Physicians' viewpoints on initiating invasive mechanical ventilation in older persons: A Q methodology study in Japan

Initiating life-supporting invasive mechanical ventilation (IMV) is a complex yet crucial decision, characterised by prognostic uncertainty and a wide range of outcomes, with profound consequences for patients, families, and healthcare systems. Older persons are at increased risk of poor outcomes. In Japan, IMV use is relatively intense in older persons. Moreover, in contrast to other countries, IMV initiation is often considered irreversible. IMV initiation in such a context is crucial, yet understudied. We used Q methodology, a hybrid quantitative and qualitative technique, to explore viewpoints on initiating IMV in older persons among Japanese physicians. A purposive sample of 42 physicians ranked 39 opinion statements on a quasi-normally distributed grid. The statements ranged from patient to societal level considerations, and participants explained their rankings in interviews. By-person factor analysis identified shared ranking patterns, interpreted as distinct viewpoints and supported by interview data. An additional question addressed ways to improve decision making. Three distinct viewpoints were identified. While the patient's expressed or inferred wishes were prioritised in all three, differences emerged in how these were weighed against family preferences and physicians' clinical judgment. This may give rise to dilemmas when preferences diverge, as current regulatory frameworks and guidelines leave room for interpretation. To improve decision making, respondents pointed to clearer guidelines enabling reassessment and reconsideration. Greater clarity and guidance may support these deliberations and promote greater consistency, particularly regarding the role of the family, requests for potentially low-value treatment, and the use of time-limited trials before definitive decisions.