With a growing number of elderly expected to die at home rather than in hospital in rapidly aging Japan, efforts are under way to train people who can ease the dying through their final days.

The End-of-Life Care Association of Japan launched in 2015 is at the forefront of initiatives to help the elderly and those suffering from terminal illnesses come to terms with their approaching end.

While family members and caregivers may have little to offer in the way of medical interventions, they will increasingly be called upon to play a significant role in addressing patients' emotional and psychological needs in the last stages of their lives.

Rika Aida, a 46-year-old care manager, has been matching care staff with service users and crafting care plans for elderly people for around 16 years. Before learning about end-of-life care, she always felt frustrated that she could not ease the mental anguish of dying patients.

"When an aging woman told me, 'I am a heavy burden on my family. I just want to die soon,' I did not know what to say to her," said Aida, who took a certification course at the association. "I was bad at handling the uncomfortable silence that followed such depressing comments. I felt I just wanted to run away from the situation," she added.

Unable to work out what to do, Aida felt a need to talk over the problem with others in her situation and learn how better to help patients prepare peacefully for death.

To meet such needs, physician Taketoshi Ozawa among others who launched the association, offered a once- or twice-a-month program to teach doctors, nurses and care providers -- and even family members -- skills to help dying patients cope with distress and anxiety.

"End-of-life care is not about encouraging dying persons. We teach participants to understand the agony that patients face. It is important to identify with their suffering, which is the disparity between the ideal situations they wish to see and the reality," said Ozawa, 54, who chairs the association and makes house calls in his community.

"We should remove suffering if possible. If not, we need to help patients recognize they have the strength to overcome it," said Ozawa.

The association has trained more than 2,000 people including medical and nursing care staffers through its two-day program. Through lectures and role-play activities, Ozawa helps participants understand how they can contribute, regardless of their profession.

Among a number of techniques, Ozawa teaches seminar participants to properly "catch the messages" delivered by patients and articulate their suffering in words by repeating their comments, even if they could be construed as very negative.

For instance, when a patient says, "I've lost my physical strength. Why did I get this disease?" an end-of-life caregiver might reply simply by repeating what the person has said in the affirmative without offering any remedies.

Done with the appropriate facial expressions, tone and style of speaking, patients may get a sense that their pain or distress has been understood, said Ozawa, adding, "People feel pleased when there is someone who can understand their suffering."

Moments of silence may not necessarily be negative, either, he said, as they could indicate that patients are trying to reveal their true feelings or sort out their thoughts. If silences last too long, he recommends asking what patients are thinking about.

Demand for such skills is expected to grow further as Japan's baby boomers will turn 75 or older in 2025 and annual deaths are projected to reach 1.5 million the same year, up some 200,000 from the current level.

As hospitals will not be able to fully accommodate the increasing number of elderly, more people in the community, including family members, will have to care for them at home.

Aida completed a written assignment after the seminar and was certified as an end-of-life care supporter by the association.

After attending the training, she said she gained confidence to communicate with elderly and terminally ill people. She began seeing noticeable differences in their reactions after employing a number of techniques she had learned, such as the art of good listening.

"Instead of remaining silent, I now repeat what patients say to show that I am listening and understanding them. Then they started telling me more of their inner feelings. Now I feel I am communicating with them on a deeper level," Aida said.

While some family members, friends or care coordinators may cease frequent visits to terminally ill patients due to grief, despair, and other reasons, simply being present in the same room can be an extremely soothing experience for patients, said Ozawa, noting that anyone can be of help to those who are dying.

"Choosing where to stay, whether to receive or not to receive medical services is also a crucial aspect of end-of-life care," said Ozawa.

According to a government survey, more than half of respondents in Japan expressed their wish to die at home but only about 10 percent actually did so. Around 80 percent died in hospitals.

The gap is believed to be attributable not only to a lack of home medical services in communities but also to excessive medical care provided by hospitals to terminally ill patients, often against their will and resulting in unnecessary pain, Ozawa said.

One way to have people determine their own fate is to let them express their intentions in writing. However, a survey by the health ministry found that although 70 percent of people said they agreed with drawing up plans for their death, only 3 percent actually do so.

Ozawa and Aida believe that family, care workers and others involved are able to facilitate talks about end-of-life care well before health conditions deteriorate.

Unfortunately, though, Aida said many patients ended up dying in hospitals despite their desire to return home because they think returning will burden family members. Some family members, for their part, appear willing to care for relatives at home, but because of misunderstandings that arise it is sometimes too late.

Ozawa is planning more training courses to make end-of-life assistance accessible to anyone regardless of where they live. He said he would like to see more people pursuing careers in the field as the experiences, contrary to what people generally believe, are often rewarding.

"There were moments when I could see patients extending their last messages and appreciation to their family or finding the meaning in their lives. When I can help them do that with peace of mind, it is precious," he said.