Implementing remote death certification in Japan: a nationwide cross-sectional study of awareness, barriers and facilitators.

OBJECTIVES: To examine awareness of remote death certification (RDC), perceptions of guideline requirements, and barriers and facilitators to implementation among physicians and nurses involved in primary and home medical care in Japan, and to explore implications for health systems facing population ageing. DESIGN: Nationwide cross-sectional web-based survey. SETTING: Primary care and home medical care settings in Japan, targeting clinicians across all 47 prefectures. PARTICIPANTS: Participants were recruited using the official mailing lists of three major national academic societies in Japan related to primary care. Individuals who were not physicians or nurses and those who did not provide consent were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were awareness of RDC guidelines and perceived barriers related to six predefined guideline requirements. Secondary outcomes included general barriers and facilitators to implementation, as well as differences according to practice location and prior consideration or implementation experience. RESULTS: Of 526 physicians and nurses included, 81.2% considered RDC necessary but only 1.1% had implemented it, and 58.0% were unaware of the 2024 revised guidelines. The most frequently reported barriers were shortages of nurses trained in information and communication technology (ICT)-based death certification (81.6%) and limited training opportunities (77.9%). Clinicians who had considered or implemented RDC were more likely to perceive guideline requirements as overly strict than those who had not (65.7% vs 42.9%, p<0.001). In remote areas, the availability of ICT infrastructure was more frequently perceived as a barrier (47.9% vs 30.9%, p=0.004). Key facilitators included regional end-of-life care networks (88.6%), improved nurse reimbursement (87.1%) and tools for family consensus-building (86.9%). CONCLUSIONS: Despite high perceived need, implementation of RDC remains extremely limited. Key barriers include workforce constraints, insufficient training opportunities and perceived rigidity of guideline requirements. Addressing these barriers through flexible implementation strategies and strengthened system-level support may facilitate the adoption of telemedicine-based end-of-life care in ageing and resource-constrained health systems.