Variation in decision-making about end-of-life care among ethnic groups creates clinical conflicts. In order to understand changes in preferences for end-of-life care among Japanese who immigrate to the United States, we conducted 18 focus groups with 122 participants: 65 English-speaking Japanese Americans, 29 Japanese-speaking Japanese Americans and 28 Japanese living in Japan. Negative feelings toward living in adverse health states and receiving life-sustaining treatment in such states permeated all three groups. Fear of being meiwaku, a physical, psychological or financial caregiving burden on loved ones, was a prominent concern. They preferred to die pokkuri (popping off) before they become end stage or physically frail. All groups preferred group-oriented decision-making with family. Although advance directives were generally accepted, Japanese participants saw written directives as intrusive whereas Japanese Americans viewed them mainly as tools to reduce conflict created by dying person's wishes and a family's kazoku no jo--responsibility to sustain the dying patient. These findings suggest that in the United States Japanese cultural values concerning end-of-life care and decision-making process are largely preserved.

OBJECTIVE: Cross-cultural ethical conflicts are common. However, little is known about how and to what extent acculturation changes attitudes toward end-of-life care and advance care planning. We compared attitudes toward endof-life care among Japanese Americans and Japanese in Japan.DESIGN: Self-administered questionnaire in English and Japanese.

The purpose of this investigation was to initiate the study of dental fear in Japan. 415 college students, aged 18-22 yr were surveyed. A standardized questionnaire which has been used in the United States was translated into Japanese and was administered to the students. More than 80% of those surveyed reported some dental fear. Six to 14% of the students reported extreme fear of the dentist. The majority of the subjects admitted that they delayed making dental appointments due to fear. Muscle tension was the most common physiological symptom reported. The dental drill and needle were the most fear-provoking stimuli.

PURPOSE Trust is a cornerstone of the physician-patient relationship. We investigated the relation of patient characteristics, religiosity, acculturation, physician ethnicity, and insurance-mandated physician change to levels of trust in Japanese American and Japanese patients.METHODS A self-administered, cross-sectional questionnaire in English and Japanese (completed in the language of their choice) was given to community-based samples of 539 English-speaking Japanese Americans, 340 Japanese-speaking Japanese Americans, and 304 Japanese living in Japan.RESULTS Eighty-seven percent of English-speaking Japanese Americans, 93% of Japanese-speaking Japanese Americans, and 58% of Japanese living in Japan responded to trust items and reported mean trust scores of 83, 80, and 68, respectively, on a scale ranging from 0 to 100. In multivariate analyses, Englishspeaking and Japanese-speaking Japanese American respondents reported more trust than Japanese respondents living in Japan (P values <.001). Greater religiosity (P <.001), less desire for autonomy (P <.001), and physician-patient relationships of longer duration (P <.001) were related to increased trust. Among Japanese Americans, more acculturated respondents reported more trust (P <.001), and Japanese physicians were trusted more than physicians of another ethnicity. Among respondents prompted to change physicians because of insurance coverage, the 48% who did not want to switch reported less trust in their current physician than in their former physician (mean score of 82 vs 89, P <.001).CONCLUSIONS Religiosity, autonomy preference, and acculturation were strongly related to trust in one's physician among the Japanese American and Japanese samples studied and may provide avenues to enhance the physician-patient relationship. The strong relationship of trust with patient-physician ethnic match and the loss of trust when patients, in retrospect, report leaving a preferred physician suggest unintended consequences to patients not able to continue with their preferred physicians. INTRODUCTIONT rust between a patient and physician is a cornerstone of the patientphysician relationship.1,2 Trust can facilitate health information exchange, 3 as well as determine a patient' s willingness to seek care, 3,4 receptivity to health promotion counseling, 5-7 openness to examination and treatment, 4,5,[7][8][9][10][11] and likelihood of return for follow-up care. 5,10 Patients with more trust in their physician are likely to be more satisfi ed with care 5,[11][12][13][14] and to have positive clinical outcomes. 5,9,11 In recent years, patient trust has been challenged by perceived confl icts of interest inherent in managed Derjung M. Tarn, MD, MS 1 Lisa S. Meredith, PhD 2 Marjorie Kagawa-Singer, RN, PhD 3 Shinji Matsumura, MD, MSHS 4 Seiji Bito, MD, MSHS 5 Robert K. Oye, MD 6 Honghu Liu, PhD 6 Katherine L. Kahn, MD 6 Shunichi Fukuhara, MD 7 Neil S. Wenger, MD, MPH 8,[15][16][17][18][19][20] and by societal changes lea...