1. Background and Government Policy
Japan has achieved an average life expectancy ranked among the highest in the world. This is a result of its excellent health and medical systems, which include a national health insurance program, public health measures, and advanced medical technology. Japan is entering an era in which it will become a super aged society ahead of other countries, and therefore it is in urgent need of actualizing a healthy society of longevity. A society fully grounded in the principles of health longevity.
In Japan, the life expectancies at birth in 2015 were age 80.75 for males and age 86.99 for females [1], which is one of the highest in the world. Moreover, the rate of aging is increasing as fast as ever lived and is projected to rise to 39.9% in 2060 [2]. As this society ages, it will face an increasing number of elderly in need of care due for such conditions as dementia, lifestyle illnesses, and articular diseases. Japan is encountering a significant challenge that must address the issues of not just living long, but also how to extend a ‘healthy life expectancy.’ If Japan is able to meet this challenge, it will help our elderly spend their lives in accordance with what they are hoping for, while also reducing the expenses or costs related to social security.
To this end, the Japanese government proposed and executing ‘ extending the healthy life expectancy of its people’ as a major theme in the ‘Strategic Market Creation Plan’ since 2013. Therein the government commits to actualizing a society by enhancing effective preventive care services and health management, activating medicinerelated industries, and developing access to better medical care and nursing care by 2030 [3].
Moreover, as for the length of time when someone is in poor health, the results of calculating that period of time, including not only the time spent taking care of someone in advanced age but also when experiencing health problems during his or her lifetime, showed that the calibrated period of time for men was 9.13 years, and for women, 12.68 years based on the data in 2010 [4].
The number of patients among both inpatients and outpatients age 65 or older tends to increase, and those age 65 or older are holding at 70.0% for inpatients, 45.0% for outpatients, with high medical costs per person[5,6]. Therefore, it seems important to help the elderly maintain a good state of physical health that doesn’t require frequent visits to a doctor, and to provide them with the medical services they hope to have. In short, the capacity to reduce pain, inconvenience, and different results in mind for the elderly during those periods when they are dealing with unhealthy conditions will be of great benefit to Gerontological Nursing in the future.
2. Expectations and the Reality of the Final Days
The Ministry of Health, Labour and Welfare, MHLW, reported in 2017 the trends in the number of deaths and place structure percentage in deaths. Death at home was over 80% until the early 50’s, then it began to decline due to progresses in medical technology, medical system establishments, and lifestyle changes. Such deaths remained the majority until 1975, but are around 13% today, whereas death in medical institutions has now over 80% [7,8].
On the other hand, according to a survey in 2008 regarding terminal care by the MHLW, around 60% of people expected to undergo medical treatment at home, though it included two groups, one who would like to stay home to the last and the other who would like to stay home basically but be hospitalized if the need should arise. [9] Also in the survey in 2014, situational questions were added. In the case of terminal cancer when the patient has enough food intake, no pain, and normal consciousness similar to those who are healthy, 70% of people expect to undergo medical treatment at home. In the case of terminal cancer when there is trouble with food intake or respiration, 37.4% of people expect to stay at home, 47.3% to be hospitalized, and 13.7% to stay at nursing facilities. In the case of a greatly debilitated condition when the patient is suffering from dementia and needing someone’s help, 59.2% of people expect to stay at nursing facilities, 26.8% to stay at medical institutions, and 11.8% to stay at home. This data reflects the fact that the majority wishes to spend their last hours at home. Among the elderly, the higher the level of consciousness and judgment is, the higher will be the level of expectation for that. Moreover, when in need of taking personal care, it seems there is an increasing expectation in terms of receiving nursing services at medical institutes or nursing facilities [10].
A policy of housing for elderly was unveiled in 2010 by the Ministry of Land, Infrastructure and Transport. It states that the proportion of the currently established state of housing for the elderly in Japan is lower than that in other advanced countries, and that the number of deaths is expected to grow by 400,000 people by 2030 based on the vital statistics. Thus, Japan is facing a big challenge in terms of securing places for the end of life [11,12].
The Annual Report on the Aging Society in 2013 by the Cabinet Office states that when there is no hope for a cure for oneself, ‘hope to let nature take its course without medical treatments just for prolonging one’s lifetime’ gained 91.0%, ‘hope to get any therapy for prolonging one’s lifetime, even just a little’ gained 5.1%, whereas, when there is no hope for a cure for your family, ‘hope to let nature take its course without medical treatments just for prolonging one’s lifetime’ gained 73.7%, and ‘hope to get any therapy for prolonging one’s lifetime, even just a little’ gained 14.7%. In addition, there is trend toward an increased intention to let nature take its course compared to 10 years ago [13].
According to the MHLW, in a 2014 survey regarding medical treatment in the final days of life, 42.2% of the people at large talk to their family about medical treatment in their final stage of life, while 55.9%, the largest percentage, did not talk about it at all. To make the instruction for the terminal care was supported 69.7% of the people at large; however, there are only 3.2% of them who supported it. Hence, when it comes to the crunch, the decision tend to be asked to the family, and their decision tend to choice toward to life prolong compared to the situation of themselves.[14] It cannot be denied that the family’s decision, which tends to choose the prolonging of life, might not respect the will of the person who is at the end stage of life.
One of major reasons many people die in the hospital is the lack of infrastructure development regarding home care systems and the quality of the dwelling. That infrastructure is readily being developed under the leadership of the relevant ministries and agencies. It will be necessary not only to develop physical infrastructures but also to enhance soft measures to reflect the wish of the elderly person at the last stage of life. From the Quality of Life perspective, it will be critical to guide and help the elderly with the following:
- Developing the ability to face oneself, including doing some soul-searching to know what kind of care you would like to have;
- Learning to talk in detail with one's family and healthcare professionals about your ideas regarding the final days.
- Making instructions for your own care, if necessary.
Competing Interests
The authors have no competing interests with the work presented in this manuscript.