The Japan Geriatrics Society 2025 Position Statement on End‐of‐Life Care for Older Adults: English Translation of the Japanese Article

ABSTRACT

This paper presents the official position statement of the Japan Geriatrics Society (JGS), updating the “2012 JGS Position Statement” regarding end‐of‐life (EOL) care for older adults. The “2025 JGS Position Statement,” which was recently published in Japanese, introduces an original definition of EOL, conceptualizing it in two stages: first, based on the individual's medical condition, and subsequently, from the perspective of the individual's life story. In this statement, EOL care refers to medical treatment and care provided at the end of life, grounded in appropriate medical judgment, respecting the individual's way of life, and safeguarding their dignity until death. To the best of our knowledge, no previous definitions have conceptualized EOL in this two‐stage manner. The best EOL care described in this statement centers on the principles and practices of palliative care and integrates not only medical knowledge and techniques for diagnosis and treatment but also the collective intellectual and cultural achievements from the natural sciences, humanities, and social sciences. Addressing the psychosocial needs of family members is also an essential component of EOL care. The “2025 JGS Position Statement” presents 10 positions to protect the human rights and dignity of older adults, beginning with opposition to ageism and further promoting palliative care, especially in the field of non‐cancer diseases.

1. Introduction

Over the past half‐century, the medical circumstances and social environment surrounding end‐of‐life (EOL) care have undergone dramatic changes. Advances in medicine have significantly extended life expectancy, resulting in a growing emphasis on providing care that aligns with the values and views on life and death of each individual until the end of life. There is also an emphasis on the choice of place of care when a growing number of people prefer home care to institutionalization at the end of life. Professional ethics position the protection of human rights and dignity, centered on respect for the individual's wishes, as the duty of healthcare professionals responsible for the task [1, 2, 3, 4, 5].

The Japan Geriatrics Society (JGS), an academic organization of professionals in healthcare for older adults, published its first “Position Statement on Terminal Care for Older Adults” [6] in 2001. This statement was designed to provide ethical guidance and principles for professionals in the field, even in times of significant changes. About a decade later, the JGS revised the statement to align with societal changes, creating the “2012 JGS Position Statement” [7]. As the baby boomer generation reached the age of 75 in 2025 [8], the JGS updated the statement to reflect current issues and future prospects, resulting in the “2025 JGS Position Statement on End‐of‐Life Care for Older Adults” (“2025 JGS Position Statement”), which was recently published in Japanese [9].

The population of people aged 75 and over has exceeded 20 million [10], and the most common age of death has also exceeded 93 for women and 88 for men in Japan [11]. As a country with one of the highest life expectancies in the world [12], we aim to create a society that respects individuals as human beings until the end of life. We hope the “2025 JGS Position Statement” will serve as guidelines for professionals who are striving to provide the best possible end‐of‐life care (EOL care) and support for individuals until the end of life, despite facing various challenges in clinical settings. At the same time, we hope that it will contribute to the peace of mind of people living in Japan.

2. Basic Position

Founded in 1959, the JGS is a nationwide, not‐for‐profit organization of geriatric healthcare professionals. The JGS has about 6200 members, including geriatricians, physiotherapists, occupational therapists, nurses, nutritionists, and others. The JGS, together with the Japan Socio‐Gerontological Society, the Japan Society for Biomedical Gerontology, the Japanese Society of Gerodontology, the Japan Society of Care Management, the Japan Academy of Gerontological Nursing, and the Japanese Society of Geriatric Pharmacy, forms the Japan Federation of Gerontological Societies that has about 19 000 members.

The JGS takes the following as its basic position. Human aging, illness, and death are part of the life cycle following reproduction, generation, birth, and growth. The life sciences address life phenomena, including aging, illness, and death. These sciences have advanced alongside research in the natural, humanistic, and social sciences. Therefore, geriatric medicine and care for older adults addressing human aging, illness, and death should be based on life sciences with a foundation in a wide range of research findings from these disciplines and emphasize ethical perspectives related to life when providing holistic care and support. The JGS also endorses the five principles for older adults proposed by the United Nations: “independence,” “participation,” “care,” “self‐fulfillment,” and “dignity” [13].

3. Methods

The JGS End‐of‐Life (EOL) Subcommittee and Ethics Committee, responsible for promoting both public and professional understanding of the ethical issues fundamental to older adult care, undertook the revision of the “2012 JGS Position Statement.”

From April 2024, in preparation for the revision of the “2012 JGS Position Statement,” the EOL Subcommittee reviewed domestic and international literature and drafted a preliminary revision. This draft was thoroughly discussed within the EOL Subcommittee, and by September 2024, a draft of the revised statement was created. Subsequently, the expanded EOL Subcommittee and Ethics Committee held further discussions, resulting in a proposed revision in December 2024. A questionnaire survey was conducted in January 2025 among all 767 JGS delegates to gather their opinions on the proposed revision. Incorporating these insights, a draft of the “2025 JGS Position Statement” was prepared in March 2025. In early April 2025, opinions were solicited from all JGS members regarding the draft. After this comprehensive process, the JGS Board approved the “2025 JGS Position Statement” in late April 2025, and it was publicly announced at the JGS Annual Academic Meeting in June 2025.

4. Purpose of the “2025 JGS Position Statement”

Everyone has the right to receive the best possible EOL care, based on medically appropriate judgment and with full respect for their values, view on their own life story, and view on life and death based on their own thoughts, beliefs, and faith. The JGS expresses its position on EOL care for older adults to protect and promote this right of each individual.

10 positions of the “2025 JGS Position Statement”.

Position 1: Opposing ageism.

Position 2: Further promoting palliative care.

Position 3: Respecting the individual's wishes and preferences.

Position 4: Promoting support for decision‐making that respects human rights, dignity, and culture.

Position 5: Promoting the provision of end‐of‐life care by a multidisciplinary team.

Position 6: Promoting clinical ethics initiatives.

Position 7: Promoting home healthcare and the community‐based integrated care system.

Position 8: Promoting death education.

Position 9: Reflecting constant research advances in healthcare.

Position 10: Seeking to build a healthcare and welfare system that protects the human rights and dignity of older adults.

5. Definitions of Terms in the “2025 JGS Position Statement”

5.1. “End of Life”

“End of life” in the “2025 JGS Position Statement” is defined as follows.

1. [Medical Prospects] The disease or senility is irreversible, further treatment is not expected to improve the condition or prevent its progression, and death is inevitable within an unpredictable but limited timeframe.

2. [Perspective on view on one's own life story] Based on (1), from the perspective from which the healthcare team views the person's entire life story, the person can be considered living the last chapter of their life story, even after well respecting the person's expressed wishes regarding their life story. ¹

When the above items (1) and (2) are met, the individual is in “end of life.”

To the best of our knowledge, no previous definitions have conceptualized EOL in this two‐stage manner: initially, based on the individual's medical condition, and subsequently, from the perspective of the individual's life story. Thus, in the “2025 JGS Position Statement,” EOL care refers to medical treatment and comprehensive care provided at the end of life that is grounded in appropriate medical judgment, respects the individual's way of life, and safeguards their dignity until death.

Behind our arrival at this definition lies the introduction of new terminology by the Ministry of Health, Labor and Welfare (MHLW) of the Japanese government. The MHLW changed the name of the “Guidelines for the Decision‐Making Process in Terminal Care” (2007) to “Guidelines for the Decision‐Making Process in Medical Treatment and Care in the Final Stage of Life” [14] in 2015. The MHLW also announced its intention to replace the term “terminal” with the “final stage of life” wherever possible. When the MHLW made the announcement without defining the “final stage of life,” the ministry explained that this was based on the concept of “aiming for medical treatment and care that respect the individual's dignity and focuses on the person's way of life until the end of life” [15]. Traditionally, “terminal” has been defined by clinicians through decisions based on predictions of life expectancy. However, current medical practice requires that we emphasize the perspective of an individual's way of life, with medical judgment serving as the foundation.

As far as life expectancy is concerned, the MHLW guidelines, as well as other major domestic report [16] and international literature [17, 18], EOL period can range from just a few days to several years. Therefore, we believe that the concept of the “final stage of life” in Japanese guidelines broadly overlaps with the definitions of EOL used in other countries, especially given the absence of a unified definition of EOL worldwide.

The concept of EOL in the “2025 JGS Position Statement” has affinity with the “dual view of life theory” [19], which holds that human life can be viewed as “biological life” focusing on the body at the foundation and “biographical life” focusing on the person's life story. The “dual view of life theory” has been introduced in the JGS “Guidelines for the Decision‐Making Processes in Medical and Long‐term Care for Older Adults—Focusing on the Use of Artificial Hydration and Nutrition” [20] issued in 2012.

Medicine inherently takes a natural scientific view that focuses on the body, but when considering what is the best medical treatment and care for each individual, it is required to “consider how to maintain physical condition to achieve the best for the person's life story.” For more information on EOL, please refer to annotation 1.

5.2. “Best Medical Treatment and Care”

The “best medical treatment and care” in the “2025 JGS Position Statement,” that is the “best EOL care,” refers to “appropriate medical treatment and care that is centered on the concept and skills of palliative care and that integrates not only medical knowledge and techniques for diagnosis and treatment, but also all intellectual and cultural achievements, including other natural sciences, humanities, and social sciences.” Palliative care has been internationally emphasized as a part of basic human rights [21, 22]. “Appropriate medical treatment and care” respects the individual as a human being, taking care of the feelings of family members and others close to the individual [23], and guaranteeing freedom from pain and suffering as much as possible even when social resources are limited.

“The best medical treatment” in the “2025 JGS Position Statement” does not necessarily mean treatment that utilizes the latest or most advanced medical technologies. Medical treatment is often invasive, especially many advanced medical treatments are highly invasive, and even medical treatments that are effective for the general adult population may cause more harm and risk to older adults as they age [24, 25, 26]. The same is true for pharmacotherapy, and it is especially important to recognize the harms of polypharmacy [27].

Therefore, consideration must be given to the condition of each individual, such as the degree of aging, the presence or absence and degree of potential organ dysfunction, and response to medications [28]. In addition, it is important to understand each person's lifestyle and life story, and to consider the individual from a holistic perspective [29]. Appropriate medical treatment that is neither too little nor too much, and medical treatment and care that values quality of life (QOL) is important as the concept of “the best medical treatment and care” [30, 31].

See also “Position—2” for the importance of palliative care.

In addition, based on an interdisciplinary study that includes not only the natural sciences but also the humanities and social sciences, it is necessary to clarify the “best medical treatment and care” that meets the needs of each older adult while understanding their lifestyle and life story [32], which is one of the JGS's basic policies.

5.3. “Dignity”

The concept of “dignity” has undergone a complex historical evolution in both Western and Eastern societies, and “dignity” today is said to be polysemic [33, 34]. The Japanese word for “dignity” originates from the Chinese language and carries nuanced meanings that differ somewhat from the English word “dignity.” Therefore, healthcare professionals in Japan have long found it challenging to interpret and apply the concept of dignity in clinical settings.

The “2025 JGS Position Statement” presents a concept of “dignity” that is applicable in clinical settings, drawing on the meanings found in the English word “dignity” [35].

Therefore, “dignity” in the “2025 JGS Position Statement” can be used in either of two senses, depending on the context. In one, it means “the feeling that one's present self, just as it is, has inherent value,” which in this case is synonymous with “self‐esteem” or “self‐affirmation.” To maintain “dignity” to the end of life, that is, to enable an individual to continue to feel positive about themselves, is one of the main objectives of medical treatment and care. Therefore, when an older adult feels that they can no longer affirm their present self (i.e., that their dignity has been lost), healthcare professionals try to help the person regain their dignity. If medical treatment is judged to have damaged the person's dignity, its withdrawal may also need to be carefully considered, with the aim of restoring the person's dignity [36].

Another meaning of “dignity” is “the value of being worthy of respect.” For instance, when we say “all people have dignity,” it means “all people are worthy of respect.” In this sense, providing medical treatment and care that respects the individual as a human being is to treat them as a person with dignity. This approach rejects imposing or controlling actions upon the individual and emphasizes the importance of honoring their way of life, values, and wishes [37].

5.4. “Older Adults”

The JGS defines “older adults” as individuals aged 75 and over, based on medical judgment and data analysis [8, 38], although the Japanese government follows the international standard used in demographic statistics that define “older adults” as those aged 65 and over.

However, the “2025 JGS Position Statement” targets older adults at the end of life, a stage in which physical and mental changes accompanying aging are highly individualized. Therefore, in the “2025 JGS Position Statement,” the term “older adults” does not denote a uniform judgment based solely on chronological age; rather, it calls for decisions to be made based on each individual's specific condition.

5.5. “Family Members and Others Close to the Individual”

The term “family members and others close to the individual” in “the 2025 JGS Position Statement” does not mean only family members in the legal sense, but includes a wider range of people (close friends, etc.) who are trusted by the individual and support the person when they are at the end of life [39]. This concept assumes that the number of single‐person households will further increase in the near future.

6. 10 Positions of the “2025 JGS Position Statement”

6.1. Position 1. Opposing Ageism

All older adults, no matter what their condition, including those with dementia, are entitled to the “best medical treatment and care.” Oppose undermedication based on chronological age.

[Rationale] The right to the “best medical treatment and care” is one of the fundamental human rights for all people. Even if one is very old and has serious disabilities, the “best medical treatment and care” must be guaranteed. As the global trend against ageism in all areas of society becomes even clearer [40, 41, 42], it is important that the “2025 JGS Position Statement” makes clear its opposition to ageism in the field of EOL care.

6.2. Position 2. Further Promoting Palliative Care

Palliative care concepts and techniques are at the core of the best EOL care. Palliative care should be used more widely for older adults, regardless of disease or disability, and maximum efforts should be made to alleviate pain and suffering and maintain and improve QOL.

1. Determining the appropriateness of medical treatment at the end of life.

The appropriateness of medical treatment at the end of life should be determined with emphasis on the perspective of palliative care [43]. Palliative care is comprehensive and respects the human rights and dignity of the individual and aims to maintain and improve QOL. From this perspective, for example, withholding or withdrawal of medical treatment should be considered when there is a possibility that some medical treatment will impair the patient's dignity or increase their suffering.

Withholding medical treatment that would compromise a person's dignity or increase their suffering, as well as withdrawal of treatment once it has begun, are neither euthanasia nor assisted suicide, even though there is some confusion among clinicians in Japan. Meanwhile, as more countries are moving toward legalizing euthanasia, assisted suicide, or both, the JGS maintains its position of not supporting either practice.

It should be noted, however, that EOL care does not exclude curative treatment. In situations where the effectiveness of medical interventions is uncertain, such as when a sudden and unexpected change in condition occurs, it is essential to implement a “time‐limited trial (TLT)” to evaluate the treatment's effectiveness and safeguard the patient's rights. For more information on TLT, please refer to annotation 2.

• 2“Satisfaction of the individual” as a criterion for judgment.

To ensure that EOL care is provided holistically, it is essential that decisions about care options are made with careful consideration of the individual's own sense of satisfaction. The outcomes of medical treatment and care should also be evaluated based on how satisfied the individual feels.

• 3Family members and others close to the individual are also included in the care process.

Healthcare professionals must recognize the physical, psychosocial, and financial challenges faced by family members and others close to the individual, provide appropriate support, and help them maintain their overall well‐being. Supporting family members and others close to the individual in a multifaceted way is crucial to ensuring the best possible EOL care for the individual.

[Rationale] Palliative care is an approach that improves the QOL of individuals and the family who are facing problems associated with life‐threatening illness. It prevents and relieves suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual [44]. In addition, the total pain that is a compounding problem caused by these factors is also addressed. EOL care can be appropriately regarded as a form of palliative care [45]. It provides a system to prevent and alleviate pain and other painful symptoms, and to support the individual to live actively as much as possible until the end of life. QOL is a subjective evaluation, and emphasis on the QOL perspective contributes to the satisfaction and happiness of the person, which in turn leads to a sense of security and happiness for the family and others close to the individual.

It is enshrined in the International Covenant on Human Rights that all people should enjoy appropriate palliative care [21]. WHO calls on countries to develop health system measures that integrate palliative care services into all national health systems and ensure that all people, regardless of type of disease or age, have access to basic healthcare services, including palliative care [46]. It is predicted that the focus of palliative care will shift to older adults worldwide [47], and in Japan, where most deaths occur in people aged 85 years or older, the spread of geriatric palliative care is the biggest challenge. The importance of palliative care is increasingly recognized not only in the field of cancer, but also in the field of organ failure, neurodegenerative diseases, cerebrovascular disease, dementia, senility, and others [25, 48, 49].

The decision on artificial nutrition and hydration, including PEG tube feeding and nasogastric tube feeding, as well as all medical procedures such as tracheotomy and mechanical ventilation, which have long been complex issues at the end of life in Japan, should also be carefully considered from the perspective of palliative care.

In addition, special enlightenment is needed regarding the alleviation of suffering in persons with dementia. In the past, there was a discourse that as dementia became more severe, the person no longer experienced pain, but it is now clear that people with severe dementia feel pain as much as people without dementia [50]. It is the responsibility of health professionals to establish methods to recognize, appropriately assess, and approach the distress of individuals who experience distress but have difficulty expressing it, and some methods are currently being developed [51].

There is a need to further disseminate the concept of palliative care and develop methods and technologies to elucidate and understand the mechanisms of suffering to provide the best medical treatment and care to older adults, who often have multiple coexisting chronic conditions, or multimorbidity, including dementia.

In addition, TLT is necessary when the effectiveness of curative treatment is uncertain, such as in the case of an acute illness or in the case of an unexpected sudden change in health. To properly implement TLT, it must be accepted as standard practice to withdraw treatment when it is no longer required. Some clinicians in Japan, however, find it psychologically challenging to discontinue a treatment once it has begun. As a result, they often choose to withhold treatment instead, which can prevent patients from benefiting from potentially recoverable interventions, running counter to medical ethics [52].

Another problem is that some clinicians misunderstand DNAR (Do Not Attempt Resuscitation) orders and incorrectly refrain from all treatment when such an order is issued, even though DNAR only instructs the withholding of CPR [53, 54].

It is also important to support family members and others close to the individual to maintain and improve their health and QOL. It is necessary to understand the needs of family members and others, connect them to appropriate services, and reduce their physical and mental burdens. It is also important to provide grief care for them, including measures to deal with anticipatory grief.

6.3. Position 3. Respecting the Individual's Wishes and Preferences

It is imperative to respect the individual's wishes and preferences in making decisions about EOL care. It is important to respect the person's wishes and preferences even when verbal expressions become difficult for the person. Preferences include non‐verbal expressions of likes, dislikes, and pleasure/displeasure.

[Rationale] The decision‐making process in healthcare respects the wishes of the individual even at the end of life. If the person eventually has difficulty in verbally expressing themselves, the decision‐making process should be based on the presumption of the individual's wishes based on their previous words and actions, and the decision‐making process should be based on respect for these words and actions [20, 39, 55] in Japan, where there is no legal system for surrogate decision‐makers.

Although situations in which an individual has difficulty with verbal expression vary, it is important to presume that, for example, even individuals with dementia possess wishes and decision‐making capacity [55]. As outlined in the “Basic Act on Dementia to Promote an Inclusive Society” (2024) [56], respecting an individual's wishes is directly tied to upholding their human rights and dignity. The protection of human rights and dignity of those with dementia is recognized as one of the most important public health issues [57].

It is also important to respect the person's preferences as much as possible. Preferences include not only verbal expressions, but also nonverbal expressions such as gestures and facial expressions related to likes, dislikes, and pleasure or displeasure. Preferences could also be read from changes in vital signs [51].

Efforts should also be made to alleviate pain so that pain and discomfort do not interfere with the expression of wishes. Alleviating as much as possible the pain and discomfort that the individual is experiencing is not only the highest priority for providing medical treatment that respects the individual as a person, but also for thereby improving the ability to express wishes and preferences [25, 51].

In Japan, it is common for healthcare providers to ask family members to make decisions on behalf of the individual when the person's wishes are unclear. However, this approach is considered inappropriate. According to the MHLW guidelines, which work as a soft law in Japan, family members are expected to infer the patient's wishes and communicate these to the healthcare team, rather than making decisions for the person themselves [23, 39]. In other words, their role is to act as “advocates who speak on behalf of the person,” not as “surrogate decision‐makers.”

Unlike countries such as the United States, Canada, or Australia, Japan does not have a formal system for surrogate decision‐makers, so terms like “proxy” and “surrogate” cannot be applied in the same way in Japan. Additionally, asking family members to act as surrogate decision‐makers can result in them expressing their own preferences rather than those of the person. In Japanese culture, where family decisions have historically carried more weight than individual decisions, this may potentially infringe upon the person's rights. The JGS recommends referring to family members in these situations as “advocates who speak on behalf of the person” [23]. The JGS also recommends that both the general public and healthcare professionals engage in advance care planning (ACP) to ensure that the wishes and preferences of individuals are respected, especially when direct communication becomes impossible [23]. For more information on wishes and preferences, please refer to annotation 3.

6.4. Position 4. Promoting Support for Decision‐Making That Respects Human Rights, Dignity and Culture

In supporting decision‐making for EOL care, it is crucial to acknowledge and respect each individual's cultural background to safeguard their human rights and dignity. Shared decision‐making (SDM) should be achieved from the perspective of the person's unique life story, enabling the formation of a thoughtful consensus. Effectively implementing SDM at each key decision‐making point also facilitates ACP.

[Rationale] The way of decision‐making that respects the individual's wishes and preferences protects their dignity and reflects the cultural characteristics of the society to which the person belongs. The person's values and view on life and death based on cultural characteristics are reflected in their own life story. Therefore, when providing decision‐making support for the choices of medical treatment and care, and the place of care, it is important that the healthcare team, based on medical information and from the viewpoint of the person's own life story, repeatedly talk with the person and family and appropriately follow the process of SDM to reach a consensus that is believed to be the best choice for the person [20].

Distinctive cultural characteristics of Japan, as compared to English‐speaking countries that place emphasis on autonomy, include the significant involvement of family members in medical decision‐making, especially at the end of life; a tendency to avoid direct self‐expression out of consideration for others within a high‐context culture where people commonly anticipate and infer others' needs and intentions (“oshihakaru bunka” in Japanese); and a preference for delegating decisions to professionals. While these traits are especially pronounced among older generations, there are considerable individual differences even within the same age group. Therefore, it is essential to make efforts to understand the wishes and preferences of each individual [23].

It is also important to ensure appropriate SDM at key points, which typically arise multiple times throughout the trajectory of illness and aging. Efforts to promote SDM help healthcare professionals gradually deepen their understanding of the individual's values, general wishes and preferences, and perspectives on life and death, thereby supporting ACP that centers on the individual. The JGS defines ACP as “a process that supports people make decisions paying respect to each individual as a human being about their future medical treatment and care” [23], and promotes its efforts to protect each person's dignity until the end of life.

When working on ACP, it is essential for healthcare professionals to emphasize the process of dialogue with the individual and family [23, 39, 58]. Understanding the needs of both the person and family members, while providing support throughout the process, is crucial for achieving truly personalized care.

Such a process of dialogue and support builds a trusting relationship between the person and family members and the healthcare team, and even when the person eventually has difficulty in expressing their wishes and preferences, the healthcare team, together with the family members, can presume the person's wishes and preferences and respect them in the SDM process [25, 51]. By doing so, the goal is to realize the best EOL care that respects the person as a human being until the end of life [23].

6.5. Position 5. Promoting the Provision of End‐of‐Life Care by a Multidisciplinary Team

Promoting the provision of EOL care for older adults by a team of professionals from the widest possible range of disciplines.

[Rationale] EOL care should be provided in a comprehensive manner by a multidisciplinary team [43, 59]. Team members can include medical professionals, care professionals, welfare service providers, administrators, members of the clergy, community members, volunteers, family members, and all other related parties, depending on the individual's physical and mental condition. Each professional should support the individual and family members by utilizing their knowledge, skills, and experiences. Each professional working together as a team is expected to perform their duties while respecting each other and the individual and family.

It is necessary to promote the use of information and communication technology (ICT) while considering measures to ensure information protection [8] to facilitate smooth cooperation among the multidisciplinary team.

6.6. Position 6. Promoting Clinical Ethics Initiatives

To realize the best EOL care from the perspective of the individual, healthcare professionals should address issues related to clinical ethics as a multidisciplinary team.

[Rationale] Today, as respect for diverse values becomes increasingly important, clinical ethics initiatives are essential for supporting and realizing decision‐making regarding EOL care and the choice of care settings from the perspective of each individual. Healthcare professionals should share information among team members as well as with the individual and family, engage in repeated discussions, deepen mutual understanding, and strive to provide the best possible EOL care tailored to the individual's perspective [37].

To support the clinical ethics practices of frontline staff, medical institutions and care facilities for older adults are encouraged to establish clinical ethics committees or equivalent organizations composed of members from various professions, as well as clinical ethics consultation teams responsible for daily operations [60].

It is essential to promote clinical ethics conferences for cases where decision‐making support or its realization is challenging, making it routine practice to address issues from the perspective of the individual while also considering how to resolve ethical dilemmas. In this process, recognizing that appropriate support for families directly contributes to supporting the individual is important. Such clinical ethics activities foster an organizational culture focused on person‐centered healthcare, which, in turn, is believed to enhance both job satisfaction and well‐being among healthcare professionals [37].

Advancing clinical ethics initiatives regarding EOL care in each medical institution and care facility for older adults is expected to contribute to the development of a culture of EOL care that reflects both the medical advancements and social changes of the era.

6.7. Position 7. Promoting Home Healthcare and the Community‐Based Integrated Care System

To enable each person to live their own life in a comfortable place until the end of life, healthcare professionals from various fields involved in integrated community care should work together as a team to support the individual and family. To respond to the new era, it is important to promote DX (Digital Transformation) utilizing new technologies such as the Internet of Things (IoT).

[Rationale] Where and how do older adults want to spend their time? This wish depends on the values of each individual. The community‐based integrated care system has been developed to realize a society in which an individual can continue to live comfortably in the place of their choice selected in accordance with their wishes and preferences, and in which they can choose the treatment and care they receive according to their own values [61, 62]. Article 2 of the “Act for Facilitating Integrated Measures for Healthcare and Long‐term Care at the Regional Level” defines the “community‐based integrated care system,” which includes the perspectives of “medical treatment and nursing care,” “long‐term care to support those with diminished activities of daily living (ADL) and rehabilitation,” “health and welfare,” “prevention of long‐term care and daily life support,” “residence and how to live,” “the individual's choice and the attitude of the person and family,” as well as the perspective that “the individual can choose to live comfortably in the community.” In the year 2025, and in anticipation of the situation in Japan in the years to come, there is a need to build a community‐based integrated care system that can respond to the new era. When an individual progresses to the end of life, this needs to be recognized by all the multidisciplinary professionals involved in the community‐based integrated care, and medical and care services including EOL care need to be reviewed and supported until the end of life [63]. It is important to provide the best possible EOL care for the person. The goal is not to provide EOL care only at home, but it is necessary to collaborate with medical institutions and nursing care facilities depending on the situation. In addition, home healthcare is a part of the community‐based integrated care system, and all healthcare professionals should promote cooperation with each other on an equal footing. To ensure seamless sharing and integration of information between professionals, it is necessary to promote the use of new technologies such as the Internet of Things (IoT) and artificial intelligence (AI) [8, 32, 63].

6.8. Position 8. Promoting Death Education

Healthcare professionals should be provided with death education as well as education on EOL care. It is also important to continue awareness‐raising activities to ensure that the public widely understands the medical treatment and care provided from the perspective of holistic healthcare.

[Rationale] For many healthcare professionals, there is insufficient time available to learn about EOL care. Death education [64], which encompasses perspectives on life and death as well as the process of accepting death, should be incorporated into both undergraduate and postgraduate training. In addition, practical education should also be provided on symptom management for those at the end of life, nursing and caregiving techniques, and communication skills with the individual and family.

Furthermore, providing death education to the general public is believed to help foster a perspective on life and death. This understanding can contribute to recognizing that EOL care both protects the human rights and dignity of the individual and supports the maintenance and improvement of their EOL [43].

6.9. Position 9. Reflecting Constant Research Advances in Healthcare

Research activities should be continuously conducted to establish scientific evidence that medical and ethical judgments regarding EOL care, as well as the methods and techniques of palliative care, are beneficial for maintaining and improving QOL. Integrating findings from the humanities and social sciences is also essential. To this end, sufficient funding and its proper, effective allocation are highly desirable.

[Rationale] With respect to all medical treatment and care, it is essential to demonstrate, as far as possible, that such interventions are beneficial for maintaining and improving the individual's QOL. It is necessary to develop palliative care methodologies and techniques for a wide range of conditions, including dementia and non‐cancer diseases. This includes examining approaches to respect the wishes of older adults experiencing cognitive decline, establishing methods for evaluating QOL at the end of life, and implementing psychosocial and physical support measures for family members. Research on EOL care at care facilities for older adults and home care settings, in addition to medical institutions, is also needed [43]. In addition, it is important to conduct interdisciplinary research that includes the humanities and social sciences rooted in the Japanese view on life and death. Currently, the research environment and funding are inadequate.

The establishment of scientific evidence based on these studies is expected to eliminate arbitrariness on the part of healthcare professionals and lead to the protection of the human rights and dignity of the individual.

6.10. Position 10. Seeking to Build a Healthcare and Welfare System That Protects the Human Rights and Dignity of Older Adults

In anticipation of a near‐future society where the medical, nursing, and welfare needs of older adults are expected to peak, it is urgent to build a stable and sustainable healthcare and welfare system that safeguards the human rights and dignity of older adults. In particular, it is essential to promote palliative care, including care for non‐cancer conditions, and to establish a new acute medical care system, including emergency services, tailored for older adults.

[Rationale] In Japan, the population aged 85 and over is expected to exceed 10 million by 2035 and reach 11.5 million by 2060 [65]. More than half of this age group requires long‐term care for assisting with diminished ADL [66], and about 40% have dementia [67]. Even in a social context where the labor force is expected to decline further due to the falling birth rate, and the number of single‐person households and those consisting only of a couple aged 65 and over is expected to further increase, it is imperative to build stable and sustainable healthcare and welfare systems that protect the human rights and dignity of older adults.

To achieve this, it has become increasingly important to integrate palliative care [21, 22], which is an essential and enduring aspect of human rights, into all areas of the healthcare system, including emergency care, inpatient care, outpatient care, and home healthcare [46].

While much medical evidence has been created in Japan in recent years regarding palliative care for non‐cancer diseases, there has been almost no progress in palliative care policies and systems that have historically focused on cancer. There is a pressing need to accelerate initiatives that embed the principles and techniques of palliative care more broadly within geriatric clinical settings.

Furthermore, distortions in Japan's healthcare system for older adults are particularly pronounced in the field of emergency medicine. The number of emergency transports continues to rise [68], especially among those aged 85 and older, and this trend is expected to persist [69]. Since many of these patients present with minor conditions, strengthening primary emergency medical services is essential. Conversely, there are many instances in which emergency interventions at the end of life do not serve the patient's best interests and may compromise their dignity. Given these circumstances, it is vital to establish systems that facilitate ongoing information sharing among patients, families, and healthcare teams, and to promote ACP to ensure that patients' wishes and preferences are respected when they are unable to communicate them directly [70].

In addition, the risk of hospitalization‐associated disability (HAD) is higher in patients aged 85 and over [71]. In particular, one in four older adults hospitalized for aspiration pneumonia loses the ability to eat due to sarcopenic dysphagia without access to appropriate rehabilitation, nutrition, and care in the acute setting [72], and 45% of older adults with dementia admitted to general hospitals are under some form of physical restraint [73]. These are serious human rights issues. To address the issues of acute care, including emergency medical treatment, it is necessary to achieve systemic reform from an overarching perspective.

In every area, it is also required to utilize existing systems to support single‐person households and those consisting only of a couple aged 65 and over, which are expected to increase significantly in the near future [74, 75], as well as to consider with all parties concerned how new systems for lifetime support for older adults, including personal guarantees, should be designed [76].

7. Conclusion: The JGS Will Work Tirelessly in Line With This Position Statement

To realize EOL care that respects each individual as a human being, the JGS, as a professional organization responsible for medical treatment and care of older adults, will devote its untiring efforts to improve the situation. We will continue to advance scientific verification of research findings in the natural sciences, humanities, and social sciences, present evidence from an academic perspective, listen widely to the public, and continue discussions. By doing so, we will continue to disseminate information on the state of EOL care in line with the changing times.

The JGS promotes that all professionals involved in the medical treatment and care of older adults should work in accordance with the “2025 JGS Position Statement” in dialogue with the individual and family. We believe that this will lead to the development of a culture of the best EOL care that places the individual as the main actor, respects the person as a human being, and supports the family. We expect that this will lead to a review of conventional medical practices from the citizen's perspective and the establishment of a new era of EOL care.

It is important for us to continue to learn what we need to learn from other countries, while recognizing each individual's values, view on their own life story, view on life and death based on Japanese history and culture, and continuing to search for appropriate ways of dealing with issues in Japan. The mission of the JGS is to realize better EOL care for older adults by listening to the public at large, being accountable to them, and actively expressing our opinions on national policies [8].

8. Annotation

1. The usage of the term “End of life (EOL)” outside Japan.

There is currently no established definition of the term “end of life” used in a variety of clinical settings from acute care medical institutions to homecare settings, although there are various debates on the definition of these terms abroad.

On the other hand, from an academic perspective, clarification of the definition of EOL is essential. Therefore, in the course of conducting and reporting research, many studies present an operational definition of end‐of‐life as a specific period (such as a certain time before death). While there is no unified standard for this period, many studies define EOL as having a life expectancy of 6 months or 1 year [77], and clinical tools and diagnostic criteria used in practice also frequently adopt a 6‐ to 12‐month timeframe as the definition of end‐of‐life.

• 2The usage of the term “time‐limited trial” (TLT) [78, 79].

A trial of treatment for a certain period of time to confirm efficacy when there is uncertainty about the efficacy of the treatment. If the treatment does not produce the effect desired by the individual or if the medical efficacy of the treatment is not recognized, it is assumed that the treatment will be withdrawn while exhausting palliative care. This is based on discussions between the individual and family and the healthcare team regarding the goals of treatment and the individual's wishes and preferences. TLT is often applied to highly invasive and burdensome therapies such as ventilators, artificial liver support, dialysis, and Extracorporeal Membrane Oxygenation (ECMO), but it can be applied to any therapy, including tube feeding and antibiotics. One of the goals of TLT is to help the individual, family, and clinicians collaboratively navigate uncertainty about the efficacy and burden of treatment in critical illnesses [79].

• 3The usage of the term “Wishes and preferences.”

When making decisions regarding medical treatment, care, and place of treatment, it is most important to respect the individual's wishes and preferences.

According to the Japanese government MHLW's “Guidelines for Decision‐Making Support in Daily Life and Social Life of People with Dementia (2nd Edition)” [55], even if a person has insufficient decision‐making capacity due to dementia or other reasons, decision‐making support should be based on the premise that the person has wishes and preferences and the ability to make decisions.

In the United States, medical decision‐making capacity is often defined as competence—a legal concept comprising four related abilities: communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and reasoning with information in a rational manner [80].

In contrast, there is no equivalent legal framework in Japan. Instead, Japanese healthcare professionals are encouraged to support individuals in expressing their preferences to the fullest extent possible. Applying the American approach to people with dementia, brain dysfunction, or various diseases could result in the assessment that they lack decision‐making capacity, consequently making it difficult to provide support that respects their humanity and autonomy.

Therefore, the “Support Guide for People with Dementia—To realize the care that takes into account the wishes and preferences of the individual until the end of life” [51], a research group funded by the MHLW Research Grant, emphasizes respect for the “wishes and preferences” that the person is able to express, even if this ability has been reduced to a considerable degree. In this case, “wishes and preferences” includes not only verbal expressions but also non‐verbal expressions of likes and dislikes, as well as pleasure and discomfort. Healthcare professionals are required to try to understand the likes, dislikes, and pleasure/displeasure expressed by the person through gestures, facial expressions, and body language. Professionals involved in EOL care should actively observe the pain associated with medical treatment and nursing care, using objective assessment methods including the Abbey Pain Scale [81].

Author Contributions

All authors are members of the JGS End‐of‐Life (EOL) Subcommittee and Ethics Committee that were responsible for compiling the “2025 JGS Position Statement,” and the JGS chairman who supervised the whole process of the revision.

Disclosure

There was no sponsor for this paper.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

Tomohiro Katsuya has received lecture fees from Daiichi Sankyo Company, Limited, Novartis Pharma K.K., Otsuka Pharmaceutical Co. Ltd., and CureApp Inc. The other authors declare no conflicts of interest.

Aita K., Nishikawa M., Hattori Y., et al., “The Japan Geriatrics Society 2025 Position Statement on End‐of‐Life Care for Older Adults: English Translation of the Japanese Article,” Geriatrics & Gerontology International 25, no. 12 (2025): 1681–1692, 10.1111/ggi.70228.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.