social workers and 301 (23.6%) nurses. Respondents were allowed to answer by selecting more than one option to describe their job role (e.g., some respondents were both nurses and medical social workers). The number of respondents who were both nursing managers and medical social workers was 81(6.3%). Cross tables for region and hospital type (S1 Table), hospital type and number of beds (S2 Table), and number of beds and region (S3 Table) are shown in Supporting Information.

Characteristics of hospitals that responded to the survey

Table 1 shows the characteristics of the hospitals that responded to the survey. The highest percentage of respondents (72.9%) cited "emergency contact information" as a difficult situation during hospitalization for persons without family, followed by "decision-making related to medical care" at 66.6%. The most commonly cited decision-making process for medical care, when the wishes of persons without family cannot be confirmed at the point when a decision regarding their medical care is required, was "decisions made by the medical care team," at 45.0%. Regarding the use of the Guidelines, the highest percentage (46.6%) of respondents answered, "We have never taken Guideline-based action," followed by 29.9% who selected, "We do not know about the Guidelines" (Table 1).

Table 1. Characteristics of hospitals that responded to the survey N = 1271.

		n	%^a
Region
	Local Area	797	62.7
	Tokyo area	245	19.3
	Osaka area	162	12.7
	Nagoya area	53	4.2
	Missing value	14	1.1
Hospital type
	Hospitals with long-term care beds	612	48.2
	General hospitals^b	522	41.1
	Regional medical care support hospitals	84	6.6
	Advanced treatment hospitals	24	1.9
	Missing value	29	2.3
Establishing entity
	Private corporation or individual	934	73.5
	Public organization	264	20.8
	National	63	5.0
	Missing value	10	0.8
Number of beds
	20–49	114	9.0
	50–99	299	23.5
	100–199	463	36.4
	200–399	250	19.7
	400+	134	10.5
	Missing value	11	0.9
Situations that were difficult to deal with during the hospitalization of a person without family (multiple responses)
	Emergency contact information	927	72.9
	Decision-making related to medical care	846	66.6
	Matters related to discharge support	783	61.6
	Matters related to hospitalization expenses	755	59.4
	Matters related to supplies needed during hospitalization	708	55.7
	Matters related to the retrieval of the body and belongings and funeral services	703	55.3
	Matters related to hospitalization plans	336	26.4
Decision-making process for medical care for persons without family (multiple responses)
	Decisions made by the medical care team	572	45.0
	Decisions made at conferences	531	41.8
	Decisions made by the attending physician	523	41.1
	Decisions made according to manuals and guidelines	381	30.0
	Decisions made by patient’s acquaintances and friends	248	19.5
	Decisions made by the ethics committee	224	17.6
	Decisions made by the medical social worker	70	5.5
	Decisions made by the nurse in charge	26	2.0
Use of the Guidelines^c
	We have never responded according to the Guidelines	592	46.6
	We do not know about the Guidelines	380	29.9
	We have taken action in accordance with the Guidelines	268	21.1
	Missing value	31	2.4

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^a Percentage divided by total number

^b Hospitals without beds for long-term care

^c Guidelines for hospitalization of persons without family and support for persons with decision-making difficulties

Regarding the number of hospitalizations of persons without family (approximate number per year), the average value was used as the approximate number per year, for responses that included a range (e.g., "1 to 3"). Consequently, respondents from 952 hospitals stated that there were at least 0.5 hospitalizations of persons without family per year, with a minimum value of 0.5 and a maximum value of 2,000. The mean (SD) was 16 (79), and the median was 5. The Nagoya area had the highest mean value of 43 (176), compared with the other regions. Advanced treatment hospitals also had a higher mean value of 27 (28) compared with other types of hospitals. Further, as the number of beds increased, the number of admissions of persons without family increased (p for trend <0.001) (Table 2). S6 Table presents the results of an analysis that excludes outliers identified by the Smirnov-Grubbs test. Specifically, test results showed that the number of admissions above 200 was an outlier, so the six hospitals that reported more than 200 admissions were excluded from the analysis.

Table 2. Number of hospitalizations of persons without family (approximate number per year) N = 952.

	n	Min	Max	Mean (SD)	Median	Percentiles			P*
	n	Min	Max	Mean (SD)	Median	25	50	75	P*
Total	952	0.5	2000	16 (79)	5	2	5	12
Region ^a
Local area	604	0.5	120	9(12)	5	2	5	10	<0.001
Tokyo area	171	1	500	24(51)	10	5	10	20
Osaka area	132	3	2000	32(176)	7	3	7	20
Nagoya area	38	1	1081	43(176)	5.5	2	5.5	15
Missing value	7	-	-	-	-	-	-	-
Hospital type ^a
General hospitals	383	1	1081	15(57)	5.5	2	5.5	15	<0.001
Hospitals with long-term care beds	463	0.5	2000	16(99)	4	2	4	10
Advanced treatment hospitals	14	10	118	27(28)	19	12	19	50
Regional medical care support hospitals	72	1	200	26(34)	15	9	15	30
Missing value	20	-	-	-	-	-	-	-
Number of beds ^b
20–49	79	1	38	6(8)	2	1.0	2	6	<0.001
50–99	217	1	360	9(28)	3	2.0	3	8
100–199	368	0.5	500	12(30)	5	2.5	5	10
200–399	189	1	2000	25(146)	8	4.0	8	17
400+	93	1	1081	41(117)	15	10.0	15	30
Missing value	6	-	-	-	-	-	-	-

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^aNumber of individual hospitalizations, excluding missing values, compared between groups by Kruskal–Wallis test.

^bNumber of individual hospitalizations, excluding missing values, compared between groups by Jonckheere–Terpstra test.

*p < .05

Between-group comparison of difficult situations to deal with in the hospitalization of persons without family

Tables 3 and 4 list the difficult situations encountered during the hospitalization of persons without family. In terms of percentage by region, a higher percentage of respondents from hospitals in the Tokyo, Osaka, and Nagoya regions selected "matters related to hospitalization expenses" as a difficult situation to deal with, compared to respondents from local regions (Table 3).

Table 3. Difficult situations during the hospitalization of persons without family (multiple responses) by region n = 1257 ^a.

		Local area	Tokyo area	Osaka area	Nagoya area	P*
Emergency contact information	Yes(%)	579 (72.6)	180 (73.5)	114 (70.4)	43 (81.1)	0.492
Emergency contact information	No(%)	218 (27.4)	65 (26.5)	48 (29.6)	10 (18.9)	0.492
Matters related to hospitalization plan	Yes(%)	231 (29.0)	49 (20.0)	40 (24.7)	13 (24.5)	0.042
Matters related to hospitalization plan	No(%)	566 (71.0)	196 (80.0)	122 (75.3)	40 (75.5)	0.042
Matters related to supplies needed during hospitalization	Yes(%)	459 (57.6)	127 (52.8)	80 (49.4)	33 (62.3)	0.103
Matters related to supplies needed during hospitalization	No(%)	338 (42.4)	118 (48.2)	82 (50.6)	20 (37.7)	0.103
Matters related to hospitalization expenses	Yes(%)	445 (55.8)	161 (65.7)	106 (65.4)	34 (64.1)	0.011
Matters related to hospitalization expenses	No(%)	352 (44.2)	84 (34.3)	56 (34.6)	19 (35.9)	0.011
Matters related to discharge support	Yes(%)	487 (61.1)	150 (61.2)	105 (64.8)	32 (60.4)	0.840
Matters related to discharge support	No(%)	310 (38.9)	95 (38.8)	57 (35.2)	21 (39.6)	0.840
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	440 (55.2)	128 (52.2)	100 (61.7)	27 (50.9)	0.257
	No(%)	357 (44.7)	117 (47.8)	62 (38.2)	26 (49.1)	0.257
Decision-making related to medical care	Yes(%)	531 (66.6)	161 (65.7)	106 (65.4)	37 (69.8)	0.947
Decision-making related to medical care	No(%)	266 (33.4)	84 (34.3)	56 (34.6)	16 (30.2)	0.947

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^a Number of persons (in %), excluding missing values, compared between groups by chi-square test. When the expected frequency of 5 or less was included, Fisher’s exact test was used.

*p < .05

Table 4. Difficult situations during the hospitalization of persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.

		20–49 n = 110				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Emergency contact information	Yes(%)	47 (61.8)	16 (47.1)	-	-	0.147
Emergency contact information	No(%)	28 (38.2)	18 (52.9)	-	-	0.147
Matters related to hospitalization plan	Yes(%)	18 (23.7)	7 (20.6)	-	-	0.720
Matters related to hospitalization plan	No(%)	58 (76.3)	27 (79.4)	-	-	0.720
Matters related to supplies needed during hospitalization	Yes(%)	35 (46.1)	19 (55.9)	-	-	0.341
Matters related to supplies needed during hospitalization	No(%)	41 (53.9)	15 (44.1)	-	-	0.341
Matters related to hospitalization expenses	Yes(%)	30 (39.5)	15 (44.1)	-	-	0.647
Matters related to hospitalization expenses	No(%)	46 (60.5)	19 (55.9)	-	-	0.647
Matters related to discharge support	Yes(%)	36 (47.4)	10 (29.4)	-	-	0.078
Matters related to discharge support	No(%)	40 (52.6)	24 (70.6)	-	-	0.078
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	31 (40.8)	12 (35.3)	-	-	0.058
	No(%)	45 (59.2)	22 (64.7)	-	-	0.058
Decision-making related to medical care	Yes(%)	39 (51.3)	15 (44.1)	-	-	0.485
Decision-making related to medical care	No(%)	37 (48.7)	19 (55.9)	-	-	0.485
		50–99 n = 296				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Emergency contact information	Yes(%)	94 (68.1)	100 (63.3)	-	-	0.384
Emergency contact information	No(%)	44 (31.9)	58 (36.7)	-	-	0.384
Matters related to hospitalization plan	Yes(%)	33 (23.9)	31 (19.6)	-	-	0.371
Matters related to hospitalization plan	No(%)	105 (76.1)	127 (80.4)	-	-	0.371
Matters related to supplies needed during hospitalization	Yes(%)	69 (50.0)	74 (46.8)	-	-	0.587
Matters related to supplies needed during hospitalization	No(%)	69 (50.0)	84 (53.2)	-	-	0.587
Matters related to hospitalization expenses	Yes(%)	67 (48.6)	69 (43.7)	-	-	0.401
Matters related to hospitalization expenses	No(%)	71 (51.4)	89 (56.3)	-	-	0.401
Matters related to discharge support	Yes(%)	78 (56.5)	71 (44.9)	-	-	0.047
Matters related to discharge support	No(%)	60 (43.5)	87 (55.1)	-	-	0.047
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	56 (40.6)	77 (48.7)	-	-	0.159
	No(%)	82 (59.4)	81 (51.3)	-	-	0.159
Decision-making related to medical care	Yes(%)	85 (61.6)	86 (54.4)	-	-	0.213
Decision-making related to medical care	No(%)	53 (38.4)	72 (45.6)	-	-	0.213
		100–199 n = 455				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Emergency contact information	Yes(%)	122 (75.8)	218 (74.1)	-	-	0.703
Emergency contact information	No(%)	39 (24.2)	76 (25.9)	-	-	0.703
Matters related to hospitalization plan	Yes(%)	43 (26.7)	82 (27.9)	-	-	0.787
Matters related to hospitalization plan	No(%)	118 (73.3)	212 (72.1)	-	-	0.787
Matters related to supplies needed during hospitalization	Yes(%)	93 (57.8)	146 (49.7)	-	-	0.098
Matters related to supplies needed during hospitalization	No(%)	68 (42.2)	148 (50.3)	-	-	0.098
Matters related to hospitalization expenses	Yes(%)	111 (68.9)	179 (60.9)	-	-	0.087
Matters related to hospitalization expenses	No(%)	50 (31.1)	115 (39.1)	-	-	0.087
Matters related to discharge support	Yes(%)	115 (71.4)	164 (55.8)	-	-	0.001
Matters related to discharge support	No(%)	46 (28.6)	130 (44.2)	-	-	0.001
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	101 (62.7)	159 (54.1)	-	-	0.075
	No(%)	30 (37.3)	135 (45.9)	-	-	0.075
Decision-making related to medical care	Yes(%)	106 (65.8)	190 (64.6)	-	-	0.795
Decision-making related to medical care	No(%)	55 (34.2)	104 (35.4)	-	-	0.795
		200–399 n = 244				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Emergency contact information	Yes(%)	83 (83.0)	77 (72.0)	-	34 (91.9)	0.019
Emergency contact information	No(%)	17 (17.0)	30 (28.0)	-	3 (8.1)	0.019
Matters related to hospitalization plan	Yes(%)	28 (28.0)	35 (32.7)	-	17 (46.0)	0.139
Matters related to hospitalization plan	No(%)	72 (72.0)	72 (67.3)	-	20 (54.0)	0.139
Matters related to supplies needed during hospitalization	Yes(%)	70 (70.0)	63 (58.9)	-	29 (78.4)	0.059
Matters related to supplies needed during hospitalization	No(%)	30 (30.0)	44 (41.1)	-	8 (21.6)	0.059
Matters related to hospitalization expenses	Yes(%)	68 (68.0)	64 (59.8)	-	30 (81.1)	0.056
Matters related to hospitalization expenses	No(%)	32 (32.0)	43 (40.2)	-	7 (18.9)	0.056
Matters related to discharge support	Yes(%)	78 (78.0)	67 (62.6)	-	32 (86.5)	0.006
Matters related to discharge support	No(%)	22 (22.0)	40 (37.4)	-	5 (13.5)	0.006
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	69 (69.0)	62 (58.0)	-	22 (59.5)	0.235
	No(%)	31 (31.0)	45 (42.0)	-	15 (40.5)	0.235
Decision-making related to medical care	Yes(%)	85 (85.0)	75 (70.1)	-	30 (81.1)	0.031
Decision-making related to medical care	No(%)	15 (15.0)	32 (29.9)	-	7 (18.9)	0.031
		400+ n = 133				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Emergency contact information	Yes(%)	38 (86.4)	14 (77.8)	19 (79.2)	41 (87.2)	0.661
Emergency contact information	No(%)	6 (13.6)	4 (22.2)	5 (20.8)	6 (12.8)	0.661
Matters related to hospitalization plan	Yes(%)	9 (20.5)	4 (22.2)	7 (29.2)	13 (27.7)	0.811
Matters related to hospitalization plan	No(%)	35 (79.5)	14 (77.8)	17 (70.8)	34 (72.3)	0.811
Matters related to supplies needed during hospitalization	Yes(%)	32 (72.7)	7 (38.9)	20 (83.3)	34 (72.4)	0.014
Matters related to supplies needed during hospitalization	No(%)	12 (27.3)	11 (61.1)	4 (16.7)	13 (27.6)	0.014
Matters related to hospitalization expenses	Yes(%)	34 (77.3)	15 (83.3)	19 (79.2)	38 (80.8)	0.959
Matters related to hospitalization expenses	No(%)	10 (22.7)	3 (16.7)	5 (20.8)	9 (19.2)	0.959
Matters related to discharge support	Yes(%)	37 (84.1)	8 (44.4)	23 (95.8)	44 (93.6)	<0.001
Matters related to discharge support	No(%)	7 (15.9)	10 (55.6)	1 (4.2)	3 (6.4)	<0.001
Matters related to the retrieval of bodies and belongings and funeral services	Yes(%)	31 (70.5)	12 (66.7)	21 (87.5)	34 (72.3)	0.355
	No(%)	13 (29.5)	6 (33.3)	3 (12.5)	13 (27.7)	0.355
Decision-making related to medical care	Yes(%)	39 (88.6)	12 (66.7)	21 (97.5)	40 (85.1)	0.217
Decision-making related to medical care	No(%)	5 (11.4)	6 (33.3)	3 (12.5)	7 (14.9)	0.217

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^a Number of persons (in %), excluding missing values, compared between groups by chi-square test. When the expected frequency of 5 or less was included, Fisher’s exact test was used.

*p < .05

The percentage of respondents that selected "matters related to discharge support" was higher in general hospitals, among the hospitals with 50–199 beds and regional medical care support hospitals, among the hospitals with 200–399 beds. Further, advanced treatment hospitals, among the hospitals with 400 or more beds, had a higher percentage of discharge support compared with other hospitals (Table 4).

Between-group comparison of decision-making processes for medical care of persons without family

Table 5 shows the decision-making processes for the medical care of persons without family when their wishes cannot be confirmed at the point when a decision regarding their medical care is required. There were no statistically significant differences in the percentages by region.

Table 5. Decision-making process for medical care for persons without family (multiple responses) by region n = 1257 ^a.

		Local area	Tokyo area	Osaka area	Nagoya area	P*
Decisions made according to manuals and guidelines	Yes(%)	233 (29.2)	73 (29.8)	53 (32.7)	17 (32.1)	0.825
Decisions made according to manuals and guidelines	No(%)	564 (70.8)	172 (70.2)	109 (67.3)	36 (67.9)	0.825
Decisions made by the medical care team	Yes(%)	348 (43.6)	111 (45.3)	80 (49.4)	24 (45.3)	0.610
Decisions made by the medical care team	No(%)	449 (56.3)	134 (54.7)	82 (50.6)	29 (54.7)	0.610
Decisions made at conferences	Yes(%)	342 (42.9)	91 (37.1)	67 (41.4)	25 (47.2)	0.358
Decisions made at conferences	No(%)	455 (57.1)	154 (62.8)	95 (58.6)	28 (52.8)	0.358
Decisions made by the ethics committee	Yes(%)	137 (17.2)	34 (13.9)	39 (24.1)	10 (18.9)	0.066
Decisions made by the ethics committee	No(%)	660 (82.8)	211 (86.1)	123 (75.9)	43 (81.1)	0.066
Decisions made by the attending physician	Yes(%)	326 (41.0)	114 (46.5)	58 (35.8)	22 (41.5)	0.184
Decisions made by the attending physician	No(%)	471 (59.0)	131 (53.5)	104 (64.2)	31 (58.5)	0.184
Decisions made by the patient’s acquaintances and friends	Yes(%)	156 (19.6)	52 (21.2)	27 (16.7)	11 (20.8)	0.719
Decisions made by the patient’s acquaintances and friends	No(%)	641 (80.4)	193 (78.8)	135 (83.3)	42 (79.2)	0.719

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a Number of persons (in %), excluding missing values, compared between groups by chi-square test. When the expected frequency of 5 or less was included, Fisher’s exact test was used.

*p < .05

However, regarding the percentage by hospital type, the percentage of respondents who selected "decisions made by the attending physician" was higher in general hospitals, among the hospitals with 50–99 beds. Compared with those in other hospitals, a higher percentage of respondents in advanced treatment hospitals, among the hospitals with 400 or more beds, selected "decisions made according to manuals and guidelines," "decisions made by the medical care team," and "decisions made by the ethics committee" (Table 6).

Table 6. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.

		20–49 n = 110				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Decisions made according to manuals and guidelines	Yes(%)	12 (15.8)	9 (26.5)	-	-	0.188
Decisions made according to manuals and guidelines	No(%)	64 (84.2)	25 (73.5)	-	-	0.188
Decisions made by the medical care team	Yes(%)	17 (22.4)	12 (35.3)	-	-	0.155
Decisions made by the medical care team	No(%)	59 (77.6)	22 (64.7)	-	-	0.155
Decisions made at conferences	Yes(%)	26 (34.2)	8 (23.5)	-	-	0.263
Decisions made at conferences	No(%)	50 (65.8)	26 (76.5)	-	-	0.263
Decisions made by the ethics committee	Yes(%)	4 (5.3)	1 (2.9)	-	-	1.000
Decisions made by the ethics committee	No(%)	72 (94.7)	33 (97.1)	-	-	1.000
Decisions made by the attending physician	Yes(%)	41 (53.9)	19 (55.9)	-	-	0.851
Decisions made by the attending physician	No(%)	35 (46.1)	15 (44.1)	-	-	0.851
Decisions made by the patient’s acquaintances and friends	Yes(%)	20 (26.3)	6 (17.7)	-	-	0.323
Decisions made by the patient’s acquaintances and friends	No(%)	56 (73.7)	28 (82.3)	-	-	0.323
		50–99 n = 296				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Decisions made according to manuals and guidelines	Yes(%)	29 (21.0)	42 (26.6)	-	-	0.263
Decisions made according to manuals and guidelines	No(%)	109 (79.0)	116 (73.4)	-	-	0.263
Decisions made by the medical care team	Yes(%)	48 (34.8)	58 (36.7)	-	-	0.730
Decisions made by the medical care team	No(%)	90 (65.2)	100 (63.3)	-	-	0.730
Decisions made at conferences	Yes(%)	49 (35.5)	55 (34.8)	-	-	0.900
Decisions made at conferences	No(%)	89 (64.5)	103 (65.2)	-	-	0.900
Decisions made by the ethics committee	Yes(%)	11 (8.0)	10 (6.3)	-	-	0.583
Decisions made by the ethics committee	No(%)	127 (92.0)	148 (93.7)	-	-	0.583
Decisions made by the attending physician	Yes(%)	68 (49.3)	59 (37.3)	-	-	0.039
Decisions made by the attending physician	No(%)	70 (50.7)	99 (62.7)	-	-	0.039
Decisions made by the patient’s acquaintances and friends	Yes(%)	31 (22.5)	33 (20.9)	-	-	0.742
Decisions made by the patient’s acquaintances and friends	No(%)	107 (77.5)	125 (79.1)	-	-	0.742
		100–199 n = 455				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Decisions made according to manuals and guidelines	Yes(%)	47 (29.2)	84 (28.6)	-	-	0.889
Decisions made according to manuals and guidelines	No(%)	114 (70.8)	210 (71.4)	-	-	0.889
Decisions made by the medical care team	Yes(%)	80 (49.7)	117 (39.8)	-	-	0.042
Decisions made by the medical care team	No(%)	81 (50.3)	177 (60.2)	-	-	0.042
Decisions made at conferences	Yes(%)	68 (42.2)	107 (36.4)	-	-	0.221
Decisions made at conferences	No(%)	93 (57.8)	187 (63.6)	-	-	0.221
Decisions made by the ethics committee	Yes(%)	20 (12.4)	36 (12.2)	-	-	0.956
Decisions made by the ethics committee	No(%)	141 (87.6)	258 (87.8)	-	-	0.956
Decisions made by the attending physician	Yes(%)	65 (40.4)	114 (38.8)	-	-	0.739
Decisions made by the attending physician	No(%)	96 (59.6)	180 (61.2)	-	-	0.739
Decisions made by the patient’s acquaintances and friends	Yes(%)	28 (17.4)	58 (19.7)	-	-	0.543
Decisions made by the patient’s acquaintances and friends	No(%)	133 (82.6)	236 (80.3)	-	-	0.543
		200–399 n = 244				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Decisions made according to manuals and guidelines	Yes(%)	33 (33.0)	38 (35.5)	-	10 (27.0)	0.639
Decisions made according to manuals and guidelines	No(%)	67 (67.0)	69 (64.5)	-	27 (73.0)	0.639
Decisions made by the medical care team	Yes(%)	63 (63.0)	50 (46.7)	-	20 (54.1)	0.063
Decisions made by the medical care team	No(%)	37 (37.0)	57 (53.3)	-	17 (45.9)	0.063
Decisions made at conferences	Yes(%)	61 (61.0)	46 (43.0)	-	22 (56.5)	0.024
Decisions made at conferences	No(%)	39 (39.0)	61 (57.0)	-	15 (40.5)	0.024
Decisions made by the ethics committee	Yes(%)	35 (35.0)	19 (17.8)	-	17 (46.0)	0.001
Decisions made by the ethics committee	No(%)	65 (65.0)	88 (82.2)	-	20 (54.0)	0.001
Decisions made by the attending physician	Yes(%)	38 (38.0)	37 (34.6)	-	19 (51.4)	0.193
Decisions made by the attending physician	No(%)	62 (62.0)	70 (65.4)	-	18 (48.6)	0.193
Decisions made by the patient’s acquaintances and friends	Yes(%)	20 (20.0)	21 (19.6)	-	8 (21.6)	0.966
Decisions made by the patient’s acquaintances and friends	No(%)	80 (80.0)	86 (80.4)	-	29 (78.4)	0.966
		400+ n = 133				P*
		General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
Decisions made according to manuals and guidelines	Yes(%)	17 (38.6)	5 (27.8)	17 (70.8)	27 (57.5)	0.012
Decisions made according to manuals and guidelines	No(%)	27 (61.4)	13 (72.2)	7 (29.2)	20 (42.5)	0.012
Decisions made by the medical care team	Yes(%)	24 (54.5)	10 (55.6)	18 (75.0)	42 (91.5)	<0.001
Decisions made by the medical care team	No(%)	20 (45.5)	8 (44.5)	6 (25.0)	4 (8.5)	<0.001
Decisions made at conferences	Yes(%)	24 (54.5)	7 (38.9)	17 (70.8)	31 (66.0)	0.127
Decisions made at conferences	No(%)	20 (45.5)	11 (61.1)	7 (29.2)	16 (34.0)	0.127
Decisions made by the ethics committee	Yes(%)	16 (36.4)	6 (33.3)	15 (62.5)	28 (59.6)	0.038
Decisions made by the ethics committee	No(%)	28 (63.6)	12 (66.7)	9 (37.5)	19 (40.4)	0.038
Decisions made by the attending physician	Yes(%)	20 (45.5)	9 (50.0)	4 (16.7)	16 (34.0)	0.069
Decisions made by the attending physician	No(%)	24 (54.5)	9 (50.0)	20 (83.4)	31 (66.0)	0.069
Decisions made by the patient’s acquaintances and friends	Yes(%)	6 (13.6)	2 (11.1)	2 (8.3)	8 (17.0)	0.820
Decisions made by the patient’s acquaintances and friends	No(%)	38 (86.4)	16 (88.9)	22 (91.7)	39 (83.0)	0.820

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^a Number of persons (in %), excluding missing values, compared between groups by chi-square test. When the expected frequency of 5 or less was included, Fisher’s exact test was used.

*p < .05

Between-group comparison of the use of the guidelines

Table 7 demonstrates the level of the use of the Guidelines. Compared with those in the other areas, a higher percentage of respondents working in hospitals in the Osaka and Nagoya areas answered that they had taken action based on the Guidelines. Further, a higher percentage of respondents working in hospitals in local areas stated, "We have never responded according to the Guidelines," compared with respondents in the other areas. Compared with those in the other areas, a higher percentage of respondents working in hospitals in the Tokyo area responded that they did not know about the Guidelines.

Table 7. Use of the guidelines by region n = 1257 ^a.

	Local area	Tokyo area	Osaka area	Nagoya area	P*
We have taken action in accordance with the Guidelines.	158 (20.4)	48 (20.2)	43 (27.0)	15 (28.3)	0.028
We have never responded according to the Guidelines.	395 (50.9)	104 (43.7)	61 (38.4)	25 (47.2)
We do not know about the Guidelines.	223 (28.7)	86 (36.1)	55 (34.6)	13 (24.5)

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^a Number of persons (%), excluding missing values, compared between groups by chi-square test.

*p < .05

Regarding hospital type, among the hospitals with 100–199 beds, a higher percentage of participants working at general hospitals responded, "We have taken action in accordance with the Guidelines," compared with those working at other types of hospitals. Among the hospitals with more than 400 beds, a higher percentage of respondents working in advanced treatment hospitals stated that they had taken action in accordance with the Guidelines, compared with those in other hospitals. A higher percentage of respondents working in hospitals with long-term care beds responded "We do not know about the Guidelines," compared with respondents in other hospitals (Table 8).

Table 8. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.

	20–49 n = 110				P*
	General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
We have taken action in accordance with the Guidelines.	3 (4.2)	1 (3.0)	-	-	0.111
We have never responded according to the Guidelines.	22 (31.0)	17 (51.5)	-	-
We do not know about the Guidelines.	46 (64.8)	15 (45.5)	-	-
	50–99 n = 296				P*
	General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
We have taken action in accordance with the Guidelines.	16 (11.9)	20 (13.2)	-	-	0.707
We have never responded according to the Guidelines.	64 (47.8)	78 (51.3)	-	-
We do not know about the Guidelines.	54 (40.3)	54 (35.5)	-	-
	100–199 n = 455				P*
	General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
We have taken action in accordance with the Guidelines.	47 (29.6)	47 (16.3)	-	-	0.004
We have never responded according to the Guidelines.	77 (48.4)	160 (55.6)	-	-
We do not know about the Guidelines.	35 (22.0)	81 (28.1)	-	-
	200–399 n = 244				P*
	General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
We have taken action in accordance with the Guidelines.	29 (29.0)	29 (27.9)	-	15 (41.7)	0.241
We have never responded according to the Guidelines.	47 (47.0)	49 (47.1)	-	18 (50.0)
We do not know about the Guidelines.	24 (24.0)	26 (25.0)	-	3 (8.3)
	400+ n = 133				P*
	General hospitals	Hospitals with long-term care beds	Advanced treatment hospitals	Regional medical care support hospitals	P*
We have taken action in accordance with the Guidelines.	14 (32.5)	4 (22.2)	15 (62.5)	16 (34.0)	0.010
We have never responded according to the Guidelines.	23 (53.5)	6 (33.3)	7 (29.2)	16 (34.0)
We do not know about the Guidelines.	6 (14.0)	8 (44.4)	2 (8.3)	15 (32.0)

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^a Number of persons (%), excluding missing values, compared between groups by chi-square test.

*p < .05

Discussion

This nationwide survey of hospitals in Japan revealed the actual condition of, and difficulties associated with, the hospitalization of persons without family, the decision-making processes for their medical care, and the use of the national Guidelines. Each year, approximately 70% of the hospitals surveyed experienced the hospitalization of a person without family, and 30% of the hospitals did not. As of 2017, there were approximately 70,000 unbefriended individuals in the U.S., and this group is estimated to grow even larger in the future [33]. Similarly, with the increase in the number of single households in Japan, hospitalization of those without family is expected to increase in the future.

In cases of the hospitalization of persons without family, collecting emergency contact information, decision-making related to their medical care, and their discharge support were cited as difficult situations. Previous research in the U.S. also identified the following as difficult situations regarding unrepresented older adults: finding a person to act as their proxy, deciding on their treatment, and finding a suitable discharge location for the patient [19]; similar situations were identified in Japan. As no previous studies have compared the problems related to persons without family by region or role of hospitals, this study provides crucial evidence. Our results demonstrate that the difficulties arising from the hospitalization of persons without family varies by region and role of hospitals. In the future, it is necessary to investigate the factors contributing to this variation and consider support that can address these factors.

Our exploration of the current situation revealed that the decision-making process for medical care, when the wishes of persons without family cannot be confirmed at the point when a decision regarding their medical care is required, is often undertaken by the medical care team or conferences. However, a relatively high percentage of decisions were also made by the attending physician. As the Guidelines recommend that decisions on medical care for persons without family are made carefully within the medical care team and are based on the tenets of the "Guidelines on the Decision-Making Process for Medical Care and Care in the Final Stage of Life" [34], we believe that the Guideline approach is spreading throughout Japan. Additionally, for situations in which urgent life-saving measures are required and it is difficult to allocate time for discussion, medical treatment is based on the judgment of the physician; thus, it is possible that a high percentage of the decision-making processes for the medical treatment of persons without family also involved decisions made by an attending physician. Prior studies have also reported that the medical decision-making process for persons without family varies depending on the urgency of their medical conditions [1, 3, 32]. In Japan, the medical decision-making process for persons without family was also found to be diverse. Still, this study did not qualitatively analyze the medical decision-making process, albeit qualitative data could have provided key insights to the findings and discussions. Future studies should examine the appropriateness of ethical considerations by qualitatively analyzing who was involved in the decision, the factors involved, who made the final decision, and so forth.

When the wishes of persons without family could not be confirmed at the point when a decision regarding their medical care was required, the decision-making process for medical care was found to vary by hospital type. The advanced treatment hospitals that had an operational structure in place would tend to use ethics committees. Hospital function evaluations also require that such hospitals have an in-house committee for clinical ethics and consider and respond ethically to individual cases [35]. One of the key terms in clinical ethics consultation cases is "handling patients without family" [36]. To solve the problems related to the hospitalization of persons without family, the further spread of clinical ethics consultation activities within hospitals is desirable. However, it is difficult to secure human resources for such activities; therefore, measures to make clinical ethics consultation a sustainable activity are recommended [37].

The use of the Guidelines was found to be low in local areas and in hospitals with long-term care beds. Based on the results of our survey, it is possible that local areas and hospitals with long-term care beds are less likely to use the Guidelines because of the small number of admissions of persons without family. The number of nearby family members and neighbors decreases in urban areas [38]; therefore, hospitalization of people without family may be less common in local areas than it is in urban areas, because of the support provided by the local population. The American Geriatrics Society recommends that a nationally uniform approach to unbefriended patients be considered for the provision of equitable health care [13]. In Japan, it is hoped that the Guidelines will be further disseminated to ensure fairness in medical care. Future research should identify medical needs for persons without family.

While we sent reminder letters in an attempt to receive responses from slow or non-responders, one limitation of this study is its low response rate (30.1%), which may be due to a selection bias in which only hospitals that are actively engaged in the hospitalization of persons without family responded to the survey. Therefore, it is possible that there is an overestimation of the percentage of hospitals that are aware of the Guidelines and the nature of their efforts to hospitalize persons without family. In addition, the survey may not represent actual family relationships because the respondents were not the patients themselves. Future research should clarify the medical needs of persons without family and the criteria for the medical decision-making process, and establish a system that can provide the best medical care for such patients. Significant differences were found between the responses of nurses and medical social workers (S4 and S5 Tables). However, no systematic differences were found in response rates or missing values by region (S7–S9 Tables). It is possible that differences in responses occurred because the amount of information and recall varied depending on the respondent’s job title. These limitations make it difficult to generalize the results.

Conclusion

Of the 4,000 hospitals included in this study, approximately 70% experienced the admission of persons without family, and 30% of the hospitals did not. The difficulties arising from the hospitalization of persons without family included gathering emergency contact information, decision-making related to medical care, and discharge support. When the wishes of persons without family could not be confirmed at the point when a decision regarding their medical care was required, the most common process was for the medical care team to make decisions. Most of the hospitals had never used the government-recommended Guidelines. Furthermore, difficulties arising in the hospitalization of persons without family and the use of the Guidelines differed significantly by region and hospital type. Significant differences were found in the decision-making processes for medical care when the wishes of persons without family could not be confirmed at the point when a decision regarding their medical care was required by hospital type. Based on our results, it is recommended that awareness regarding the Guidelines and clinical ethics consultation activities should be spread within hospitals to address the difficulties encountered during hospitalization of persons without family. Moreover, effective interventions should be undertaken to secure human resources for such activities and make them mainstream in medical care for persons without family.

This study’s strength is its nationwide examination of the actual conditions and difficulties related to the hospitalization of persons without family in Japan, the medical decision-making process, and the use of the Guidelines. In addition, comparisons were made by region and role of hospitals in Japan. Since no previous studies have focused on the nationwide hospitalization of persons without family in Japan, it is hoped that the results of this study will help create a system in which everyone can receive appropriate medical care, regardless of the presence of family.

Supporting information

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

Click here for additional data file.^{(33.5KB, docx)}

S1 Questionnaire

(DOCX)

Click here for additional data file.^{(29.4KB, docx)}

S1 Table. Region and hospital type.

(DOCX)

Click here for additional data file.^{(11.6KB, docx)}

S2 Table. Hospital type and number of beds.

(DOCX)

Click here for additional data file.^{(11.4KB, docx)}

S3 Table. Number of beds and region.

(DOCX)

Click here for additional data file.^{(11.6KB, docx)}

S4 Table. Comparison between nurses’ and medical social workers’ responses.

(DOCX)

Click here for additional data file.^{(21.7KB, docx)}

S5 Table. Comparison between the number of hospitalizations of persons without family reported by nurses and medical social workers (approximate number per year).

(DOCX)

Click here for additional data file.^{(12.5KB, docx)}

S6 Table. Number of hospitalizations of persons without family excluding outliers >200 (approximate number per year).

(DOCX)

Click here for additional data file.^{(17.7KB, docx)}

S7 Table. Comparison of response rates by region.

(DOCX)

Click here for additional data file.^{(14.2KB, docx)}

S8 Table. Comparison of missing values by region.

(DOCX)

Click here for additional data file.^{(15.6KB, docx)}

S9 Table. Comparison of missing values by hospital type.

(DOCX)

Click here for additional data file.^{(15.2KB, docx)}

Acknowledgments

We express our gratitude to all study participants and co-operators. We thank Editage for English editing a draft of this manuscript.

Data Availability

Relevant data to this paper are publicly available in the Zenodo repository (https://doi.org/10.5281/zenodo.7966406).

Funding Statement

This study was supported by Health Science and Labor Research Grants, Japan [(Project Number 201A1013, https://mhlw-grants.niph.go.jp/project/ 148967) to ZY] and JSPS KAKENHI [(Grand number 21K02056, https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-21K02056/) to SY]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0276090.r001

Decision Letter 0

Federica Canzan

28 Mar 2023

PONE-D-22-25512Current situation of the hospitalization of persons without family in Japan and related medical challengesPLOS ONE

Dear Dr. Yamazaki,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewer #1: Yes

Reviewer #2: Partly

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: The authors reported the current situation of the hospitalization of persons without family. The manuscript is well-written and informative for readers. There is a minor concern to accept this article.

1. There may be the response biases by the job of the responders. Did the result differ depending on the responder’s job?

Reviewer #2: In this study, Yamazaki et al. describe the results of a survey that was administered to hospitals in Japan to collect information about their policies with regard to patients who do not have family members, as well as the frequency with which they encounter such patients.

Major concerns:

1. As the authors note, the response rate was quite low, and the results are puzzling, in a way that makes me concerned about the survey instrument or survey administration. For example, is it really true that 319 hospitals cared for zero patients without family in an entire calendar year? (Given data from the U.S. that such persons represent 16% of all ICU patients, which the authors cite, this seems highly unlikely.) The maximum value (2000) also seems improbable. Do we have any idea where the respondent would have come up with these numbers? At our institution, no one tracks the number of admissions of patients like this, so anyone answering such a survey would be making an educated guess. It might potentially be informative to see whether there are systematic differences in surveys completed by a nurse manager (vs. a social worker), but I do not know that this will address the underlying issue.

2. The authors state that 70% of hospitals had allowed a hospitalization of a person without family (eg., ll. 37-38), presumably because of the 319 hospitals that reported zero such admissions. I would be careful here and would consider re-wording this, especially in light of the authors’ observation (ll. 87-88) that persons in Japan have been denied hospitalization if they do not have family. The fact that many hospitals reported zero hospitalizations does not, itself, imply that such hospitalizations are not allowed — just that they did not occur.

3. Were any analyses done to look at patterns of survey nonresponse? Since the authors wish to draw conclusions about differences among hospitals of different sizes/ types, it is important to know whether there were systematic differences in response rates in these groups.

4. It would be helpful for the authors to be more explicit about what the government guidelines recommend for such patients, which is never stated. I was also unsure about the distinctions between other approaches to decision-making (e.g., what is the difference between decisions made by the attending physician and decisions made by the medical team? what about decisions made at conferences? when decisions are made according to manuals/ guidelines, who is actually making them?).

Minor:

The manuscript would be improved, in several places, by further attention to the language, including:

1. The sentence at ll. 70-72 is not clear.

2. I am not sure that “function” is the correct word here.

**********

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Reviewer #2: No

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PLoS One. 2023 Jun 2;18(6):e0276090. doi: 10.1371/journal.pone.0276090.r002

Author response to Decision Letter 0

27 Apr 2023

April 26, 2023

Emily Chenette

Editor-in-Chief

PLOS ONE

Re: Manuscript ID: PONE-D-22-25512

Dear Emily Chenette,

Thank you for your email and review of the manuscript [PONE-D-22-25512]. We thank you and the reviewers for providing constructive comments regarding the improvement of the original manuscript.

Here, we are including a Word file of our revised manuscript. All changes have been made in response to the reviewer's suggestions, and itemized responses to the reviewer's comments are also provided below.

We believe that we have addressed the reviewers’ comments and hope that the revised manuscript is now acceptable for publication in the PLOS ONE. Thank you for your generous consideration. Grammatical corrections have been made under the guidance of an English editing specialist, but the content remains unchanged.

We have addressed the editorial points as follows.

Journal Requirements:

1. [ Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.]

Response:

Thank you for your suggestion. Data were prepared using PLOS ONE style requirements.

２．[Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Response:

Thank you for your suggestion. We have added a note about informed consent to the Materials and Methods section.

Lines 149–151: All participants provided written informed consent prior to participation. By returning the questionnaire, participants indicated their consent.

3. [Thank you for stating in your Funding Statement:

“This study was supported by Health Science and Labor Research Grants, Japan (Project Number 201A1013) and JSPS KAKENHI Grand number 21K02056.”

Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.]

Response:

Thank you for your suggestion.

We have modified our Funding Statement as follows, which we have also included in our cover letter.

“This study was supported by Health Science and Labor Research Grants, Japan [(Project Number 201A1013, https://mhlw-grants.niph.go.jp/project/148967) to ZY] and JSPS KAKENHI [(Grand number 21K02056, https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-21K02056/) to SY]. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.”

We would appreciate it if you could correct the information in the online submission system.

4. [Thank you for stating the following in the Acknowledgments Section of your manuscript:

“This study was supported by Health Science and Labor Research Grants, Japan (Project Number 201A1013) and JSPS KAKENHI Grand number 21K02056.”

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This study was supported by Health Science and Labor Research Grants, Japan (Project Number 201A1013) and JSPS KAKENHI Grand number 21K02056.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.]

Response:

Thank you for your suggestion. We removed our Funding Statement from the manuscript. The Acknowledgements have been revised. Lines 389–391.

The funding statement will be updated to

“This study was supported by Health Science and Labor Research Grants, Japan [(Project Number 201A1013, https://mhlw-grants.niph.go.jp/project/148967) to ZY] and JSPS KAKENHI [(Grand number 21K02056, https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-21K02056/ to SY). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.]”

We would appreciate it if you could update our information in the online submission system.

Reviewers' comments:

1. [There may be the response biases by the job of the responders. Did the result differ depending on the responder’s job?]

Response:

Thank you for your suggestion.

We have added material comparing between the responses of nurses and medical social workers. (S5 and S6 Tables)

Significant differences were found in reporting hospital affiliation, number of inpatients, and use of guidelines. It is possible that nurses and medical social workers may differ in the amount of information and the situations they recall. A discussion of this analysis was added to the study limitations. Lines 356–361.

Major concerns:

1. [As the authors note, the response rate was quite low, and the results are puzzling, in a way that makes me concerned about the survey instrument or survey administration. For example, is it really true that 319 hospitals cared for zero patients without family in an entire calendar year? (Given data from the U.S. that such persons represent 16% of all ICU patients, which the authors cite, this seems highly unlikely.) The maximum value (2000) also seems improbable. Do we have any idea where the respondent would have come up with these numbers? At our institution, no one tracks the number of admissions of patients like this, so anyone answering such a survey would be making an educated guess. It might potentially be informative to see whether there are systematic differences in surveys completed by a nurse manager (vs. a social worker), but I do not know that this will address the underlying issue.]

Response:

Thank you for your suggestion. We will explain each of these questions.

1. Explanation of our response rate

[the response rate was quite low, and the results are puzzling]

Response:

The response rate of a previous study by Farrell et al [Reference 21]. of physicians, nurses, and social workers who are members of the American Geriatrics Society (AGS), which had a relatively similar study design to our study, was 2.7%. We believe that the response rate of the present study is also acceptable for analysis; however, we consider that it makes it difficult to generalize the results. We mentioned this in the limitations of the study. Lines 359–361.

2. Whether the value is true

[For example, is it really true that 319 hospitals cared for zero patients without family in an entire calendar year? Given data from the U.S. that such persons represent 16% of all ICU patients, which the authors cite, this seems highly unlikely.]

Response:

First, I would like to thank you for the very important points you have made.

After you pointed this out to us, we double-checked Reference 22 and realized that our description was incorrect. The values were corrected as follows. Line 69.

Line Before revision After revision

69–70 the unbefriended status accounts for 16% of intensive care unit patients the unbefriended status accounts for 5.5% deaths among intensive care unit patients

Your point was absolutely correct. We apologize for the incorrect statement.

3. Explanation of the maximum value 2000

[The maximum value (2000) also seems improbable. Do we have any idea where the respondent would have come up with these numbers?]

Response:

From what we heard informally in the course of our research on people without family, there are hospitals in Japan that are actively accepting people without family. Furthermore, one of the reasons for actively accepting people without family is to obtain medical reimbursement. Thus, we considered that a maximum value of 2000 was also possible. However, as the above information was obtained informally, it could not be included in our paper.

The purpose of this study was to quantify the reality of hospitalization of people without family. We believe that the figures we obtained need to be analyzed qualitatively in future studies.

As a sensitivity analysis, we added a table (S7 Table) that excludes outliers of 200 or more (n=6) as calculated by Smirnov-Grubbs test.

4. Explanation of limitation of our study

[anyone answering such a survey would be making an educated guess.]

Response:

This type of study is an empirical investigation, and it may be subject to selection bias and recall bias.

A previous study by the pioneering Farrell et al. (reference 21) also pointed out similar concerns as a limitation. We believe that the numbers obtained need to be interpreted based on possible selection and recall biases. We have noted this in the limitations of the study. Lines 364–369.

[It might potentially be informative to see whether there are systematic differences in surveys completed by a nurse manager (vs. a social worker)]

Response:

Tables comparing responses by the director of nursing and medical social worker have been added as supplemental material (S5 and S6 Tables). Significant differences were found in reporting hospital affiliation, number of inpatients, and use of guidelines. It is possible that nursing managers and medical social workers may differ in the amount of information and the situations they recall. A discussion of this analysis was added to the study limitations. Lines 347–361.

2. [The authors state that 70% of hospitals had allowed a hospitalization of a person without family (eg., ll. 37-38), presumably because of the 319 hospitals that reported zero such admissions. I would be careful here and would consider re-wording this, especially in light of the authors’ observation (ll. 87-88) that persons in Japan have been denied hospitalization if they do not have family. The fact that many hospitals reported zero hospitalizations does not, itself, imply that such hospitalizations are not allowed — just that they did not occur.]

Response:

Thank you for your suggestion. We believe you are correct and have revised the wording.

Line Before revision After revision

37–39 Approximately 70% of the target hospitals had allowed the hospitalization of a person without family. Approximately 70% of the target hospitals had experienced the hospitalization of a person without family, and 30% of the hospitals did not.

288–290 Approximately 70% of the hospitals surveyed allowed the hospitalization of a person without family each year. Each year, approximately 70% of the hospitals surveyed experienced the hospitalization of a person without family, and 30% of the hospitals did not.

364–365 approximately 70% allowed the admission of persons without family approximately 70% experienced the admission of persons without family, and 30% of the hospitals did not.

3. [Were any analyses done to look at patterns of survey nonresponse? Since the authors wish to draw conclusions about differences among hospitals of different sizes/ types, it is important to know whether there were systematic differences in response rates in these groups.]

Response:

Thank you for your suggestion.

Since there was no information on the type of hospital to send the survey, and it was ascertained from the returned responses, it was not possible to compare the collection rate for each type of hospital. Selection bias was eliminated by random sampling.

A supplemental document was prepared to compare collection rates by hospital region (S8 Table).

In addition, comparisons of the percentage of non-responses per question by region and hospital type were made, but no systematic differences were found (S9 and S10 tables). Lines 357–359.

4. [It would be helpful for the authors to be more explicit about what the government guidelines recommend for such patients, which is never stated.]

Response:

Thank you for your suggestion. In the Introduction, we mentioned the content of the guidelines. Lines 92–95.

[I was also unsure about the distinctions between other approaches to decision-making (e.g., what is the difference between decisions made by the attending physician and decisions made by the medical team? what about decisions made at conferences? when decisions are made according to manuals/ guidelines, who is actually making them?).]

Response:

Thank you for your questions.

The guidelines recommend decision-making by the patient and the multidisciplinary care team. However, several approaches are currently used for decision-making regarding medical care for people without family, including decisions by physicians [1] or ethics committees. Nonetheless, all of these approaches have limitations, and consensus has not yet been reached [2]. Therefore, in this study, several possible approaches were presented in the form of a questionnaire, and surveyed in order to understand the current state of the decision-making process regarding medical care for people without relatives in Japan.

Decision-making by the attending physician indicates that the attending physician makes decisions alone. Decision-making by the medical team indicates that the decision is made by a multidisciplinary team, including physicians, nurses, and medical social workers. Conferences include events that do not include multiple professions. The detailed decision-making process according to manuals and guidelines needs to be analyzed qualitatively in future studies.

The limitations of the study mention the need for an in-depth study of the medical decision-making process. Lines 320–324.

References

1. Courtwright A, Rubin E. Who should Decide for the Unrepresented?　Bioethics. 2016 ;30(3):173-80. doi: 10.1111/bioe.12185.

2. Weiss BD, Berman EA, Howe CL, Fleming RB. Medical decision-making for older adults without family. J Am Geriatr Soc. 2012;60(11):2144-50. doi:10.1111/j.1532-5415.2012.04212.x.

Minor:

The manuscript would be improved, in several places, by further attention to the language, including:

1. The sentence at ll. 70-72 is not clear.

Response:

Thank you for your suggestion.

The following modifications have been made.

[In the U.S., adults without surrogates are typically white, male, 65 years or older, have nuclear family, and are not socially disconnected.] Lines 70–72.

2. I am not sure that “function” is the correct word here.

Response:

Thank you for your suggestion.

“Function" has been corrected to "role."

“Special functioning hospitals” has been corrected to "Advanced treatment hospitals."

Attachment

Submitted filename: Response_to_Reviewers.docx

Click here for additional data file.^{(28.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0276090.r003

Decision Letter 1

Federica Canzan

22 May 2023

Current situation of the hospitalization of persons without family in Japan and related medical challenges

PONE-D-22-25512R1

Dear Dr. Yamazaki,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Federica Canzan

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Reviewer #1: The manuscript was appropriately revised for the reviewer's question. I have no additional comment regarding this manuscript.

Reviewer #2: The authors have substantially improved the manuscript and have addressed the majority of the comments from the prior review. I have one remaining suggestion: information about the differences in responses between nurses and social workers does not appear until the second-to-last paragraph of the Discussion. This should at least be reported in the Results.

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PLoS One. doi: 10.1371/journal.pone.0276090.r004

Acceptance letter

Federica Canzan

24 May 2023

PONE-D-22-25512R1

Current situation of the hospitalization of persons without family in Japan and related medical challenges

Dear Dr. Yamazaki:

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

Click here for additional data file.^{(33.5KB, docx)}

S1 Questionnaire

(DOCX)

Click here for additional data file.^{(29.4KB, docx)}

S1 Table. Region and hospital type.

(DOCX)

Click here for additional data file.^{(11.6KB, docx)}

S2 Table. Hospital type and number of beds.

(DOCX)

Click here for additional data file.^{(11.4KB, docx)}

S3 Table. Number of beds and region.

(DOCX)

Click here for additional data file.^{(11.6KB, docx)}

S4 Table. Comparison between nurses’ and medical social workers’ responses.

(DOCX)

Click here for additional data file.^{(21.7KB, docx)}

S5 Table. Comparison between the number of hospitalizations of persons without family reported by nurses and medical social workers (approximate number per year).

(DOCX)

Click here for additional data file.^{(12.5KB, docx)}

S6 Table. Number of hospitalizations of persons without family excluding outliers >200 (approximate number per year).

(DOCX)

Click here for additional data file.^{(17.7KB, docx)}

S7 Table. Comparison of response rates by region.

(DOCX)

Click here for additional data file.^{(14.2KB, docx)}

S8 Table. Comparison of missing values by region.

(DOCX)

Click here for additional data file.^{(15.6KB, docx)}

S9 Table. Comparison of missing values by hospital type.

(DOCX)

Click here for additional data file.^{(15.2KB, docx)}

Attachment

Submitted filename: Response_to_Reviewers.docx

Click here for additional data file.^{(28.5KB, docx)}

Data Availability Statement

Relevant data to this paper are publicly available in the Zenodo repository (https://doi.org/10.5281/zenodo.7966406).

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PERMALINK

Current situation of the hospitalization of persons without family in Japan and related medical challenges

Sayaka Yamazaki

Nanako Tamiya

Kaori Muto

Yuki Hashimoto

Zentaro Yamagata

Roles

Abstract

Introduction

Materials and methods

Results

Characteristics of hospitals that responded to the survey

Table 1. Characteristics of hospitals that responded to the survey N = 1271.

Table 2. Number of hospitalizations of persons without family (approximate number per year) N = 952.

Between-group comparison of difficult situations to deal with in the hospitalization of persons without family

Table 3. Difficult situations during the hospitalization of persons without family (multiple responses) by region n = 1257 a.

Table 4. Difficult situations during the hospitalization of persons without family (multiple responses) by hospital type and number of beds n = 1242 a.

Between-group comparison of decision-making processes for medical care of persons without family

Table 5. Decision-making process for medical care for persons without family (multiple responses) by region n = 1257 a.

Table 6. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 a.

Between-group comparison of the use of the guidelines

Table 7. Use of the guidelines by region n = 1257 a.

Table 8. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 a.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Federica Canzan

Roles

Author response to Decision Letter 0

Decision Letter 1

Federica Canzan

Roles

Acceptance letter

Federica Canzan

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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Cited by other articles

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Table 3. Difficult situations during the hospitalization of persons without family (multiple responses) by region n = 1257 ^a.

Table 4. Difficult situations during the hospitalization of persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.

Table 5. Decision-making process for medical care for persons without family (multiple responses) by region n = 1257 ^a.

Table 6. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.

Table 7. Use of the guidelines by region n = 1257 ^a.

Table 8. Decision-making process for medical care for persons without family (multiple responses) by hospital type and number of beds n = 1242 ^a.