Yet the Japanese residents were more apt to express doubts about their approach compared with U.S. residents. According to the researchers, only 12 percent of the Japanese doctors reported being "completely certain" that their approach was the best. By contrast, 49 percent of U.S. medical residents said they were completely certain. This finding may be explained by the fact that Japanese attitudes toward end of life care have been in a state of transition in the past two decades. Changes in family structure as a result of urbanization may be responsible for the change as well as increasing media coverage. Palliative care is also expanding in Japan. Although in 1990 there were only three specialized wards for palliative care in Japan, by 2002, there were 89 such wards.

Though the researchers did not delve into the reasons for the differences in approaches, several explanations have been hypothesized from previous studies. One cause for that divergence may stem from the types of cancers that are prevalent in each country. One of the most common cancers in Japan is gastric cancer, which has a high mortality rate. Given this poor prognosis, many Japanese health professionals have felt patients will become depressed or give up home. Another reason stems from the long tradition of family decision making in Japan. Frequently, a family caregiver is informed by the physician of a patient's cancer diagnosis, treatment plan, and prognosis before the patient is told the truth. After di
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