As the proportion of deaths due to old age has increased in recent years, the number of deaths in nursing facilities for the elderly has also increased. A bonus fee for providing end-of-life care（EOLC）was introduced to these facilities in 2006, which have promoted EOLC provision since then, and about 80% of facilities now have a basic policy for providing EOLC. More specifically about the terms of the bonus fee, since 2015, mandates have been introduced to improve care quality through inter-professional work. In 2021, the provision of EOLC was allowed to be calculated from 41 days prior to death. As such, the evaluation process has changed to include early efforts to confirm the resident's wishes and to establish a care policy well advance of death. Consequently, the content added as a requirement in each bonus fee revision has stimulated the improvement of EOLC practices.

When a resident's physical function seems to be declining, the point of care practice in the facilities is to communicate with the residents and their families sufficiently to respect their wishes. During an unstable/deteriorating stage, just before the end-of-life stage, high-quality EOLC practices are vital; these include observation by care workers, assessments by nurses, and cooperation with part-time physicians in facilities. With consideration for the family regarding the burden of decision-making, support is provided, so that the family（and resident）becomes the primary decision-maker.

Bereaved families highly evaluate the EOLC provided by the facilities. This is because they consistently provide decision-making support, respecting the wishes of the residents and their families and providing highly individualized daily care for the residents.

Geriatric health service facilities（GHSFs）play important roles as intermediate care facilities for elderly individuals temporarily when they need rehabilitation before returning home. As the population ages, elderly persons spending their end-of-life（EOL）period in GHSFs is increasing. About 90 percent of the family of elderly persons who died at GHSFs satisfied with the EOL care provided at GHSFs. The factor associated with the satisfaction was providing information by multi-disciplinary team to the family in earlier stage of EOL. As GHSFs is providing service at home with day rehabilitation and home-visiting rehabilitation, GHSFs can provide services not only limited to the users end of life, but also to their continuing life.

Approximately 70％ of people in Japan wish to spend the last days of their lives in their own familiar home, but less than 20 ％ of people actually spend their final days at home. Many die in hospital, receiving treatment in hospital until the end. This poses a major challenge in two respects: the quality of life of patients and the appropriate use of healthcare resources.

Three factors are particularly important in the large gap between hope and reality in the final stages of life: decision-making support, home care support systems, and the burden of family care（and the patient's reservations about it）. These three factors influence each other.

No one knows which choice is the right one, especially in the final stage of life. That is why it is important that the choice is a satisfactory one. Shared decision making, in which the patient/family and the home care support team share the outlook on the course of the disease and consider together which choice is best for the patient, is fundamental. In this process, the patient's wishes are respected to the maximum extent possible, even if they have dementia. Care should also be taken not to place the responsibility for decision-making solely on the family.

Multidisciplinary support for home care is provided in accordance with the chosen treatment policy. As the patient's condition becomes unstable towards the end of life, family members and care professionals often feel anxious. Empowerment by medical professionals is important.

Cooperation of family members in care is important, but their involvement might make care difficult, especially in the case of dementia. Attention should also be paid to creating a situation in which family members can be involved in care with a reasonable sense of distance.

In Japan's hyper-aged society, many elderly people in the final stages of life are transported to emergency and intensive care facilities. However, many of them have not done Advance Care Planning（ACP）, and emergency/intensive care physicians need to perform “emergency ACP”. In the United States, there is a large body of evidence that communication skills training for intensive care providers enables better ACP. The authors have developed a Japanese version of Vital Talk, a well-known training method. This paper illustrates the communication skills advocated by the Japanese version of Vital Talk, and describes a method for emergency/intensive care providers to better communicate “bad news” to patients and their families, including frail elderly patients in the final stages of life, and to provide “emergency ACP” that respects the patient's sense of values.

In the future, an aging society will advance, and a multi-death society will arrive. Medical care is becoming more sophisticated, diagnostic techniques, treatment techniques, treatment equipment, therapeutic drugs, etc. have developed, and the number of diseases and conditions that can be treated has increased, and the scope of treatment adaptation is also expanding. The requests of patients and their families range from “I want you to do whatever you can” to “you don’t have to go that far anymore”, but while there are treatments and intervention methods that can be implemented, it is best to negotiate with how much intervention should be made. Judgement is difficult, especially when “death” is involved.

As the lifespan increases and the aging of the population progresses, it is clear that the number of people with dementia or cognitive function will gradually increase. What kind of response should be selected from treatment to care of those people? What is the best? “Hospitals” are divided into advanced acute, acute, convalescent （recovery rehabilitation, regional comprehensive care）, chronic. And among the outpatient clinics, there is home-visit medical care. There are also, nursing home for the aged, health facility for the aged, elderly housing with services, nursing home, and group home for the aged, etc. There are various responses according to the function of each place. Each has problems and ingenuity. As for the cause of death at the time of death diagnosis, it would be difficult to judge whether it is “sick death due to disease” or “natural death” or “death due to old age”.

I will report on the current situation of “end-of-life care” of dementia in the community comprehensive care ward of our hospital.

Frailty, advanced multimorbidity and uncertainty are important for palliative care in the elderly. To provide quality palliative care, a detailed palliative care assessment needs to be carried out and a proactive approach needs to be taken based on the assumption that there is uncertainty.

The Ministry of Health, Labor and Welfare has conducted a survey on end-of-life care for the public approximately every five years since 1992. So far, a total of seven surveys have been conducted. Recent surveys suggest that many members of the public prefer to spend their end of life in places other than medical institutions, such as care homes for the elderly or their own homes, if they were to develop dementia in the future.

However, because doctors are not always available at non-medical institutions, which may prevent them from promptly diagnosing death, and because of misunderstanding regarding Article 20 of the Medical Practitioners Law, it has been reported that some patients are forced to be hospitalized at a medical institution during the end of their lives, and the medical institution becomes their place of death.

Therefore, this paper discusses the general public's opinions regarding the final place of life based on the results of the above-mentioned survey by the Ministry of Health, Labor and Welfare, interprets Article 20 of the Medical Practitioners Law on （a diagnosis of death and） death certificate, and explains the related notification by the Ministry of Health, Labor and Welfare.

Medical Practitioners' Act, Article 20

No medical practitioner may provide medical treatment or issue a medical certificate or prescription without personally performing a medical examination, nor issue a birth certificate or certificate of stillbirth without personally being in attendance at the birth, nor issue a certificate of post mortem examination without personally performing the fact examination; provided, however, that this does not apply to a death certificate that has been issued where a patient undergoing medical care has died within 24 hours of the medical examination.