The terms “thanatology” and “gerontology” were both created at the same time in 1903 from Greek by Metchnikoff. Both fields are of an interdisciplinary nature comprising sciences (natural and social) and humanities, i.e. philosophy, religion, literature, etc. Both fields should have been studied integrally and comprehensively.
However, this has not been hitherto successfully done, partly because the development of thanatology has lagged behind gerontology. Until the 1980s, dealing with death had tended to be taboo except in religion, philosophy and bioethics.
Over the past three decades, evidence-based studies on quality of dying and/or death (QOD (D)) in relation to terminal care have developed mainly in the United States and Canada. That is largely due to the mechanisms of the conceptual framework and the development of measurements for assessing the process and outcomes for quantitative end-of-life research for QOD (D). Further investigations using operational concepts at the end of life are warranted.
However, investigations of thanatology should not be restricted to QOD (D) in the short span at the end of life. QOD (D) should be discussed in relation to QOL throughout the entire life. The method for researching these issues in that field will be narrative as in the observed literature including biography, pathography, etc., rather than quantitative. Both studies in sciences and humanities are expected to contribute to the development of thanatology. The present paper includes the author's personal opinions regarding topics currently raised, although he is not able to demonstrate the topological significance for the framework of the whole of thanatology.

View full abstract

How to respond to the terminally ill situation has been an important issue in Japan since the advancement of medical technology makes it possible to prolong life without any hope of recovery, the patient being in the perpetual vegetative state, for instance. In the United States, where four principles of biomedical ethics was born in 1970s, they enacted a natural death act and made a judicial decision, such as Karen Quinlan case, to introduce the new element of ethics of autonomy to respond to the new era. The situation in Japan is static, however, and even today some physicians and lawyers argue that the withdrawal or withholding of a life prolonging measure would give rise to a charge of murder.
Now substantial number of parliamentary members prepare a draft bill of the so called death with dignity act. In this article, I analyze each article of this bill to express my concern that it may make the situation worse, while it could give a relief of legal immunity to a medical provider who would comply with the requirement under the bill. Since the law is regarded as formalistic, uniformly applied and inflexible in Japan in general terms, this act if enacted may not help the development of medical ethics in the end of life situation. In consideration of the fact that, since the Health Ministry issued a process guideline for the end of life treatment in 2007, no scandal of police investigation of this sort has occurred, it may be wiser to see the development of health professionals' guidelines and leave the matter to medical ethics.

View full abstract

As important participants in a shared decision-making process, patients and their families are expected to form informed intentions, on the basis of which they build consensus with other participants to make shared decisions. Not only decision-aids, but also actual support by medical workers is needed via communication with patients and families. Concerning this support, the following points are discussed in the present paper.
First, there are two guidelines published in Japan regarding the medical decisionmaking process. On the surface, the guidelines for the medical decision-making process in terminal stages created by the Ministry of Health, Labor and Welfare (2007) might seem to recommend individualistic self-determination by patients so far as they are competent. However, with careful word-by-word analysis, they actually recommend respect for patient self-determination based on the consensus reached by deliberation between the participants. The guidelines for the decision-making process concerning artificial hydration and nutrition for elderly people by the Japan Geriatrics Society (2012) explicitly recommend the preceding points of the MHLW guidelines and add more detailed explanations.
Second, the latter guidelines demonstrate the “information-sharing and consensusseeking model,” a type of shared decision-making including a process of communication, wherein the patient and other participants share information and seek consensus on the basis of the patient's way of life. Through such a process, the participants support the patient (and the family) to reach an informed decision.
Third, ACP, the process of making a care-plan in advance, is best understood on the basis of the information-sharing and consensus-seeking model. Not only the advance directive for the end of life, but also many other decisions before the end should be deliberated in advance. Sharing the patients' way of living and values should be the basis for the advance shared care planning.

View full abstract

The focus of demand for medical care is shifting substantially toward elderly people, due to the rapid advance of the super-aging society, so a paradigm shift is required in approaches to medical care and the provision thereof.
The 20th century was a time of great progress and achievement in the evolution of curative medicine. Curing involves finding and removing the cause of organ damage. Until we reach our 60s, diseases tend to take the form of a single problem in a single organ, so there was high demand for curative medicine. However, in the 21st century, now that the average life expectancy is in excess of 80 years of age, most medical demand is focused on chronic systemic diseases, in which lifestyle-related diseases complicate the aging process.
If we try to cure a single problem in a single organ without giving consideration to achieving an appropriate balance with the rest of the body, problems can emerge in maintaining the harmony between the system as a whole and the functions of individual organs, which can exacerbate issues with the patient’s general condition. Accordingly, medical care for elderly people needs to focus not simply on curing people, but on shaping and supporting their ability to take care of themselves, so that each person can live the life they want.
Another issue is the paradigm shift away from hospital-centered medical care to community-centered medicine. In Japan, we have built a system for the provision of medical care in which everything from birth through to death takes place in a hospital. This has been supported by the system of universal insurance, but its limitations have now come into stark focus.
In future, based on an understanding that there are limits to both financial resources and service provision, we will need to change to a more effective, efficient medical care system, in which hospitals specialize in the functions that only hospitals can offer, and medical and nursing care are provided in the community as a whole in an integrated manner.

View full abstract

Now, more than ever, we need to think about how we will meet our end. Various life-prolonging treatments are progressively being developed. Our healthcare system is based on universal health insurance coverage. The peaceful nation of Japan has become a society with the world’s highest life expectancy. Although we should be able to choose how we meet our end, we no longer understand how far medical care should intervene.
We humans are creatures of nature. We will all decline with advancing age and ultimately cease even to be able to eat for ourselves. That is because the body is about to cease living. The amount of hydration and nutrition that we need will gradually decrease. We are going to die, so we do not need it anymore. The less is inside us, the more peacefully we can die.
Humankind has known since ancient times that dying of old age is the most peaceful of deaths. However, we in modern times have come to regard death as a taboo, obsessively trying to avoid the reality before our eyes and believing that a dying person will go on living if we give them an infusion or a gastrostomy feeding tube, even though it prolongs the agony.
Medicine was originally a science for people. Right now, we have reached the point where we need to consider approaches to medical care during the final chapter of our lives. The term“ peaceful death,” which I myself coined, advocates that if treatment aimed solely at prolonging life is meaningless, we should not hold people liable for withholding such treatment.
It is the law of nature that we live and then die, and modern medicine will be complete once we develop the ability to adjust medical care in old age.

View full abstract

Having been involved in home nursing since 1992, I have provided home end-of-life care to numerous people. Based on my experience, I have come to realize the vital tasks in implementing home end-of-life care are (1) changing ways of thinking among the public (overcoming their devotion to hospitals); (2) changing ways of thinking among health care practitioners (conquering the stereotype among themselves that home care is impossible); (3) establishing a system of regional medical collaboration; (4) enhancing community nursing care systems; and (5) developing comprehensive administrative systems that enable continuum of care from prevention to end-of-life care.
Four examples that bear this out are described: a case of home end-of-life care for a young cancer patient, the case of an elderly lung cancer patient living alone, the case of an extremely elderly person not requiring any complex care equipment, and the case of a patient with gastrostomy tube, who insisted on oral feeding.
This paper touches upon the concept of fraility (infirmity) and presents ideas for a final farewell fulfilling the surviving family members’sense of accomplishment. Moreover, empirical knowledge of home end-of-life care can provide useful information for the care in living environments other than the home.
On supporting aging in the accustomed community requires building communities in which integrated community care actually functions. To this end, providing preventive care as a point of contact for integrated community care, the Kurashi-no-Hokenshitsu (The Daily Life Healthcare Room), has served to accomplish tasks (1), (2) and (3) above, while lobbying for tasks (4) and (5).
Integrated community care is necessary not only for elderly people, but also for those who face difficulties in their daily lives, so efforts in this area are expected to be extended and linked into regional development.

View full abstract

The Care Town Kodaira Team was launched in October 2005 to provide both cancer and non-cancer palliative care in the community. What we aim to provide is inhome palliative care. Of course, home medical care is not the same as in-home palliative care.
The Team combines a variety of services in a single establishment, including home medical examinations based on the principle of palliative care, home nursing, inhome care support services, and daycare center that also support users with complex medical needs, as well as meal delivery services and other services that help to support in-home care. This is because our experience of hospice facilities has led us to the realization that high-quality palliative care—even that delivered in-home—requires a multidisciplinary team that can meet face-to-face.
October 2015 marks the 10th anniversary of the Team's establishment. This paper reports on the reality of this initiative, describing links with the community and how this has given rise to the formation of a Bereaved Families Association, some members of which now participate in the Team's activities on a voluntary basis. Furthermore, a home hospice initiative inspired by the original program in the Miyazaki area was launched within the Team's service area in April 2014.
The basic principle of palliative care, which aims to provide total care, is the provision of universal care applicable not only in clinical practice, but also in a variety of settings within the community. We are confident that this will forge links between people in areas that are already beginning to be described as isolated communities and could become a key principle of regional regeneration.

View full abstract

When I give lectures, I always ask the audience three questions: “where, how, and from whom do you want to receive end-of-life care?” Eighty percent of them replied, “I'd rather be at home. I'd like my family to look after me at the end of my life. But I know that's probably impossible.”
It is estimated that the annual number of deaths in Japan will grow by about 400,000 to 1.6 million in 2025, when the baby boomers reach the age of 75. Medical advancement has brought long life expectancy in which people spend quite a long period of time receiving some kind of daily living support till the end of their life. Furthermore, caring capacities of the communities and of the families are getting weaker through structural changes of the society. “Where, how, and by whom long term-care will be provided” is a major issue to everyone.
Kasan-no-Ie [Mom's House] was opened in 2006 as an answer to the above question. It is an initiative to relocate people to a home-like environment in their neighborhood. They live in a group of five people when they are no longer able to live alone independently. Medical and nursing care services are outsourced to visiting practitioners, who form a multidisciplinary team to offer personalized care. Living assistance is provided in form of informal support 24 hours a day, 365 days a year. The support complements formal public services. A network of citizens in Miyazaki is utilized, providing integrated community care. They provide close complementary support to enable those living in Kasan-no-Ie to continue living in their familiar neighborhood surrounded by familiar people till the last moment of their lives. Families will have no regrets on their beloved one's end of life care.
Home hospice care is a movement that restores the culture of end-of-life care to communities and to families.

View full abstract

How should we face our final days? Naturally, there are various options: battling with cancer until the end, wanting to die naturally in one’s own home, and wishing to be allowed to die with dignity, among others. Having had breast cancer discovered at the age of 34 and having experienced a local recurrence, all I could think about at the time was of battling to stay alive for as long as possible, even if it was just one extra day. However, although ten years have now passed, I still do not have a clear idea of what I want to do in the years to come, if I grow old. My wishes might differ according to my age or family situation when the time comes. In the super-aging society with a declining population, there might be economic constraints in terms of how to finance huge treatment costs. We might have to meet our deaths with impaired judgment, due to dementia or other conditions. I believe that as we face an age of large numbers of deaths, some kind of rules will inevitably be formulated about dying with dignity. However, the first thing that we need to do is to build a support system that enables us to think about what we want and to convey this to our families and those around us, so that we can experience a dignified death, with as little suffering as possible and with which we and (if they are around) our families can feel satisfied.

View full abstract

The Japanese population is aging at a rate hitherto unseen anywhere in the world. In particular, the common assumptions about society and systems will be forced into a metamorphosis by the advent of 2025, when the baby-boom generation will become “latter-stage elderly” (those aged 75 or over).
More specifically, while the classical approach in the future will be to deploy preventive policies to ensure that everyone can maintain their self-reliance as much as possible, the big question will be how – once it has become normal for people to require the assistance of others for a certain period before they die – to ensure quality of life that will enable each person to continue to live as they choose in the community and be able to say that they are glad to be alive.
The integrated community care system tries to achieve this. This paper verifies the principles and nature of integrated community care and then introduces the structure and techniques used in the Kashiwa Project, as a practical model aimed at translating this into reality. The key points are the promotion of multidisciplinary partnerships encompassing home medical care and the development of housing for seniors that offers key services around the clock, including home medical and nursing care services.
In addition, bearing in mind the practical examples at the Kashiwa Project, this paper explains specific approaches to programs promoting partnerships between home medical care and nursing care, which will be the main key to implementing systemic reforms aimed at the integrated provision of medical and nursing care. Finally, it asserts that innovative change is required in order to ensure that our lifestyles and attitudes become more suited to our super-aging society.

View full abstract

The purpose of this study is to reveal the budgetary system for hospitals based on cost accounting. Interviews were conducted with 6 hospitals in 2013.
This study reveals that hospitals aspiring towards management based on responsibility accounting use monthly cost accounting data focusing on controllability by each responsibility center (i.e. department). The study also shows that the budget consists of revenue, calculated by medical fees and the number of patients, and variable expense, calculated at a rate proportional to the revenue, in each department. We also find that the number of patients functiones as an important performance indicator in budgetary control.
The results imply that top management uses the budget as an interactive tool with managers. When managers propose major projects, top management make decisions decides based on financial feasibility, communicating with the manager.

View full abstract