Health, 2015, 7, 934-945
Published Online August 2015 in SciRes. http://www.scirp.org/journal/health
http://dx.doi.org/10.4236/health.2015.78111

The Effect of Educational Intervention
regarding Advance Care Planning
for Advance Directives
Yae Takeshita1*, Mika Ikeda2, Sayaka Sone3, Michiko Moriyama3
1

Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
Osakikamijima Town Government, Toyota-gun, Japan
3
Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan*
Email: takeshita0307@rice.ocn.ne.jp
2

Received 14 July 2015; accepted 4 August 2015; published 7 August 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract
This study aimed to examine the effects of empowerment and education intervention to promote
Advance Care Planning (ACP) for residents in a highly aged and depopulated region. The study utilized a single-group pre- and post-test design and was conducted in Osakikamijima, Hiroshima,
Japan. The researchers and town officials together formed an ACP committee and created an intervention framework. An ACP workshop was held for the participants and a self-administeredquestionnaire was carried out before, immediately after, and 3 months after the workshop. A totalof 125 residents participated in the workshop and 87 of them completed more than 80% of thequestionnaire items, whose responses were analyzed as valid responses. The number of participants who completed the AD increased significantly three months after the workshop (p = 0.008).
There was a slight increase in the frequency of consultation with the family, but no change wasobserved in terms of consultation with healthcare providers. The educational intervention increased the respondents’ awareness and knowledge of ACP but did not affect the autonomous decision-making process regarding end-of-life care. This strategic process of ACP empowered theresidents’ awareness and attitude towards end-of-life care with an increased completion rate of
AD. On the other hand, cognitive barriers remained toward communication and decision-making
shared with healthcare providers. Insufficient consultation with family members also became
evident. Therefore, a new intervention strategy which helps increase communication with healthcare providers needs to be formulated and guidelines for consultation with the family and others
need to be prepared.
*

Corresponding author.

How to cite this paper: Takeshita, Y., Ikeda, M., Sone, S. and Moriyama, M. (2015) The Effect of Educational Intervention
regarding Advance Care Planning for Advance Directives. Health, 7, 934-945. http://dx.doi.org/10.4236/health.2015.78111

Y. Takeshita et al.

Keywords
End-of-Life, Advance Care Planning, Advance Directives, Community Empowerment

1. Introduction
In Japan, the rate of aging is currently at 25.1% and is advancing faster than any other rate in the world [1]. In
addition, the population has started to decrease as of 2005, and the society entered a new stage where the death
rate exceeded the birth rate [2]. Inevitably, Japan’s healthcare system, known for their excessive number of hospital beds, must prepare for this change and the government has begun reforming medical care to shift from a
hospital-focused to a home care-focused system [3]. On the other hand, community and people’s preparations
for dying at home are inadequate. While the rate of those who wanted to die at home was 49.5% [4], that ofdeath at home was only 12.8% in 2012 [5].
What is causing this gap and why are dying at home not more prevalent? Several factors have been discussed.
1) The large number of hospital beds [6] makes hospitalized treatment easier, and Japan has become used to thisas a reality. 2) The number of families with three generations cohabiting has decreased, leading to an increase in
those living alone or only with the elderly [7]. Although the public long-term care insurance system is available,
the reality is that there is inadequate service for those living alone [8]. 3) There exists anxiety over care provided
by the family, the burden of caregiving work involved, and fear regarding responses during emergencies, even if
they live with families. Therefore, dying at home is avoided and, instead, people choose to die in hospitals [9][11]. 4) Finally, a care manager responsible for service arrangements and health/nursing care providers themselves consider that dying at home can be difficult if the family cannot provide adequate care [12]. 5) Additionally, advance directives (AD), which are legislated in the West, are not legislated in Japan [13] and there is noeffective, legal method of carrying out the wishes of an elderly person. Moreover, medical and nursing care providers have lack of knowledge regarding AD [14], and people in Japan lost learning opportunities and experiences to have natural death without having any invasive medical treatment.
Despite these limitations, Japan is currently compensating for the lack of knowledge of both its citizens andhealth/nursing care providers through a concept called advance care planning (ACP), designed to promote dying
at home. ACP is being promoted in community through the integrated community care system, which is a system designed to support regional home care system by 2025 when Japan’s elderly population is expected to peak[15]. ACP is defined as “process of communication among patients, their health care providers, their families,
and important others regarding the kind of care that will be considered appropriate when the patient cannot makedecisions” [16] with AD at its center. ACP programs that have demonstrated effectiveness are being developed[17] and they have proven popular in England, USA, and Australia; interestingly, this popularity has been limited in Japan.
One reason for this slow uptake is the aforementioned psychological resistance of both health/nursing careproviders and citizens. Other reasons include the lack of promotion for the ACP process in order to compensate
for the lack of knowledge of both citizens and health/nursing care providers, and that topics regarding end-oflife care tend to be avoided because they conjure images of death.
Community empowerment is effective for widespread awareness of the concepts of ACP and to tie these to
implementation. This is a process by which a region’s citizens critically assess their own situation, realize common issues, and take action to improve and resolve the causes of these issues by creating societal change [18].
Awareness of issues by all citizens in a region and subsequent proactive action against these issues will be effective in order to reform society, even with factors preventing the spread of ACP.
Therefore, in this study, we selected one region and performed community awareness activities directed tohealth/nursing care providers and citizens alike in order to promote ACP in the integrated community care system, and we have reported on the changes to awareness and behavior based on this intervention. Furthermore,
we measured promotion through the completion of written AD and discussions about end-of-life care with family and health care professionals as goals for the development of ACP.

1.1. Literature Review of ACP in Japan
In an awareness survey conducted in 2014 by the Ministry of Health, Labour and Welfare on 2179 people in the935

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general population, those with completed AD comprised 3.2%. Meanwhile, 42.2% responded that they had discussed with their families, but only 2.8% responded that they spoke in detail [19]. Amidst these conditions, theproportion of those responding in favor of living wills (LW) rose from 47.6% in 1998 to 61.9% in 2008 [19], indicating a gradual increase in awareness of the importance of indicating one’s preferences toward end-of-lifecare.
Searching literature databases (MEDLINE, the Cumulative Index to Nursing and Allied Health Literature[CINAHL], and the Japan Medical Abstracts Library) for ACP and AD in Japan revealed most studies regarding
the awareness of AD or LW. Several studies focused on the complete rate of AD or the practicality of AD [11][20]-[22], as well as the compliance and content of AD and LW [23]-[25]. However, there was only one interventional study regarding the creation of LW [26]. In this educational intervention for AD, a lecture was given
to the interventional group comprised of the regional elderly population and who discussed AD in small groups;
meanwhile, the control group were given handouts. In comparing the two groups, the proportion of those who
discussed with their families and health care providers increased significantly; however, a significant increase
was not observed for writing a LW (5.7%).
As demonstrated above, Japan has not yet reached a stage where it can facilitate awareness of study-focused,practical interventions from a community empowerment perspective, despite the fact that the importance of ACP
is well known.

1.2. Characteristics of Osakikamijima as a Research Field
Osakikamijima has a population of 8207 and is designated an isolated island. The proportion of elderly people is
45.4%, while those aged over 75 years comprise 26.7% (as of January 1, 2014) [27]. In 2012, the total numberof deaths was 165, with 92.1% of those experiencing death outside their home (51.7% in the hospital, 19.4% in
the clinic (with beds), and 15.8% in nursing homes) [28]. While the proportion of those wishing to live out theirlives in the comfort of their own homes is high, the actual number of those able to do so is low.

2. Methods
2.1. Participants and Recruitment
Participants were non-hospitalized residents aged over 20 years living in the region. A notice was sent to all
residents of Osakikamijima, where a workshop was given (Figure 1), and the workshop participants were usedin this study. The person whose cognitive function declined was excluded.
Established the ACP committee and planned theintervention framework-Planned ACP workshops-Made a workbook of ACP "Ending notebook"(including advance directive)

Announcement of workshop to residents(approximately 8,000)-Distributed the ACP leaflet to the community
Let regional residents know about ACP activities throughbrochures

Workshop (n = 128)
-Lectured about ACP and AD-Distribute the ACP workbook-Taught how to write the ACP workbook

PretestPosttest 1

Individual Support
Evaluation(all questionnaires returned n = 87)

Figure 1. Project framework.

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2.2. Research Design

Single-group pre and posttest study.
Intervention method: We outlined the framework and performed the intervention at the corresponding step in
Figure 1.
Step 1: Established ACP committee and planned intervention framework: A joint committee between Osakikamijima and the researchers was established in order to create a region where it was possible to live out one’s
life on the island. The participating members were the Mayor of Osakikamijima, government employees from
Osakikamijima, the town’s medical association, the town’s Council of Social Welfare, the community comprehensive care center, the nursing care service office, the home-visiting nursing station, and an informal municipalorganization.
Step 2: Created an ACP workbook: We created a workbook “Ending Notebook” to help guide the ACP
process. The contents included wishes for how to live in the future, personal history, messages to important
people, preference of medical/nursing care, management of money and assets, and funeral arrangements. For
medical/nursing care, participants noted the disease diagnoses and remaining life, if they were given the information from the healthcare provider. Questions regarding palliative care such as pain management and the useof life-prolonging treatments (artificial feeding, cardiopulmonary resuscitation, use of artificial respirator) wereanswered with one of three options: yes, no, and unsure. Space was included for free comments, as well as inputting the names of each participant’s family physician and the proxy decision makers. Additionally, space wasincluded to record the date when discussions with the healthcare provider and family took place.
Step 3: Announcement of the workshop to residents: We created a leaflet explaining ACP and announced theworkshop for the promotion of ACP in the town’s PR brochure, which was distributed to all residents of Osakikamijima. The public health nurse of the town urged opinion leaders, such as the regional welfare commissioner
and heads of neighborhood associations, to participate; at the same time, the public health nurse urged citizen
participation through door-to-door canvassing.
Step 4: Implemented the workshop: The workshop was implemented over four sessions (60 minutes/session, 2days). There was a two-week gap between the two workshop sessions (Figure 2). The workshop was structured
to take into account learning elements based on Bloom et al. [29]: affective domain (attitude), cognitive domain
Cooperation between residents, administration, and academics
to build a rich, forward-thinking ACP
Workshops (4 sessions)
Attitude (by Buddhist priest)-teaching from Buddhism-how to live and how to die
Knowledge (by primary care physician)-statistics related to death in Japan-medical care system-medical treatment if hospitalized
Knowledge (by nursing academic)-home health care when dying-concept of ACP and AD-right to self-decision making-details of living and dying at home-community resources; formal and informal support
Practice (by community nurse)-how to write the workbook-details of AD: writing living will; deciding on a legal representative-life-prolonging treatment
advantages and disadvantages-how to use the workbook
communicate with family members and physicians
Increase preparedness to write AD
Increase intent to decide and write AD
Increase discussion with families and healthcare professionals
Complete ACP

Figure 2. Process of completing ACP.

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(knowledge), and psychomotor domain (behavior). We employed a regional key person to increase participant
awareness. The regional head priest of the Buddhist temple gave a lecture on living and dying from the perspective of Buddhism. A physician for the head of the town’s medical association gave a lecture on the current stateof end-of-life care in Japan, as well as medical knowledge pertaining to end-of-life and life-prolonging treatment.
Additionally, the physician shared their thinking regarding end-of-life care. A nursing academic, who was amember of the ACP committee, explained dying in a familiar environment, concepts and processes of ACP and
AD, the importance of autonomous decision-making and caregiving at home using social resources. A publichealth nurse promoting ACP explained the contents of the ACP workbook and provided specific guidance on
how to complete it. Additionally, the nurse explained frequently-asked questions while completing the workbook. Finally, to make AD effective, the nurse explained the importance of discussions with family and healthcare providers.

2.3. Evaluation and the Process
Theoretical process of having effects in this study is shown in Figure 2. Participation in the workshop led to anincrease in knowledge about ACP (knowledge). The number of people endorsing ACP increased (attitude) as
awareness about its importance spread, which subsequently led to greater autonomy regarding decisions about
end-of-life care (attitude). These factors helped to prepare for ACP. As a result of autonomous decisions about
end-of-life care, the completion rate of AD and discussions with family and health care providers increased (behavior), ultimately leading to popularization of ACP.
In order to demonstrate these effects, the AD completion rate was set as the primary endpoint and the numberof discussions with health care providers and family as the secondary endpoint. Additionally, the tertiary endpoints were the degree of awareness of ACP, AD knowledge scale, endorsement of ACP, awareness of the importance of ACP, Autonomy Preference Index (API), and preferences toward end-of-life care. Questions regarding awareness and preferences were constructed by the researcher using previous studies as a reference [26].

2.4. Date Collection
We performed self-administered questionnaires according to the 3 points shown in Figure 1 and collected data.
We asked prior to the workshop (pretest: baseline) and 3 months after (posttest 2), questions whether “completed the AD” and “had discussions with family or healthcare providers about end-of-life care.” We asked
about ACP awareness, the AD knowledge scale, endorsement of ACP, awareness of the importance of ACP,
API, and preferences toward end-of-life care before and after the workshop (pretest, posttest 1).
For awareness of ACP, we asked whether they had knowledge of AD, LW, and legal representatives (yes/no).
For testing AD knowledge, the advance directive knowledge test [30] was administered. This scale was developed to evaluate the effect of interventions promoting the education of AD writing. Japanese version of this test
contained 8 true-false items dealing with concepts and facts related to AD [31]. The test includes themes such aslegal considerations, importance, communication with others, appropriate use, and timing. This scale score wascalculated by assigning a score of 1 and 0 to correct and incorrect answers, respectively. More correct answers
indicated a higher degree of knowledge (score range = 0 - 10). Reliability and validity were tested.
Attitudes toward ACP were evaluated by asking whether they agreed with writing an AD or discussing thiswith healthcare providers and family (endorsement of ACP), as well as whether they thought this was important(awareness of the importance of ACP). API is a measure of the degree of decision-making regarding medical
procedures [32]. There are two subscales for API, but the Japanese version was classified into three independent
subscales of “information seeking” “case-based decision making” “non case-based decision making.” In thisstudy, the generalized subscale measuring the degree of decision-making was used. This 4-item API (non casebased decision making) subscale uses a 5-point Likert scale with responses ranging from 1 (strongly agree) to 5
(strongly disagree). In accordance with prior research, a score was rated from 100 for “strongly disagree” to 0
for “strongly agree” and was converted the scores at each step of the analysis so that a higher degree of autonomy led to higher scores. Reliability and validity were tested [33].
To ascertain their end-of-life preference, participants were asked the following: If there is no chance of recovery from your illness, would you like to receive the following treatments? (Examples given were cardiopulmonary resuscitation, artificial ventilation, and artificial nutrition.) Participants chose one of four answers: 1)
yes, I would; 2) leave it to the physician to decide; 3) leave it to my family to decide; or 4) no, I would not.

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2.5. Data Analysis

In order to make comparisons before and after the workshop (before and 3 months after the workshop), McNemar’s test was used for the completion of AD, discussions, ACP awareness and endorsement of ACP. The t-test
was used for total scores of AD knowledge Scale, the Wilcoxon rank sum test was used for the awareness ofimportance of ACP and API, and the marginal homogeneity test was used to analyze preferences toward endof-life care. Statistical significant level was set at p < 0.05.

2.6. Ethical Considerations
This study was approved by the Ethics Committee of Hiroshima University. A written consent form was takenfrom all workshop participants. Before signing, all participants were explained the purpose of this project, thatstudy participation was voluntary, that they could withdraw at any time, that personal information would be secure, and the method of publication with protection of privacy.

3. Result3.1. Outlines of Participants
A total of 125 people participated in the workshop; 90 participants responded to all three evaluation points, and87 who completed >80% of items were analyzed as valid responses.
The basic characteristics of the participants are shown in Table 1. The average age was 64.1 (SD = 13.4),
54.2% were aged over 65 years, 63 participants (75.0%) were female, 18.4% lived on their own, 81.6% lived
with another, 87.2% had a family physician, 56.0% had experience with major operations or hospitalization, and77.0% had experience of care giving for their family. A total of 77.3% of participants over 65 years of age rated
their subjective degree of health as good.

3.2. Educational Effects on Making Advance Directives
Tables 2-5 show the changes before and after the workshop.
3.2.1. Behavior: Change of Behavior toward Developing AD
The completion rate of making AD is the primary endpoint of this study. The number of participants who responded that they had completed the AD was 1 out of 72 (1.4%) before the workshop, which rose to 9 out of 72(12.5%) at three months after the workshop (p = 0.008) (Table 2).
Table 1. Participant demographics.
N

Mean (±SD) or N (%)

Age (years)

83

64.1

(13.4)Sex (female)

84

63(75.0)

Living arrangement
CoupleParents and children
Alone
With others

87

36
28
16
7

(41.4)(32.2)(18.4)(8.0)

Has primary physicians

8675(87.2)

Health condition
Very good
Good
Fair
Poor
Very poor

85

10
57
9
8
1

(11.7)(67.1)(10.6)(9.4)(1.2)

Past medical history of surgery/hospitalization

84

47(56.0)

Caregiving experience for terminally ill or serious conditions

87

67(77.0)

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Table 2. Attitude, cognition, and behavior change after the workshop.
Pre

Post

N

a

p-value
Yes

(%)

Yes

(%)

Change of behavior toward developingadvance directives
Completed writing advance directives
Discussed with the family
Discussed with the physician

72
74
72

1
29
5

(1.4)
(39.2)
(6.9)

9
37
4

(12.5)(50.0)(5.6)

0.008a0.057a1.000aChange of knowledge of advance care planning
Was aware of advance directives
Was aware of living wills
Was aware of durable power of attorney

86
84
79

35
23
52

(40.7)(27.4)(65.8)

72
62
66(83.7)(73.8)(83.5)<0.001a<0.001a0.001a

The advance directives knowledge test score: Mean (±SD)

76

5.1

(2.2)

6.2

(1.8)

<0.001b

Chanege of attitude toward ACP: Endorsement of ACP
Agreed with making advance directives
Agreed with discussing end-of-life care

79
86

76
85

(96.2)(98.8)

7785(97.5)(98.8)

1.000a1.000aMcNemar test, bt-test.

Table 3. Change of attitude toward ACP: Awareness of importance of ACP.
Pre

Post

Total

Making advance directives is important
Strongly agree
Agree
DisagreeStrongly disagree

76

Discussion about end-of-life care is important
Strongly agree
Agree
DisagreeStrongly disagree85

p-value
N

%

N

%

32
41
3
0

(42.1)(53.9)
(3.9)
(0.0)

41
33
2
0

(53.9)(43.4)
(2.6)
(0.0)

72
11
2
0

(84.7)(12.9)
(2.4)
(0.0)

67
16
1
1

(78.8)(18.8)
(1.2)
(1.2)

0.129

0.157

Wilcoxon rank sum test.

Table 4. Score of the change of Autonomy Preference Index (N = 64).
Pre

Post
p-value

Mean

(±SD)

Mean

(±SD)

The important medical decisions should be made by your physician, not by you.

43.8

(30.5)

46.9(35.2)

0.344

You should go along with your physician’s advice even if you disagree with it.

51.2(28.3)

55.1(31.9)

0.132

When hospitalized, you should not be making decisions about your own medical care.

50.8(33.6)

50.8(31.8)

0.917

If you were sick, as your illness became worse,
you would want your physician to take greater control.

41.0(30.0)

43.8(31.8)

0.392

Wilcoxon rank sum test.

Discussing end-of-life care with healthcare providers and family are the secondary endpoints of this study.
Participants who had discussed end-of-life care with family before the workshop totaled 39.2%, which rose to
50% at three months after the workshop; however, this difference was not significant (p = 0.057). Participants
who had discussed end-of-life care with healthcare providers before the workshop totaled 6.9%, and this was
5.6% at three months after the workshop; therefore, there was no change (p = 1.000).

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Table 5. Changes in life-saving treatment preferences (N = 80).
Pre

Post
p-value

N

(%)

N

(%)

Cardiopulmonary resuscitation
Yes, I would
Leave it to the physician
Leave it to my family
No, I would not
I cannot decide

14
26
9
26
5

(17.5)(32.5)(11.3)(32.5)
(6.3)

8
29
13
26
4

(10.0)(36.3)(16.3)(32.5)(5.0)

Mechanical ventilation
Yes, I would
Leave it to the physician
Leave it to my family
No, I would not
I cannot decide

4
24
11
37
4

(5.0)
(30.0)(13.8)(46.3)
(5.0)

5
21
12
39
3

(6.3)
(26.3)(15.0)(48.8)(3.8)

Artificial nutrition
Yes, I would
Leave it to the physician
Leave it to my family
No, I would not
I cannot decide

6
17
13
41
3

(7.5)
(21.3)(16.3)(51.3)
(3.8)

7
13
9
47
4

(8.8)
(16.3)(11.3)(58.8)
(5.0)

0.486

0.893

0.275

Marginal homogeneity test. Question “If there is no chance of recovery from your illness, would you like to receive the following treatment?”

3.2.2. Knowledge: Awareness of ACP and Changes to the Degree of AD Knowledge
Awareness and acquisition of knowledge are the tertiary endpoints of this study. A total of 40.7%, 27.4%, and65.8% of participants responded that they were aware of ACP (AD/LW/durable power of attorney) before theworkshop, which rose to 83.7%, 73.8%, and 83.5%, respectively after the workshop. These differences were statistically significant (p < 0.001, p < 0.001, p = 0.001, respectively) (Table 2). The scores of AD knowledge wasan average of 5.1/10 (SD = 2.2) before the workshop, which rose significantly to 6.2 (SD = 1.8) after the workshop (p < 0.001) (Table 2).
3.2.3. Attitudes: Endorsement of ACP, Awareness of Importance, API
Most participants agreed prior to the workshop that end-of-life care and AD writing should be discussed; thispercentage did not change post-workshop (p = 1.000, p = 1.000, respectively) (Table 2). Over 95% of participants before and after the workshop responded that writing the AD and discussing it with family and healthcare
providers are important and there were no changes between pre and post-workshop (p = 0.129, p = 0.157, respectively) (Table 3). In all four questions measuring the degree of autonomy regarding medical treatment byAPI, there was no significant difference before and after the workshop (p = 0.344, p = 0.132, p = 0.917, p =0.392, respectively) (Table 4).
3.2.4. Preferences toward End-of-Life Care
Preferences for life-prolonging treatment—such as cardiopulmonary resuscitation, artificial respiration, and artificial nutrition—did not change before or after the workshop (p = 0.486, p = 0.893, p = 0.275, respectively)(Table 5).

4. Discussion
4.1. The Effect of Patient Characteristics on the Results
Compared to the rate of aging for Osakikamijima, the proportion of the elderly in this study was 54.2%, suggesting that a greater number of elderly participated in the workshop. Among participants aged over 65 years, ahigh proportion answered that their subjective health was good, which, when compared to prior studies [34],suggests that the elderly in this study were healthier. Additionally, the percentage of workshop participants living alone was 18.4%, which is similar to the same percentage for Osakikamijima (17.2%) [35], indicating that
common people participated in the study.

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The workshop was announced widely in the town’s PR brochure and given that participation was voluntary,
we surmise that the participants were an active group of individuals with a high degree of interest in end-of-lifecare. This group comprised people who were older but healthy and who did not live alone. The proportion ofparticipants with a family physician exceeded 80%. Compared to the percentage obtained through an investigation of 5667 people over 20 (32.8%) [36], the study participants have adequate access to a family physician, despite being elderly. Moreover, because we selectively informed the regional welfare commissioners, we inferthat the participants include those with a role in the region or with high consciousness. These individuals arelikely to be opinion leaders in the region, and their involvement and effect on group dynamics is important for
future promotion and popularization.

4.2. Effect of This Interventional Project
The primary endpoint of the AD completion rate increased significantly as a result of the educational intervention in this study. Compared to the completion rate of 5.7% after intervention reported by Matsui [26], our study
showed a higher completion rate. Given that the Ministry’s investigation showed an increasing trend of citizens
in favor of the LW [19], the changing preferences of citizens could also have influenced our results.
Additionally, there are three reasons that might explain our results: 1) Ease of instructions and provision of
examples; we distributed a model AD after the workshop. 2) Selection of influential people as the presenters. 3)
Ease of writing the AD; AD from Five Wishes [37] or Caring Connections [38], and LW from the Japan Society
for Dying with Dignity [39] used in previous references are all limited to a Do/Do not selection regarding
life-prolonging treatments and do not allow for a non-decision. The AD we developed for this study allows answers other than Do/Do not, and can be completed even if a decision has not yet been made.
As a result of investigating methods through collaboration and coordination with the town government fromthe planning phase, we believe that the group dynamics on the island foster region-wide concerns, ultimately
leading to an increase in the number of people writing AD. In other words, resident participation and empowerment were effective in producing the results. Before the workshop, fewer than half of the participants knew thespecific methods of ACP, such as AD and LW; this knowledge increased significantly after the workshop. Familiarity with legal representatives and the knowledge scale for AD also increased significantly, suggesting thatchanges in attitude toward writing are possible.
Knowledge and completion rate increased, on the other hand, the degree of autonomous decisions about API
and preferences for life-prolonging treatment did not change before and after the workshop. Even after theworkshop, 26% - 50% of participants responded that the decision for life-prolonging medical treatment is up to
the family or healthcare provider, and no improvement to autonomy was observed. Even though autonomy is an
important factor for promoting ACP [40], there have been no civil rights movements regarding medical procedures in the past in Japan, possibly leading to lower autonomy [41]. Therefore, it is necessary for Japanesepeople to aware the importance of critically considering their belief system and attitude regarding medical procedures they are going to take. As a fact, participants who responded that they discussed end-of-life care withfamily and healthcare providers before the workshop reevaluated their discussion as inadequate after being
shown more specific content. There is no clear guidance on what type of end-of-life care requires discussion in
Japan. For this reason, it is possible that people do not know what to discuss regarding end-of-life care. Therefore, it will be necessary to standardize the quality of discussions using the AD as a tool so that discussions reflect the preferences of a patient at their end of life.

4.3. Obstacles Preventing the Effective Function of ACP: The High Barriers ofCommunication between Citizens and Healthcare Providers
This study revealed some issues regarding ACP education in Japan. The results showed a slight increase in thenumber of discussions with family, whereas this number did not change for discussions with healthcare providers. The mentality to defer decision-making to the healthcare provider on specific medical procedures did notchange. One reason for this may be that AD is not legislated. In Japan, there is no opportunity for patients to obtain information on AD or to create one, as regulated by the Patient Self-determination Act. Additionally, there
is some paternalism when healthcare providers made decisions because patients were dependent on healthcare
providers as “citizens do not know any better regarding medical treatment” [42]. Therefore, the fact that someone else was making decisions about a medical treatment that one was receiving was never questioned. This de-942

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pendent model is gradually changing to an autonomous decision-based model [43]; however, legislation mandating information regarding AD to elderly patients over the age of 75 years may be required to break throughthis psychological dependency. In parallel, providing a common forum within the region for health care providers, care managers, and citizens to discuss successful dying at home will also lead to reformation of awareness.

4.4. Future Consideration
Promoting ACP without organized legislation may be difficult; however, citizens deserve the best medical care,and the mentality that one cannot consider their own QOL at the end-of-life and that it is the responsibility of thehealthcare provider must be changed. For this to happen, efforts cannot fall strictly on citizens (patients) andhealthcare providers must be willing to facilitate information exchange regarding end-of-life care, including
providing the time for discussions. Both sides must make an effort toward autonomous decision-making. In fact,some studies suggest patients who asked to complete AD or receiving an explanation about AD have a higher
AD completion rate [44], suggesting that a two-sided effort by patients and healthcare providers alike can move
ACP forward.

5. Conclusions
 Given that the AD completion rate increased in Osakikamijima, the empowerment and education intervention for the region’s citizens was effective.
 There was a slight increase in discussions with family, but no change regarding discussions with health careproviders.
 The education intervention increased awareness and knowledge regarding ACP, but did not change the autonomous decision-making process regarding end-of-life care.
 In Japan, the legislation does not yet provide a forum for thinking about ACP; however, in the future, citizens will have to change their mentality in order to decide their own medical treatment during their end-oflife stage. At the same time, it will be important for health care providers to approach these issues from theirperspectives as well.

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