Context: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. Objectives: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. Design: Self administered survey and qualitative study using open question and content analysis. Setting: Japan. Participants: Physicians known to have cared for a patient who had presented a living will prior to death. Measurements: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. Main results: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. Conclusions: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.