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Objectives: To analyse the decision making for end of life care for patients with cancer at a teaching hospital in Japan at two periods 10 years apart. Design and selling: Retrospective study conducted in a 550 bed community teaching hospital in Okinawa, Japan. Patients: There were 124 terminally ill cancer patients (45 women; 79 men; median age, 69 years) admitted either in 1989 and 1999 for end of life care with sufficient data to permit analysis. Main measurements: Basic demographic data, notification to the patient that he or she had cancer, patient involvement in do not resuscitate (DNR) orders, and various medical interventions which were performed in the month prior to the patient's death were evaluated. Results: In 1989 none of the patients were notified of their diagnosis; in 1999 five patients were informed (p = 0.026). Of the 113 (91%) patients with a written DNR order, none were involved in consenting to the DNR order. In the month before death, patients in both groups received non-palliative treatments such as feeding tube placements (five in 1989; five in 1999), total parenteral nutrition (six in 1989; eight in 1999), and intravenous albumin infusion (four in 1989; five in 1999). Morphine use increased (30%) significantly in 1999 compared with the 1989 group. Conclusions: The majority of patients dying of cancer were still not informed of their diagnosis and were seldom involved in DNR decision making at a teaching hospital in Japan. There was no change in the number of potentially futile interventions that were performed (6-13%) but morphine use increased. Modern ethical education is urgently needed in Japanese medical practice to improve decision making process in the end of life care. [ABSTRACT FROM AUTHOR]