The issue of end-of-life decision-making has become increasingly important in the super-ageing society that is Japan. Until now, however, there are little regulation and no legislation on end-of-life medical issues, such as forgoing life-sustaining treatment (LST) or advance directives. In 2007, the Ministry of Health, Labour and Welfare developed the first guideline on the decision-making process for terminal medical treatments. This guideline includes two key elements: (1) respecting patient self-determination and (2) broadening decision-making on the course of care to involve the healthcare team. However, it leaves many terms undefined and the position of liability is vague, leading to much uncertainty in healthcare practice. Revisions to the guideline in 2018 have emphasised advance care planning, but the completion rate for advance directives has, however, remained low, and this may be explained by practical and sociocultural factors. In light of this situation, we argue that we need further research and discussion to seek the best end-of-life decision-making framework that is most suitable for Japanese culture.