End-of-Life Care: A Doctor’s Advice for a Peaceful Farewell

The Dilemma of Life-Sustaining Treatment in Hospitals

There was once a controversial policy proposal: “Make end-of-life care self-funded.” This raised strong resistance and anxiety, as the question of how to handle the inevitable end-of-life care was something no one could avoid.

Should patients be kept alive through artificial ventilation and IV drips, or should they switch to palliative care? The choice swings between the patient’s own wishes and the feelings of the family.

In reality, over 80% of Japanese people die in hospitals, and only about 10% pass away at home. Despite the growing availability of home healthcare, where individuals can cherish their own time during their final days, most people still choose to die in a hospital. Why is that?

Life-sustaining treatments in hospitals often include artificial ventilators, CPR, IV drips, tube feeding, dialysis, and chemotherapy—medical practices focused on simply keeping the life going. However, Dr. Mitsushige Yamanaka, director of the Shirohige Homecare Clinic, questions this approach.

“When it comes to terminally ill patients, hospitals often think, ‘If they can’t eat, give them IV drips.’ But giving an IV drip can cause the body to swell from the fluids, increase ascites and mucus, and actually make breathing harder. It adds unnecessary suffering to a body that is trying to quietly close its chapter” (Dr. Yamanaka).

When receiving end-of-life care at home, palliative care takes precedence. However, many patients and families still view home-based palliative care as the last resort after treatment options are exhausted. But this isn’t the case.

“By using opioids (medical narcotics) and steroids appropriately, we can relieve pain and fatigue, and sometimes even restore activity. It’s possible to travel, enjoy meals with family—palliative care doesn’t shorten life, it restores the time to live as one truly desires.”

At Dr. Yamanaka’s clinic, full-time physicians provide 24/7 care, 365 days a year. They personally respond during nights and holidays, offering patients and their families a great sense of security.

“In home healthcare, just go to the hospital if there’s a problem is meaningless. The core of homecare is to be fully responsible for the patient until the end—this is the origin of home healthcare. Patients and families can trust the process because they know we promise to be by their side until the very end. Home healthcare requires a commitment not to give up halfway through. With that commitment comes trust. And most importantly, being able to face the end of life at home, in the person’s own space and in their own way, is the greatest value of home healthcare.”

The same applies to cancer treatment.

“Even if we shrink the tumor, there are surgeries and chemotherapy treatments that may not lead to recovery or a healthy life. In these cases, the option to choose palliative care, which removes pain and suffering, and allows someone to live their last days as they wish, is just as valid.”

Dr. Yamanaka raises an important question:

“When an elderly person has little stamina or recovery ability to withstand surgery, is it really the best choice to push them into an operation? The key question is not ‘How to shrink the cancer,’ but ‘How do we live the remaining time?'”

While chemotherapy and surgery can extend life, the side effects and complications often impair the quality of life. On the other hand, introducing palliative care alleviates pain and increases the time spent living gently and peacefully. Fighting cancer is not the only way to live. Choosing to live peacefully and true to oneself until the very end is also a precious choice.

Preparation You Can Make Because You Know the Time of Passing

In hospitals, families are often faced with the binary question: “Do you want life-sustaining treatment, or not?” However, Dr. Yamanaka questions this very premise.

“Some family members feel strong resistance to answering ‘No’ to life-sustaining treatment. It might sound like they are abandoning their loved one. That’s why I focus not on the question of ‘Do you want life-sustaining treatment or not?’ but on thinking together with the family about ‘How to live fully until the end.'”

Having cared for over 1,000 patients in home healthcare, Dr. Yamanaka has become adept at sensing the “remaining time” from even the slightest changes.

“Even when a patient is speaking energetically, I can sometimes tell that the end is near based on subtle changes in their voice or facial expression. The final moment can come suddenly, like descending a steep staircase. That’s why I share these signs with the family and work with them to think about ‘how to spend this time.'”

In home healthcare, if a patient can no longer eat, the focus is not on forcing IV fluids but on respecting the body’s natural process. In some cases, subcutaneous fluids are used to provide minimal hydration, but the goal is not to prolong life—it’s to ease suffering.

“When we reduce the IV fluids, families often feel anxious. But reducing fluids actually helps ease breathing and softens their expression. The natural drying of the body is a process that reduces suffering. That’s why I always carefully explain this to the family and make sure they understand and agree before reducing the fluids.”

Dr. Yamanaka’s team includes over 200 professionals, including doctors, nurses, pharmacists, and counselors, who hold daily conferences to share information.

“Doctors alone cannot support a patient until the end. By collaborating with caregivers, pharmacies, and nurses, we can make the wish to die at home a reality.”

End-of-life care is not unnecessary. On the contrary, it is absolutely essential. However, it should not involve prolonging life at the cost of suffering or adding to the patient’s pain.

“End-of-life care is neither about forcing someone to live nor doing nothing. It’s about alleviating suffering, fulfilling the patient’s wishes, easing the family’s anxieties, and allowing the person to pass away in their own way. That’s what end-of-life care should be.”

As the post-war baby boomer generation approaches old age, Japan is entering an era of super-aging. Politicians who have called for privatizing end-of-life care should think carefully. What is truly needed is not pushing the burden onto individuals but creating a system where everyone can pass away with dignity and peace of mind.

Mitsushige Yamanaka
Graduated from the Faculty of Law at Keio University and the Faculty of Medicine at Gunma University. After working in medical activities in Africa, he became the youngest-ever mayor of Matsusaka City, Mie Prefecture, in 2009, serving two terms. After stepping down, he transitioned to home healthcare and currently runs the Shirohige Home Healthcare Clinic in Edogawa, Tokyo, with a team of around 200 staff members. He is dedicated to community healthcare.