INVITED NOTE
Nagoya J. Med. Sci. 83. 669–671, 2021
doi:10.18999/nagjms.83.4.669

Reconsideration of medical treatment and care for older
adultsToshihiko Wakabayashi
Nagoya University Graduate School of Medicine
Nagoya Garden Clinic
Focused Ultrasound Therapy Center, Kaikoukai Healthcare Corporation Nagoya Kyoritsu Hospital
Preventive Medicine and Law Section of the Tomei Senior Life Support Center Co. Ltd.

ABSTRACTThe advance care directive is a device for deciding one’s own end-of-life care by giving directions onterminal care in advance. A family discussion in the field about these documents is essential to decide
the best management measures.
Keywords: ACD, ACP, elderly, medical care, active euthanasia
Abbreviations:
ACD: advance care directive
ACP: advance care planning
ALS: amyotrophic lateral sclerosis
MHLW: Ministry of Health, Labour and WelfareThis is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

MAIN TEXT
Supported by a universal health insurance system, Japan has established a healthcare system
where all citizens can equally receive the world’s highest level of medical services. For thisreason, medical staffs strive to provide life-prolonging treatments universally as much as possible
regardless of patients’ backgrounds and situations. However, whether they provide the medicaltreatment that the patient wishes to receive remains to be clarified.1
Recently, a shocking report was released about a patient with amyotrophic lateral sclerosis
who had been receiving life-prolonging treatment with a ventilator connected to the tracheostomytube because she was awake and alert but could not move her limbs or breathe independently.
However, about her current situation, the patient expressed that “It wasn’t supposed to be likethis” but ended up in that situation before she finally hoped for “active euthanasia.” She had
continuous talks about her future progress and treatment for her disease with the chief physician
and seemed to have finally decided her treatment at an early stage of the disease. Of course,Received: January 5, 2021; accepted: April 30, 2021
Corresponding Author: Toshihiko Wakabayashi, MD, PhD
AEON Mall, Nagoya Noritake Garden, 3F, 3-1-17, Noritake-shinmachi, Nishi-ku, Nagoya 451-0051, Japan
Tel: +81-52-938-5600, Fax: +81-52-938-5601, E-mail: wakaba@garden-cl.jp
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Toshihiko Wakabayashi

it was clearly explained to her beforehand that “active euthanasia” was not accepted legally inthe country. However, as a result, she was puzzled over her current situation, because it wasunlike the condition that she imagined in the early stage of the disease. She wished for activeeuthanasia because she felt that her “reality was not accepted.” It was in a situation that she
could not declare her intentions by herself, and the remark to relieve herself of her suffering
moved many Japanese to tears.
Japan has not established a legal system to support informed consent in a terminal caresettings, which sometimes causes confusions like that of the patient. When recovery from anillness is no longer possible, “death with dignity” becomes an option, in which the dying person’sintention is to have a natural death without receiving further life support. An increasing numberof patients who opt for this end-of-life decision in a way that their families can understand are
gradually increasing even in Japan. This is a totally different situation from euthanasia.
Each patient has different wishes for the kind of medical treatment they want to receive at theend-of-life. Desires and responses to life-prolonging treatments are also different. Data from theMinistry of Health, Labour and Welfare (MHLW) show that approximately 70% of the patientsare unable to decide or express their preferred medical treatment and care in life-threatening
situations.
In May 2007, the MHLW released the “Guidelines on the decision-making process for end-oflife care.” It stated that patients’ wishes should be respected and that crucial decisions should bemade by medical treatment and care teams. However, the guidelines do not mention the immunity
requirements for discontinuing life-prolonging treatment once started.2 This means that the patientmust plan carefully in advance, because the treatment could not be regressed once given.
When one faces end-of-life, it is often unpredictable. No one can predict when a stroke,
myocardial infarction, or dementia will occur. Some have offered the opinion that terminal care
wishes should be discussed with family and close friends on a regular basis and that a third
party should be informed about these wishes beforehand. However, unlike some Western countries,
Japan’s legal system lags behind in this regard.3
Accordingly, in recent years, in Japan, advance care planning (ACP), or life meeting withfamily and care managers has been recommended, where terminal care wishes can be discussed
in advance.4 An advanced care directive (ACD) is also helpful, as it allows patients’ wishes tobe respected when the need arises in a terminal care setting by documenting their end-of-lifecare preferences and preparing a notarial deed beforehand.5
The ACD is the only device for deciding end-of-life care by giving directions on terminal
care in advance in case one becomes unable to communicate these wishes in the future. Priorarrangements are important for smooth implementation when the need arises by designatinga medical proxy who should be informed in case of an emergency. One must have a family
discussion with experts in the field about these documents and should be informed of the best
management measures.6
Individuals are urged to consider these major decisions ahead of time before it is too late.

DISCLOSURE STATEMENT
The author has no conflicts of interest related to this study.

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Reconsideration of elderly medical care

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Appendix 1: Contents of the advance care planning
An advance care planning (ACP) is a process that enables individuals to make plans about
their future healthcare. It is applicable to adults at all stages of life. Participation in ACP has
been shown to reduce stress and anxiety for both patients and their families, and leads toimprovements in end-of-life care. The components of ACP include: 1) a substitute decision makerand 2) an advance care directive.

Appendix 2: Contents of the advance care directive
An advance care directive (ACD) informs medical doctors on the type of care patients prefer
if they are unable to make medical decisions and/or speak for themselves in the following
scenarios: 1) serious accident, 2) severe and terminal illness, 3) coma, and 4) severe confusion
or late stages of dementia. Forms are available for individuals to fill out and inform physicians
about their end-of-life care preferences, such as 1) a healthcare power of attorney (POA), 2)
living will, and 3) “Do not resuscitate” order. One can change the ACDs at any time but mustensure that the substitute decision maker receives a copy of the revised ACD. However, ACDs
are not legally recognized in Japan. According to a 2017 survey by the Ministry of Health, Laborand Welfare, 66% of surveyed individuals supported the idea of ACD but only approximately
8% had an ACD prepared previously.