COVID-19 Vaccination Decision-Making for Residents With Dementia in Japanese Long-Term Care Facilities: A National Cross-Sectional Survey.

Background: COVID-19 vaccination is critical for residents of long-term care facilities (LTCFs), yet Japan's requirement for individual written consent creates dilemmas for residents with dementia who lack capacity. We examined consent practices and expected ethical support in Japanese LTCFs. Methods: In August 2021, immediately after the priority vaccination for the elderly ended in July, a questionnaire was mailed to the directors of 4381 LTCFs nationwide. Results: Valid responses were obtained from 495 facilities, and 24.0% of the respondents reported full vaccination coverage. The leading reason for non-vaccination was lack of family consent (50.9%), which surpassed resident refusal (8.1%). When resident consent could not be confirmed but a reachable family member existed, 98.3% were vaccinated based on family consent. When neither resident consent nor a contactable family member was available, 73.5% of residents were vaccinated based on an assessment of their best interests. Ethical issues were mainly handled via multidisciplinary conferences (73.1%) or managerial decisions (e.g., director judgment; 41.8%). For future support, facilities expected guidance from the local government or public health centers (53.3%) and LTCF associations (36.8%), followed by in-house ethics committees or consultation teams (36.0%). Conclusion: Despite regulations requiring individual consent, many facilities proceeded with vaccination based on family consent or staff judgment. To ensure vaccinations are conducted in accordance with both the substituted judgment standard and the best interest standard, current regulations governing vaccination should be revised. Furthermore, external entities, especially local governments and sector associations, are expected to play key roles in supporting ethical decision-making in LTCFs.