Age and Ageing 2022; 51: 1–9
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RESEARCH PAPER

Family social support and stability of preferences
regarding place of death among older people: a3-year longitudinal study from the Japan
Gerontological Evaluation Study
Kenjiro Kawaguchi1 , Kazushige Ide1 , Katsunori Kondo1,2
1

Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba 260-8670,
Japan
2
Department of Geriatric Evaluation, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology,
Obu 474-8511, Japan
Address correspondence to: Kenjiro Kawaguchi. Email: kkawaguchi0413@gmail.com

Abstract
Background: it remains unclear how family relationships could aﬀect stability of end-of-life care preferences.
Objective: to describe change patterns of preferred place of death (POD) among older people and to examine associations
between family social support and stability of preferences regarding POD.
Methods: this longitudinal study of 1,200 noninstitutionalized independent Japanese older people aged over 65 years usedpanel data between 2016 and 2019 from the Japan Gerontological Evaluation Study (JAGES). Preference stability was deﬁned
as the congruence of preferred POD based on questionnaires between baseline and follow-up. We performed multiple logistic
regression analysis and gender-stratiﬁed analysis to examine associations between social support (spouse, children living
together and children living apart) and preference stability.
Results: only 40.9% of participants had stable preferences. For a spouse, both receiving and providing social support was
associated with less stable preferences (OR: 0.63, 95% CI: 0.43–0.93; OR: 0.55, 95% CI: 0.38–0.80, respectively), andproviding social support to children living apart was associated with more stable preferences (OR: 1.35, 95% CI: 1.03–1.76).
In gender-stratiﬁed analysis, signiﬁcant associations between preference stability and providing social support to a spouse
among women (OR: 0.53, 95% CI: 0.34–0.82) and providing social support to children living apart among men (OR: 1.72,
95% CI: 1.16–2.55) were observed.
Conclusions: family social support was associated with the stability of preferences, and the associations diﬀered by support
resources and gender. Incorporating family members in the process of end-of-life care discussion may be necessary forestablishing stable preferences.
Keywords: social support, place of death, preferences, older people, end of life care
Key Points• Only 40% of older people had stable preferences regarding place of death over three years.
• For women, providing social support to a spouse was associated with less stable preferences.
• For men, providing social support to children living apart was associated with more stable preferences.
• Preference stability may require periodic reassurance and family involvement in end-of-life care discussions.

1

K. Kawaguchi et al.

Introduction
The world population is rapidly aging. The proportion of theworld population aged over 65 years has risen from 6% to
9% between 1990 and 2019, and is expected to double by
2050 [1]. The rapid growth of the older population has raised
concerns about care for older people, especially end-of-life(EOL) care.
Providing high-quality EOL care compatible withpeople’s preferences and values is vital. To respect anindividual’s autonomy, experts in EOL care recommend
identifying and sharing the individual’s goals and preferencesfor EOL care, such as treatments and place of death(POD), through discussions with health care professionals[2]. Although properly understanding their preferences isessential for fulﬁlling them, preferences regarding EOL
care can vary over time. Therefore, preferences should beelicited through iterative discussions on the premise ofsuch changeability [3]. Meanwhile, fulﬁlling preferences
depends on the assumption that they are somewhat stable[4, 5]. If individuals’ preferences are too ﬂuid and unstable,
it is impossible to provide EOL care in the manner they
truly wish. Thus, knowledge of the factors that can change
preference stability would enable timely discussions andreassurance of preferences [6].
POD is an essential component in EOL care. Achieving
individuals’ preferred POD is signiﬁcant to them, theirfamily members, and their caregivers and is considered asa quality indicator of palliative care [7]. A systematic review
indicated that family is the most inﬂuential environmental
factor on care preferences of older people with advanced illnesses, and family-related concerns and the degree of family
support available signiﬁcantly aﬀect their care preferences[8]. Therefore, the quality of family relationships may aﬀect
the stability of preferences for POD.
Social support is a qualitative aspect of social relationships[9]. It has two primary dimensions: emotional support (e.g.
valuing, loving and caring for someone) and instrumental
support (e.g. ﬁnancial aid); moreover, it is bidirectional, thatis, it involves receiving and providing support [10]. Family social support motivates people to commit to healthier
behaviours for family members [11]. Moreover, people withfamily social support are likely to consider and discuss EOL
care in advance [12] and may have more stable preferences
for their family members’ beneﬁt. However, the associations
between family social support and preference stability havenot been well studied [8].
The eﬀect of family social support on stability of EOL
care preferences may vary according to gender. A systematic
review demonstrated that women tended to withhold medical treatments at the end of their lives compared to men[13]. According to previous research, women with advanced
cancers were more likely than men to prefer palliative careand to have do-not-resuscitate orders [14]. These ﬁndings
indicate that individuals’ attitudes toward EOL care may
diﬀer by gender [15]. However, the inﬂuence of gender onthese relationships remains unknown.

2

This study aimed to describe change patterns of preferred
POD over time among Japanese older people, to examine
the associations between family social support and preference
stability, and to investigate gender diﬀerences in the associations. A clear understanding of preference stability and thelink between family social support and stability may enable
more older people to fulﬁl EOL care preferences.

MethodData sources

We used data from the Japan Gerontological Evaluation
Study (JAGES) [16]. The JAGES is an ongoing prospective
cohort study of the social determinants of health among
noninstitutionalized adults aged over 65 years who are independent in activities of daily living. Surveys have been conducted to inquire about health habits, psychological factors
and a broad range of social determinants almost every three
years since 2003. We used data from the 2016 and 2019waves. The self-reported survey questionnaires in both waves
comprised the core questions and one of the eight modules
randomly distributed to the participants [16]. Each module
had unique questions, and one module featured a question
about the preferred POD.
Participants

The questionnaires were mailed to 34,566 individuals in2016 (at baseline) and 45,971 individuals in 2019 (at followup). The response rates were 64.4% (n = 22,258) and 54.0%(n = 24,806), respectively. Participants were informed that
selecting an acceptance checkbox on the questionnaire andreturning it would signify consent to participate. This study
included 1,268 participants who answered questionnaires inboth waves. Sixty-eight participants were excluded becauseof missing information on family social support at baseline.
The ﬁnal sample included 1,200 participants.
Outcome variable

The preferred POD was assessed using the following question: ‘Where would you like to spend the last days ofyour life?’ Responses were ‘home,’ ‘hospital,’ ‘hospice,’ ‘nursing home,’ ‘assisted living facility’ and ‘unknown.’ ‘Nursing home’ and ‘assisted living facility’ were combined into
‘institution’ in our analysis. Missing values were classiﬁed
into the ‘unknown’ category. Stability of POD preferences
was deﬁned as the congruence between responses (except forunknown) at baseline and follow-up. The other combinations were categorised as unstable.
Explanatory variables

Social support was assessed using four items [10]: ‘Do you
have someone who listens to your concerns and complaints?’(Receiving emotional support), ‘Do you listen to someone’s
concerns or complaints?’ (Providing emotional support), ‘Do

Family social support and stability of preferences regarding place
you have someone who looks after you when you are sick andconﬁned to a bed for a few days?’ (Receiving instrumental
support), and ‘Do you look after someone when he/she issick and conﬁned to a bed for a few days?’ (Providing instrumental support). Each item had seven possible response categories: spouse, children living together, children living apart,
relatives, neighbours, friends and others. Participants wereallowed multiple selections. As per this study’s scope, we
limited social support resources to three family relationships:
spouse, children living together and children living apart.
Participants who answered ‘yes’ to the items of receiving
emotional and/or instrumental support were deﬁned as those
who received social support. Likewise, providing emotional
and/or instrumental support was uniﬁed into providing
social support. Not receiving social support or providing
social support were treated as reference categories.
Covariates

We included sociodemographic and health-related factors as
possible confounders based on previous research [17, 18].
We decreased the number of categories for some categoricalvariables to avoid few observations per category.
Sociodemographic factors

Sociodemographic factors included age, educational attainment, marital status, living arrangements, equivalized household income and population density. Age was classiﬁed into
four groups: 65–69, 70–74, 75–79 and ≥80 years. Educational attainment (years of education) was categorised into
three groups: ≤9 years, 10–12 years and ≥13 years. Marital
status was divided into married and single. Living arrangements were classiﬁed as living alone and living with others.
Equivalized household income was calculated by dividing
the normalised household gross income by the square root of
the number of household members and was categorised into
three groups: <$20,000, $20,000–39,999 and ≥$40,000
per year (1 dollar = 100 yen) [19]. Population density per
km2 of the inhabitable area was categorised into three groups:<1,000, 1,000–4,000 and >4,000 persons per km2 [20].
Health-related factors

Health-related factors included depressive symptoms,
self-rated health, self-reported medical conditions andinstrumental activities of daily living (IADL). Depressive
symptoms were assessed using the Japanese short version of
the Geriatric Depression Scale (GDS) (score range: 0–15;
higher scores indicated worse depressive symptoms) [21].
Depressive symptoms were dichotomized into two groups:
no depression (GDS < 5) and depression (GDS ≥ 5) [22].
Self-rated health was assessed with a standard oneitem rating: ‘How would you rate your health at present?’
Response categories (excellent, good, fair and poor) weredichotomized into good (excellent/good) and poor (fair/poor)[23]. Self-reported medical conditions were categorised
into two groups: presence or absence [23]. IADL wasmeasured using the ﬁve-item Tokyo Metropolitan Instituteof Gerontology Index of Competence [24], which examines
ﬁve activities that people may perform in daily life: (i) using
public transportation, (ii) shopping for daily necessities, (iii)
preparing meals, (iv) paying bills and (v) handling theirown banking. Individuals with a total score of ﬁve wereconsidered independent, and those with a total score of lessthan ﬁve were dependent [25].
Statistical analysis

We performed descriptive statistics for the changes in
preferences regarding POD. We conducted multiple logistic
regression analysis to estimate the odds ratios (ORs) ofpreference stability regarding POD for social support and the
95% conﬁdence intervals (CIs). In Model 1, we estimatedthe ORs for each social support variable. In Model 2, allsocial support variables were considered simultaneously.
Additionally, after testing for interactions between genderand each social support using Model 1, we performed
a gender-stratiﬁed analysis to examine these associations
using Models 1 and 2. Furthermore, in gender-stratiﬁed
analysis, we examined the associations between emotional
or instrumental support and preference stability using
Model 1.
Missing values and multiple imputation

Missing values across all variables ranged from 0 to 12.4%(equivalized household income). A total of 21.0% (252of 1,200 participants) were incomplete, which can lead tobiased or ineﬃcient estimates. To address this issue, we
performed multiple imputation by chained equations to
impute incomplete variables, including the outcome variable, and created 40 imputed datasets. The estimates andstandard errors were obtained for each imputed dataset
separately using logistic regression analysis and combinedwith Rubin’s rules [26]. In a sensitivity analysis, we examined
whether similar results were obtained by categorising themissing values on the preferred POD as ‘unknown’ responses(Model 1).
All analyses were performed using Stata/SE 16.0 (StataCorp, College Station, TX, USA). All P-values were twosided, and the statistical signiﬁcance level was set at a Pvalue < 0.05.

Results
Table 1 presents the participants’ characteristics. The mean
(standard deviation) age was 72.9 (5.4) years, and 52.5%
were women. Of the participants, 429 (40.9%) had stablepreferences.
Table 2 shows a comparison of the preferences regarding
POD between baseline and 3-year follow-up stratiﬁed bygender. Hospital for women and home for men were themost consistent choices (59.4% and 59.2%, respectively).
The preference for institution was the least stable over the3

K. Kawaguchi et al.

391 (32.6%)363 (30.2%)
282 (23.5%)
164 (13.7%)
630 (52.5%)324 (27.0%)
500 (41.7%)375 (31.3%)
293 (24.7%)
893 (75.3%)
151 (13.3%)
988 (86.7%)
484 (46.1%)
439 (41.8%)
128 (12.2%)
219 (18.2%)
382 (31.8%)
599 (49.9%)934 (80.2%)
231 (19.8%)
78 (6.7%)
1,090 (93.3%)
108 (9.2%)
1,061 (90.8%)248 (21.7%)
894 (78.3%)

observed no signiﬁcant interactions of each social support
variable by gender (Table 3).
Table 4 presents the results of the gender-stratiﬁed analysis of the associations between family social support andpreference stability. Women who provided social support toa spouse were 47–50% less likely to have stable preferences(Model 1, OR: 0.53; 95% CI: 0.34–0.82; Model 2, OR:
0.50; 95% CI: 0.32–0.79), whereas men who provided social
support to children living apart were 72–73% more likely tohave stable preferences (Model 1, OR: 1.72; 95% CI: 1.16–
2.55; Model 2, OR: 1.73; 95% CI: 1.17–2.58). Regarding
the two types of social support, providing instrumental support to a spouse was signiﬁcantly associated with less stablepreferences among women (OR: 0.59; 95% CI: 0.39–0.89),
while providing emotional and instrumental support wassigniﬁcantly associated with more stable preferences amongmen (OR: 1.57; 95% CI: 1.04–2.36; OR: 2.06; 95% CI:
1.30–3.28, Table 5).
In our sensitivity analysis, the overall results were similar
to those of the initial analyses. Exceptionally, borderline
signiﬁcant associations between providing social support tochildren living apart and preference stability were observed.
Additionally, women receiving social support from a spouse
were less likely to have stable preferences (Appendix Table 1
available in Age and Ageing online).

865 (72.1%)
397 (33.1%)
543 (45.3%)

Discussion

Table 1. Baseline characteristics of study participants
Variables

Categoriesn (%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Age (years)

65–69
70–74
75–79
≥80
Gender
Women
Education (years)
≤9
10–12
≥13
Marital status
SingleMarriedLiving arrangements
Living alone
Living with others
Household income ($ per year)<20,000
20,000–39,900≥40,000
Population density (persons per km2 ) <1,000≥1,000–4,000>4,000Geriatric Depression Scale
No depression
Depression
Instrumental activities of daily living Dependent
Independent
Self-rated health
Poor
Good
Self-reported medical conditions
AbsentPresent
Receiving social support
SpouseYesChildren living together
Yes
Children living apart
Yes
Providing social support
SpouseYesChildren living together
Yes
Children living apart
Yes
Preferred place of deathHome
Hospital
Hospice
Institution
Unknown

868 (72.3%)
379 (31.6%)
511 (42.6%)
390 (36.0%)
248 (22.9%)
128 (11.8%)
72 (6.6%)245 (22.6%)

3 years among women and men. Only 216 (39.8%) womenand 213 (42.2%) men had stable preferences.
Table 3 provides the results of the multiple logistic regression analysis for the associations between social support andpreference stability regarding POD. In Model 1, for a spouse,
both receiving and providing social support was signiﬁcantly
associated with less stable preferences (OR: 0.67; 95% CI:
0.46–0.96; OR: 0.58; 95% CI: 0.41–0.84). Providing social
support to children living apart was signiﬁcantly associatedwith more stable preferences (OR: 1.33; 95% CI: 1.02–
1.73). In Model 2, adjusted for social support variables
simultaneously with all covariates except marital status, we
obtained comparable results to those in Model 1 (OR: 0.63;
95% CI: 0.43–0.93 for receiving social support from a
spouse, OR: 0.55; 95% CI: 0.38–0.80 for providing social
support to a spouse, and OR: 1.35; 95% CI: 1.03–1.76
for providing social support to children living apart). We

4

This study showed that approximately 40% of the participants maintained their preferences during the 3-year followup period. Women with stable preferences tended to favour
hospital as a POD, whereas men tended to favour home.
After adjusting for confounders, for women, providing social
support (emotional support) to a spouse was related to lessstable preferences, whereas for men, providing social support(emotional and instrumental support) to children living
apart was related to more stable preferences.
Inconsistent with our ﬁndings, a previous systematic
review [27] reported that ∼80% of study participants did
not change their home death preferences. This may be
because, ﬁrst, our study participants were healthier—90% ofthem reported good self-rated health—than the participantsin the systematic review. Meanwhile, the systematic review
included relatively vulnerable patients, such as terminallyill patients. Another systematic review [5] suggested that
seriously ill patients had more stable EOL care preferences
than older people without serious illnesses. They may
consider and answer questions about preferred POD more
carefully because the questions may be more relevant tothem. Second, this study’s follow-up period was longer thanthat of previous studies. Generally, preferences are more
likely to change during a longer follow-up period. Only few
studies [28] had a follow-up period of more than 2 years
because of participants’ poor health status. Third, preference
instability may stem from the unique characteristics of older
Japanese people. A study [29] involving this population

Family social support and stability of preferences regarding place
Table 2. A comparison of preferences regarding POD between baseline and 3-year follow-up by gender
Women

Follow-up

BaselineHome

Hospital

Institution

HospiceUnknown

Row totalHome
Hospital
Institution
HospiceUnknown
Column total

78 (53.1%)
8 (6.1%)5 (6.4%)3 (5.5%)20 (15.3%)
114

19 (12.9%)
82 (62.1%)
20 (25.6%)
11 (20.0%)
24 (18.3%)
156

4 (2.7%)7 (5.3%)25 (32.1%)
1 (1.8%)6 (4.6%)43

11 (7.5%)
11 (8.3%)
9 (11.5%)
31 (56.4%)
15 (11.5%)
77

35 (23.8%)
24 (18.2%)
19 (24.4%)
9 (16.4%)
66 (50.4%)
153

147 (100.0%)132 (100.0%)78 (100.0%)55 (100.0%)131 (100.0%)
543

Men

Follow-up

BaselineHome
Hospital
Institution
HospiceUnknown
Column totalHome
141 (61.6%)
23 (21.3%)
4 (8.5%)1 (5.9%)16 (15.4%)
185

Hospital
37 (16.2%)
58 (53.7%)
23 (48.9%)
3 (17.6%)
22 (21.2%)
143

Institution
1 (0.4%)2 (1.9%)6 (12.8%)
0 (0.0%)5 (4.8%)14

Hospice6 (2.6%)2 (1.9%)4 (8.5%)8 (47.1%)
6 (5.8%)26

Unknown
44 (19.2%)
23 (21.3%)
10 (21.3%)
5 (29.4%)
55 (52.9%)
137

Row total
229 (100.0%)108 (100.0%)47 (100.0%)
17 (100.0%)104 (100.0%)505. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 3. Results for multiple logistic regression models of the association between social support and stability of preferences
regarding POD
Social support

Model 1a
Odds ratio (95% CI)

Model 2b
Odds ratio (95% CI)

Gender∗ Social supportc
Odds ratio (95% CI)

Reference
0.67∗ (0.46–0.96)
0.85 (0.63–1.15)
1.05 (0.81–1.37)

Reference
0.63∗ (0.43–0.93)
0.87 (0.64–1.17)
1.03 (0.79–1.34)

Reference
1.37 (0.71–2.65)
1.08 (0.61–1.92)
1.15 (0.69–1.90)

Reference
0.58∗∗ (0.41–0.84)
0.92 (0.68–1.25)
1.33∗ (1.02–1.73)

Reference
0.55∗∗ (0.38–0.80)
0.92 (0.68–1.25)
1.35∗ (1.03–1.76)

Reference
1.65 (0.87–3.14)
1.43 (0.81–2.53)
1.44 (0.87–2.38). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Receiving social support
No social support
SpousedChildren living together
Children living apart
Providing social support
No social support
SpousedChildren living together
Children living apart

95% CI: 95% conﬁdence interval. ∗ P < 0.05. ∗∗ P < 0.01. a We examined associations between each social support variable and stability of preferences regarding
POD after adjusting for covariates (age, gender, education, marital status, living arrangements, household income, population density, GDS, IADL, medical
conditions and self-rated health). b Social support variables (spouse, children living together and children living apart) were simultaneously entered into the models
with all covariates except marital status (age, gender, education, living arrangements, household income, population density, GDS, IADL, medical conditions andself-rated health). c Gender ∗ Social support represents an interaction term between gender and social support. The statistical signiﬁcance of the interaction term
was examined using Model 1. d The marital status variable was not included in the models due to multicollinearity.

demonstrated that their wishes for EOL care frequently
varied during short periods of interviews. They tend to
entrust EOL decision-making to others, such as medical careproviders [30], which may deprive them of opportunities
to consider EOL issues earnestly and destabilise theirpreferences.
We found gender diﬀerences in the associations betweensocial support and preference stability. Several previous studies [6, 17] reported that social support helped to stabilise
EOL care preferences; however, gender was not considered.
In this study, women preferred hospital as POD, andwhen they provided social support to a spouse, their preferences were more likely to change. This may arise fromconcerns about being a burden on the family [31]. A national
survey [32] reported that more than 70% of the generalpublic recognised not being a burden on the family—a wish

that might arise from their caregiving experience—as themost important factor in choosing their POD. According
to a national survey [33], women accounted for 65% of
adults aged over 65 years who had cared for family members.
Additionally, women caregivers reported greater caregiverburden [34], higher depressive symptoms [35] and poorer
physical health [36–38] compared with men. Their unstablepreferences might imply that they are conﬂicted between
their true desires for EOL care and concerns about being aburden on their family [39].
Consistent with previous research, men were more likely
than women to prefer home as POD [40, 41]. Men also
had more stable preferences when providing social support
to children living apart. This could be because men expect
their children to provide EOL care as a reward for theirsocial support [8]. Furthermore, providing social support

5

K. Kawaguchi et al.
Table 4. Results for gender-stratiﬁed multiple logistic regression models of the association between social support andstability of preferences regarding POD
Women
Social support

Men

Model 1a
Odds ratio (95% CI)

Model 2b
Odds ratio (95% CI)

Model 1a
Odds ratio (95% CI)

Model 2b
Odds ratio (95% CI)

Reference
0.69 (0.45–1.07)
0.95 (0.61–1.48)
0.98 (0.68–1.40)

Reference
0.68 (0.43–1.09)
0.96 (0.63–1.49)
0.96 (0.67–1.38)

Reference
0.53 (0.25–1.12)
0.78 (0.50–1.22)
1.21 (0.83–1.77)

Reference
0.49 (0.23–1.05)
0.78 (0.50–1.22)
1.20 (0.82–1.76)

Reference
0.53∗∗ (0.34–0.82)
0.88 (0.57–1.35)
1.10 (0.77–1.58)

Reference
0.50∗∗ (0.32–0.79)
0.84 (0.55–1.29)
1.10 (0.77–1.59)

Reference
0.65 (0.33–1.32)
1.02 (0.66–1.58)
1.72∗∗ (1.16–2.55)

Reference
0.57 (0.28–1.16)
1.00 (0.64–1.56)
1.73∗∗ (1.17–2.58). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Receiving social support
No social support
Spousec
Children living together
Children living apart
Providing social support
No social support
Spousec
Children living together
Children living apart

95% CI: 95% conﬁdence interval. ∗∗ P < 0.01. a We examined associations between each social support variable and stability of preferences regarding POD after
adjusting for covariates (age, education, marital status, living arrangements, household income, population density, GDS, IADL, medical conditions and self-rated
health). b Social support variables (spouse, children living together and children living apart) were simultaneously entered into the models with all covariates except
marital status (age, education, living arrangements, household income, population density, GDS, IADL, medical conditions and self-rated health). c The marital
status variable was not included in the models due to multicollinearity.

Table 5. Results for gender-stratiﬁed multiple logistic regression models of the association between emotional or
instrumental social support and stability of preferences regarding POD
Receiving emotionalsocial support

Providing emotionalsocial support
Odds ratio (95% CI)

Receiving
instrumental social
supportOdds ratio (95% CI)

Providing
instrumental social
supportOdds ratio (95% CI)

Odds ratio (95% CI)

Reference
0.75 (0.50–1.13)
0.93 (0.61–1.44)
0.91 (0.63–1.30)

Reference
0.74 (0.50–1.09)
0.81 (0.52–1.25)
1.19 (0.82–1.72)

Reference
0.71 (0.47–1.09)
0.95 (0.61–1.47)
1.05 (0.73–1.51)

Reference
0.59∗∗ (0.39–0.89)
0.94 (0.61–1.45)
1.02 (0.70–1.49)

Reference
1.11 (0.65–1.88)
0.83 (0.48–1.45)
0.98 (0.63–1.53)

Reference
1.17 (0.71–1.92)
0.92 (0.56–1.52)
1.57∗ (1.04–2.36)

Reference
0.72 (0.36–1.43)
0.84 (0.53–1.32)
1.35 (0.91–2.02)

Reference
0.77 (0.46–1.29)
1.25 (0.78–2.00)
2.06∗∗ (1.30–3.28). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Women
No social support
SpouseaChildren living together
Children living apartMen
No social support
SpouseaChildren living together
Children living apart

95% CI: 95% conﬁdence interval. We examined associations between each social support variable and stability of preferences regarding POD after adjustingfor covariates (age, gender, education, marital status, living arrangements, household income, population density, GDS, IADL, medical conditions and self-rated
health). ∗ P < 0.05. ∗∗ P < 0.01. a The marital status variable was not included in the models due to multicollinearity.

may make them feel valued and enhance their willingness
to live [42, 43], which can lead to their preference forliving at home until death. Additionally, a close parent–children relationship may motivate discussions about EOL
care preferences [12] and solidify their preferences. We did
not obtain signiﬁcant results for children living together due
to the lack of male participants who lived with their sons ordaughters (22.2% and 16.7%, respectively, data not shown).
Further research is required on this topic.
Our study suggests important implications for healthcare practices. Our ﬁndings support that healthy older
people require periodic re-evaluation of their preferencesfor EOL care due to their ﬂuctuating preferences [4, 44].
Our study also demonstrates how family social support isassociated with preference stability. Healthcare professionals
often regard family members as a threat to patient autonomy

6and discuss preferences with patients in isolation [45].
However, it may be preferable to consider the family context
and facilitate family members’ participation in EOL carediscussions regardless of the individual’s decision-making
capacity. Healthcare professionals are likely to play anessential role in addressing family concerns or resolving
conﬂicts between an individual’s and family’s preferencesin the triadic relationship of an individual, family andhealthcare professionals [46, 47]. This may allow individuals
to have more stable preferences and realise them.
The strengths of our study include the relatively large
sample size and longer follow-up period compared withprior studies. Additionally, gender diﬀerences in the associations between social support and preference stability were
investigated. Nonetheless, our study has certain limitations.
First, we included physically independent older people. We

Family social support and stability of preferences regarding place
could have obtained diﬀerent results from near-death participants. However, identiﬁcation of an individual’s preference
through repeated discussions is recommended for people ofany age or stage of health [48]. Understanding how preferences in healthier people ﬂuctuate over time is beneﬁcial.
Second, we targeted only Japanese people, which may limit
the generalizability of our ﬁndings [49]. Third, we examined
the link between social support and preference stability bylimiting the social support resources to family. As community engagement in EOL care is gaining interest [50], futurestudies should investigate how other social support resources
inﬂuence preference stability. Lastly, we selected preferred
POD as an EOL care preference because the 2019 wave did
not contain other questionnaire items regarding EOL carepreferences. Further research on other EOL preferences isrequired.

Conclusion
Only 40% of noninstitutionalized independent older people had stable preferences regarding POD over 3 years.
Women providing social support to their spouses were lesslikely to have stable preferences, while men providing social
support to children living apart were more likely to havestable preferences. To our knowledge, this is the ﬁrst study
to focus on the associations between family social support and preference stability and gender diﬀerences in theirassociations. Incorporating family members in discussions
regarding individual’s preferences about EOL care, including
POD, may contribute to more stable preferences and theirrealisation.
Supplementary Data: Supplementary data mentioned in
the text are available to subscribers in Age and Ageing online.
Acknowledgements: This study received ethics approval
from the Ethics Committee of Chiba University Faculty of
Medicine (No. 2493), the National Center for Geriatrics andGerontology (No. 992) and Nihon Fukushi University (No.
10-05).
We are grateful to Dr Masashi Tanaka for useful discussions.
We would also like to thank Editage (www.editage.com) for
English language editing.
Declaration of Conﬂicts of Interest: None.
Declaration of Sources of Funding: This work was supported by Grant-in-Aid for Scientiﬁc Research (15H01972,
15H04781, 15H05059, 15K03417, 15K03982, 15K16181,
15K17232, 15K18174, 15K19241, 15K21266, 15KT0007,
15KT0097, 16H05556, 16K09122, 16K00913, 16K02025,
16K12964, 16K13443, 16K16295, 16K16595, 16K16633,
16K17256, 16K17281, 16K19247, 16K19267, 16K21461,
16K21465, 16KT0014, 17K04305, 17K04306, 25253052,
25713027, 26285138, 26460828, 26780328, 18H03018,
18H04071, 18H03047, 18H00953, 18H00955, 18KK0057,
19H03901, 19H03915, 19H03860, 19K04785, 19K10641,

19K11657, 19K19818, 19K19455, 19K24060, 19K20909,
20H00557) from JSPS (Japan Society for the Promotion of
Science); Health Labour Sciences Research Grants (H26Choju-Ippan-006, H27-Ninchisyou-Ippan-001, H28Choju-Ippan-002, H28-Ninchisyou-Ippan-002, H30Kenki-Ippan-006, H29-Chikyukibo-Ippan-001, H30Jyunkankinado-Ippan-004, 19FA1012, 19FA2001, 21FA1
012, 21K19635), Research project on health and welfare
promotion for the elderly from the Ministry of Health,Labour and Welfare, Japan; the Research and Development
Grants for Longevity Science from Japan Agency for Medical
Research and development (AMED) (JP18dk0110027,
JP18ls0110002, JP18le0110009, JP20dk0110034, JP21lk0
310073, JP21dk0110037), the Research Funding forLongevity Sciences from National Center for Geriatrics
and Gerontology (24-17, 24-23, 29-42, 30-30, 30-22, 2019, 21-20); Open Innovation Platform with Enterprises,
Research Institute and Academia (OPERA, JPMJOP1831)
from the Japan Science and Technology (JST); a grant fromthe Japan Foundation For Aging And Health (J09KF00804),
a grant from Innovative Research Program on Suicide
Countermeasures (1-4), a grant from Sasakawa Sports
Foundation, a grant from Japan Health Promotion &Fitness Foundation, a grant from Chiba Foundation for
Health Promotion & Disease Prevention, the 8020 Research
Grant for ﬁscal 2019 from the 8020 Promotion Foundation(adopted number: 19-2-06), grants from Meiji Yasuda LifeFoundation of Health and Welfare.

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Received 4 March 2022; editorial decision 15 July 20229