Background: Although the number of elderly cancer patients who require chemotherapy has increased, few studies have investigated the process of palliative chemotherapy decision-making and care needs of elderly patients with advanced cancer. Methods: The study was conducted at Nagoya University Hospital in Japan from April to October 2017. Face-to-face interviews were conducted with patients over 70 with advanced cancer (n = 15, median age = 77 years, range 70 - 82) who made decisions of palliative chemotherapy initiation within 6 months. Patients’ families and physicians were also interviewed individually. Interview transcripts were qualitatively analyzed using a deductive-inductive approach. Results: Four main themes emerged: physician’s awareness of paternalism, training of communication about serious news, spiritual-care needs assessment, and support with the team. Both the patients and the physicians felt the necessity for physicians’ paternalism in patients’ decision-making. The physicians found treatment decision-making for elderly patients difficult because of the patients’ diversities. Patients had spiritual pains from the time of diagnosis and they continued throughout treatment periods. They fought the illness with the support of surroundings as a team. Conclusions: Paternalism was emphasized from both elderly patients and physicians in palliative chemotherapy decision-making. Improvement of the communication skills of physicians was needed. Patients had spiritual-care needs beginning with the early phase of the treatments and fought as a team with their supporters, including physicians against the cancer. Physicians should be aware of that and be actively involved in whole-patient care.