From 2020 to 2022, Covid-19 was in fashion world wide. Many people were sick and died, and sometimes family members of a patient couldn’t meet at last time. Many people might think what was successful dying. On the other hand the number of aging people is expected to increase in Japan or Korea, and death may be an immediate problem. “Dying well” is studied about concept of good death. This concept arose from the hospice movement. A previous study [ 1] showed that matters such as symptom management, preparation for death, achieving a sense of completion, decision about treatment preferences, and being treated as a “whole person” are consistently important among patients, bereaved family members, and physicians. Miyashita, et al. [ 2] developed a “Good Death Inventory (GDI)” to measure how people perceived a good death or a desirable death process. Morita, et al. [ 3] conducted a cross sectional survey among palliative care physicians for Japan, Taiwan, and Korea using GDI. However, this study was focused on physicians and it is not clear how ordinary people think about good death cross culturally. Although Ando, et al. [ 4] conducted a survey among general people in Japan and Thailand land, this study conducted only in Asian countries. A common view is that the world can be divided into two cultures: individualist and (North America and Northern Europe) and collectivist/family-focused (e.g., Asian and Southern Europe). Since culture is important to consider in advanced care planning at end-of-life [ 5], we think that we need to investigate differences in both individualist and collectivist/ family focused. So in this study we included Japan, Korea, and America.

Similar concept of good death, people have view of life and death, sometimes called as death attitude. Wong, et al. [ 6] developed a Death Attitude Profile to measure death attitude. Hirai, et al. [ 7] developed a Death Attitude Inventory in Japan. After that, Kuroda, et al. [ 8] investigated death attitude for Japanese cancer patients, and showed views of life and death may differ according to sex, age and physical condition, and view can be useful in predicting where patients may wish to spend their final days. Also Tsuji and Tabuchi [ 9] revealed the relationships between terminal care attitude, personal attributes, and views on life and death of care workers in nursing home. In these studies, participants were patients or health care workers, and it is not clear how ordinary people think about death attitude. To clarify differences and characteristics among culture about concept of death in order to use in medical care situations, we planned to investigate concept of good death and view of life and death of ordinary peoples among Japanese, Korean, and American.

Participants were Japanese 93, (South) Korean112, and American 100, they were healthy ordinary people. Japanese were from Western Japan. Korean were from nation-wide reflecting ages and gender constitutions. American were from some states.

We used the Good Death Inventory (GDI) [ 2] and the Death Attitude Inventory (DAI) [ 7]. The GDI has 10 core components and 8 optional and measure how participants perceived a good death or a desirable death process, total 18 factors and 18 items. We added an item about “Death as a sleep” because some people want to do traditionally. The DAI has 7 factors and 27 items. Reliability and validity of both inventories were approved. For American, we translated from Japanese to English, then we conducted back translation from English to Japanese. The profession who understand Japanese and English confirmed this translation. For Korean, a profession translated from Japanese to Korean and another profession conducted back translation from Korean to Japanese. Moreover we asked “age”, “gender”, “death of familiar persons”, “visiting a hospital during last year”, and “with or without religion.”

In Japan, researchers distributed and collected envelopes including questionnaires to ordinary people who participated in workshop, office, or music party and so on. In Korea, online survey was performed with the GDI and the DAI. Then co-researcher send data from Koran to us. In America, we asked data collection for a cooperation and the officer collected data by online survey and send data to us.

We conducted one-factor analysis of variance on mean scores of the GDI and the DAI.

This study was approved by the Research Ethical Committee of Daiichi University of Pharmacy (approval number R03-002) and Yonsei University Health System, Severance Hospital, Institutional Review Board (approval number 4-2021-0966).

We showed the background of participants inTable 1. About age, the rate of 70-79 age Korean (19.1%) was higher than that of Japanese or American. About gender, the rate of female is higher than male in Japanese and American. As for religion, about 60% people in Korean and American had religion, though 14% Japanese.Table 2 showed score of the GDI.

In Japanese, the highest score is about “Not being a burden to others (6.33),” following “Physical and psychological comfort (6.15)” and “Environmental comfort (6.15).” The lowest score is about “Religious and spiritual comfort (3.38).”

In Korean, the highest score was about “Not being a burden to others (6.35),” followed “Being respected as an individual (6.31).” The lowest score was about “Receiving enough treatment,” following “Pride and beauty (5.54).”

In American, the high score was about “Feeling that one’s life is worth living (5.06),” following “Good relationships with family (5.06).” The low score was about “Unawareness of death (4.24),” following “Pride and beauty (4.29).

We conducted one-factor analysis of variance to compare scores of Japanese, Korean, and American (Table 2). The score of Japanese and Korean was equal statistically and America was significantly low from question number 1 to 13. The score of “Unawareness of Death” and “Religious and spiritual comfort” of Korea was the highest of the three countries.

There was not significant difference among three countries about “Receiving enough treatment.” And for an additional question about “Death as a sleep,” the score of Korean was highest.

The results of one-factor analysis of variance on score of the DAI is shown inTable 3.

As for “After life view,” the score of American was higher than those of Japanese or Korean. About “Death Anxiety/Fear,” the score of Japanese was the lower than those of Korean and American.

The scores of American about “Death as release” “Death Avoidance” and “View of a predestined lifespan” were the highest, following Korean and Japanese. The score of “Sense of Purpose of life” is higher than other factors in each country, and that of Japan was lower than other two countries.

From results of comparison (Table 2), the tendency that there was not significant difference between scores of Japanese and Korean in many factors, and American’ score was lower than two countries totally. Now we will discuss on characteristic points.

Japanese regard “Not being burden to others (6.33)” as the most important. Korean also regard it as the most important (6.35). It may be influenced by Asian culture of confucianism. Miyashita et al. [ 2] showed that Japanese general population might tend to emphasize the relationship with others rather than autonomy, and familial cohensiveness is a common attribute of Japanese and Asian cultures [ 10]. Thus Japanese and Korean in the present study regard “Not being burden to others” as important.

The score of “Religious and spiritual comfort” of Japanese was the lowest in Japanese scores, also comparing Korean and American. Since 14% Japanese have a religion, 56.4 % Korean, 65% American respectively, Japanese don’t regard “religious and spiritual comfort” as so important. Japanese at the present study might image of a particular or specific religion, and they may think religious aspect as important.

The score of “Being respected as an individual” in Korean was also high. It supports previous study of Morita et al. [ 3] in which physicians of Korean regarded “being respected as individual” as important. As for “Unawareness of death,” the score of Korean was the highest and that of Japanese was the lowest. Additionally, the score of Korean for “Death as a sleep” was the highest. One of the reasons is followings. The rate of suicide in Korean is high of OECD countries, because elders do not enjoy social security fully and economically sever [ ]. These facts may show that Korean would not confront sever social stress, rather they prefer “Unawareness of death” or “Death as a sleep.” However, on the other hand, the score of “Control over the future” is high. It may show that there are two streams which one group want to know the future and the other do not want to be aware of death. It may reflect of differences of ages.

American regard “Feeling that one’s life is worth living” as the most important. It shows that they may regard meaning or worth of their life as important. From the study of Dignity Therapy [ 13], people in Western culture regard work, attainments, and their social role as important. Thus American might regard “feeling that one’s life is worth living” as important.

The score of “Sense of Purpose of life” is higher than other factors in each country in common. Although people have different thinking for death, they have same thinking for living in common such that people have sense of purpose of life.

The score of “After life view” of American was the higher than that of Japanese and Korean. The reason why might be that 65% of American participants have religion, which rate was the higher than Korean or Japan. Then many American might believe afterlife in the present study. Steinhauser et al. [ 1] showed that 89% and 85% of USA patients emphasized “being at peace with God” and “prayer” respectively, although the corresponding rate were 37% and 52% in Japan.

The scores of American about “Death as release” and “Death Avoidance” were the highest of the 3 countries. American would like to avoid to think of death and think that death is release from burden of this word after life.

As for Japanese, the score of “Death Anxiety,” “Death as Release, and ” Death Avoidance” were the lowest. That is, Japanese may confront their end of life recently. One of the reason is that people recognize their own death by prevalence of the COVID-19 and many people’ death. A little ago, Miyashita et al. [ 2] showed that Japanese like to be unawareness of death, that is, autonomy seemed to be low, however the present study show high autonomy of Japanese. It supports that Japanese positively want to know their disease or future [ 3].

Lastly we propose some lately thinking of good death. Chen et al. [ 14] investigate good death from perspective of healthcare providers in Shanghai. And family member’s early involvement in caring for patients at the end-of-life stage helps achieve a good death. Mendoza [ 15] said that calling a death “good” is value judgement that might not necessarily get along to the patients. And she propose a new model of “Respectful Death.” It basically is model in which they dying, the family and professionals all work together and support death other with the goal of improving end-of-life care. Also Cohen-Masfield & Brill [ 16] showed another types of end-of-life care with quality of life such as euthanasia. In future, we need to think end-of-life care for death with cultural difference or new trend.

Although participants were about 100 in each country, we may need much more participants to confirm these results. And we used a back translation to use Japanese questionnaire for Korean and American. In these days, the Chinese version of the Good Death Inventory was developed [ 17]. In future we referrer it and need to use suitable questionnaire.

Meier, Gallegos, Thomas et al. [ 18] showed defining Good Death (successful dying) by literature review and the core is similar to Japanese version GDI. In future we may develop a GDI in common with other countries.

Japanese and Korean regard “not burden to others” as important for good death, and American regard “feeling that one’s life is worth living” as important. Japanese do not regard religion or spiritual comfort as important so much, and they have positive autonomy for good death and death attitude. Korean have two streams such that one regard “control over future” and the other regard “unawareness of death” as important. Since we found some difference for good death and view of life and death, we can refer these differences in clinical situations.

This study is not related with patent.

Supplementary Materials: There was not supplementary Materials.

Author Contributions:

Conceptualization: MA.

Methodology: MA, MM, IL, NY

Investigation: MA, HK, IL. Writing review: MA, HK, MM, IL, NY

Funding: This study was supported by Grant-in Aid for Scientific Research C (20K11011).

Data Availability Statement: If someone want to know data, Ando, M. can propose data in a possible range.

Acknowledgments: We thanks for participants in each country at heart. This study was supported by the National Center Consortium in Implementation Science for Health Equity (N‐EQUITY) from the Japan Health Research Promotion Bureau (JH) Research Fund (2019-(1)-4), and JH Project fund (JHP2022-J-02).

Conflicts of Interest: There was no conflict of interest.