When culture shapes the final chapter: Lessons from Japan for palliative aged care

An article written by Dr Yumi Naito, Associate Lecturer, College of Nursing and Health Sciences, Flinders University

This article has been prepared from Dr Yumi Naito's seminar presentation for the Research Centre for Palliative Care, Death and Dying (RePaDD) on 17 March 2026, "Cultural Influences on End-of-Life Decision Making for Older Adults in Japan" (15mins) with the assistance of AI, and reviewed by Dr Naito for accuracy.

If you've worked in aged care for any length of time, you'll know that end-of-life conversations are rarely straightforward. Add deeply held cultural frameworks, around family, authority, and what it means to die well, and the complexity grows. Dr Yumi Naito from Flinders University has been exploring exactly this territory, examining how Japanese culture influences end-of-life decision-making for older adults.

Her findings are grounded in the Japanese healthcare context, but they offer a useful lens for anyone supporting older people with Japanese heritage. Japan has the highest life expectancy in the world, with 30% of its population aged over 65. It's also a society with a strong, cohesive cultural identity and some deeply embedded values that shape how illness, family, and dying are understood.

Dr Naito highlights five concepts that are particularly relevant in end-of-life care:

• Omakase - trusting and deferring to medical expertise, often without asking questions or voicing personal preferences.
• Amae - a valued sense of dependence on others; expecting to be cared for is culturally appropriate.
• Sekentei - concern for public appearance and family reputation, which can influence what decisions get made and what gets said aloud.
• Ishindenshin - intuitive, non-verbal communication; the expectation that others will understand without explicit words.
• Omoiyari - compassionate consideration for others, which can lead people to withhold distressing information to protect loved ones.

Where This Creates Complexity in Clinical Practice

In the Japanese healthcare system, these values tend to play out in some consistent ways. Decision-making is often family-centred rather than individual. An older person may genuinely expect their family to make decisions on their behalf. Sharing a terminal prognosis directly with a patient may be avoided out of omoiyari, with families sometimes requesting that difficult news be withheld. And while Japan has government guidelines for advance care planning, they aren't legally binding, so family dynamics carry significant weight in practice.

For clinicians working in Japan in palliative and end-of-life care, navigating these patterns and balancing patient autonomy with family involvement, managing disclosure sensitively, and working within a more hierarchical structure is challenging.

When Dr Naito reflected on how her research might apply to Japanese migrants, such as those living in Australia or further abroad, she noted that her experience would suggest that there is a degree of assimilation to local practices creating more readiness to adopt a country’s’ communication style and ways of doing things.

However, that doesn't mean cultural heritage stops mattering. Like all people from culturally and linguistically diverse (CALD) backgrounds, older Japanese Australians may hold a blend of values, some shaped by their country of origin, some by their life here, and some by their own individual experience. But family may still play a central role. Silence may carry meaning. The desire not to be a burden may run deep.

The key is not to assume either way. We shouldn't presume how much or how little cultural heritage is influencing an older person's preferences and expectations. Dr Naito's research is a good reminder that cultural competence isn't about having a checklist. It's about genuine curiosity, asking open questions, noticing what's said and what isn't, and creating space for family involvement without sidelining the person at the centre of care.

For any older person from a Japanese background, or indeed any background, the most useful starting point is the same: What matters to this person, and who matters to them?

The answers will vary. That's the point. And even though national palliative care priorities are to provide person-centred care including shared decision-making; particularly around end-of-life planning, choosing to not make decisions, is also a decision.

For more information on the specific needs of individuals and groups as they age, palliAGED has a summary of useful information and resources to support practice.

Author

Dr Yumi Naito

Associate Lecturer, College of Nursing and Health Sciences

Flinders University