Opinion survey among nursing students on family

Earlier discharges of patients from hospital are increasing needs for supports for home medical care, which is causing changes in the activities of medical providers for patients and family members. Meanwhile, it is suggested that the younger generation is more indifferent to family members along with the increase of nuclear families or households consisting of only one member. This time, the author conducted an opinion survey among nursing students for the purpose of understanding how nursing students think of the family and using the data as a reference for the education. The survey was conducted in FY2000 and FY2001 for the questions selected from the "National Lifestyle Popularity Survey". The results indicate that nursing students intend to have families while keeping working and are willing to fulfill their responsibilities as a family member of which relation is close. It is considered possible to guide nursing students to practice nursing respecting the position and feeling of the patient by letting them understand social changes and the individuality of the patient based on the way nursing students think of the family.     

Questionnaire survey for doctors in the area of cooporation efforts when a terminal cancer is transformed to home medical care

In order to smoothly transform a terminal cancer patient from hospital to home medical care, we surveyed based on questionnaires to examine doctor's roles of each primary and regional hospitals and its cooperation among the hospitals. We established two types of questionnaires for two groups, a primary doctor group and a regional doctor group, and distributed and collected them. A total of 123 doctors (35 primary doctors and 88 regional doctors) responded out of 185 doctors, and the collection rate was 66.5%. The survey result indicated that there were significant differences among the primary and regional doctors in evaluating patient's family members for understanding of the patients disease at the time of discharge, how to give a treatment to the patient, alleviating patient's disease conditions and a mental support given by doctor to family members from the hospital. Meanwhile, about 70% of regional doctors answered that family members had some sort of anxieties during a night and at the time of emergency to care the patient. It also revealed that about 70% of regional doctors had experienced troubles in coordinating with a primary hospital. On the other hand, 62% of primary doctors answered that they always provided necessary care to the patient at the time of emergency. In providing a safe and a high degree of QOL in home medical care settings, it is important to have specific common purposes among the two groups of doctors and patients. Furthermore, the primary and regional doctors have to be cooperative, specify duty roles when the patient is transformed to home medical care, and to have ways to accomplish mutual common goals for patients.     

The roles of a visiting nurse for a terminal stage patient with chronic renal failure: a case study

A visiting nursing service was provided for an 87-year-old male patient with terminal stage of chronic renal failure. Although his primary doctor told us that the patient's prognosis is no good with general prostration, the patient was cared at home because his family strongly wanted him in a home care environment. The patient, who is having a right nephrostomy catheter and urethrovesical indwelling catheter and is in an unstable condition due to dehydration caused by an aggravation of renal failure, left the hospital in the end of August in 2005. Meanwhile, a family care giver was feeling uneasiness due to a lack of experience in giving medical treatment and to care for the patient. Therefore, a visiting nurse provided support to reduce the caregiver's anxiety and taught how to observe the patient's conditions, to give medical treatment and a method to care the patient at home. As a result, the patient's symptom was little improved to a lesser degree of stable condition. The family caregiver's anxiety was also reduced as well. The roles of a visiting nurse for a terminal stage patient are: (1) to urge the family care giver to obtain basic self reliant home care techniques, (2) to create a division of clear roles among the family members, (3) to execute an individualized life for the patient and family, (4) to try to establish a system to cooperate with a medical support group.     

Comparison of the families of terminal stage cancer patients who underwent HPN and the nurses who cared those patients in their thoughts on home care

In the home care for terminal stage cancer patients, the quality of life of patients has been regarded as more important than the QOL of their family. Now, however, we think the QOL of the family of the patients is as important as that of the patients themselves. We investigated the opinion of the families and nurses by questionnaire in the HPN care for terminal stage cancer patients and compared them. The family answered positively about HPN, but they had a negative opinion in that they do not want to undergo HPN because they felt a heavy burden and responsibility in caring for patients, and they do not want to cause these feelings in others in their family. The nurses also answered positively about HPN, and they answered that they want to undergo HPN if they have terminal stage cancer. These results suggest that the family feels a greater burden and responsibility in caring for patients at home than the medical staff realize. The medical staff should support the family as well as terminal stage cancer patients and should not force our own opinions as medical staff.     

Present situation of terminal care and home rehabilitation at Karuizawa Hospital

Rehabilitation is usually considered to have the connotation of regaining function or reintegration into society, and no direction or achievement regarding the time of involvement or details of request has been suggested for the terminal rehabilitation in the patients with cancer who can't expect to have any improvement. Dieatz defines four phases for the goal of rehabilitation in the patients with cancer; Preventive Phase, Recovering Phase, Supportive Phase and Alleviative Phase. This time, we encountered a couple of cases in patients with cancer: patients who gained QOL through developing environment and setting goals that enable them to maintain the active daily life (ADL) at the supportive phase; and patients who realized us when relieving the pain while losing self-consciousness due to psychosomatic changes at the alleviative phase. In this report, we discuss what care can be provided at the phase when trust of the patient/family members is established, at the phase when care providers can grasp needs, and at the phase when the needs can be satisfied. We also report on how the patient and family member reacted to the direct hand massage provided by the physical therapist at the terminal stage. The rehabilitation system for home care at each phase is discussed in association with practical side and problems of the rehabilitation in the future terminal care.     

Home medical care from our hospital

From April, 1996 to March, 1999, our hospital provided home medical care on a 24-hour basis for fifty patients with advanced or terminal cancer. Eventually, twenty-four patients died at home and twenty-six in the hospital. Stability of health status, the presence of willing and able caregivers, as well as a greater number of house-calls are suggested factors in facilitating a death at home. However, the patients who died in the hospital were obliged to readmit themselves until the time of death due to caregivers' reasons such as fatigue, emotional stress and/or health problems. In addition to timely availability and accessibility of respite care, psychosocial support for family caregivers by liaison nurses remains an issue to be solved in future.     

An experimental weekly visit of the ward at Higashi Yamato Hospital--a holistic cooperation

The city of Higashi Yamato is located in the northern part of Tama, Suburbs of Tokyo, and the population of Higashi Yamato is approximately 80,000. The Higashi Yamato visiting nursing station was opened in April 1998. As of April 2006, we have over 100 patients, and the aggregate visiting nursing services have provided more than 600 cases. Our station's uniqueness is that forty percent of the patients have malignant neurological disorders and are terminal stage patients, and that they are all covered by medical care insurance. We also provide nursing services to patients who are expected to be dying peacefully at home averaging 4 patients per month. Higashi Yamato Hospital, attached to the visiting nursing station, is an acute phase hospital and has 274 beds. The average hospital stay for our patients was 13 days in 2005. We promote an early discharge from the hospital for patients who have a high need of medical and nursing care and for the patients who are at the terminal stage. However, there were many cases where visiting nursing care services were provided because of a local care manager's request rather than a visiting nursing care need for patients who will be discharged soon from the hospital and for those expecting to have the service. In reality, we have observed a family being felt that his or her patient was pushed out from the hospital, a family who has no confidence in taking a nursing task at home, and a family who could not cope with the patient's changing condition. Therefore, we wanted resolve these observed problems urgently to create close cooperation with the hospital in order to provide continued nursing care after a patient is discharged from the hospital and to have home medical care safely. As a result, we planned a visit to the ward on a weekly basis starting on February 2006. We report here because we had a good result.     

Key issues in death at home

After our facility was first opened, we provided terminal care for one patient with terminal stomach cancer. In this case palliative care, so important in terminal care, and care for the family was insufficient, and in the end we had to abandon the process assuring the kind of death the patient wished for at home. Learning from this experience, we have provided terminal care to about 150 patients based on each patient's outlook on life and view of life and death. These patients have included terminal cancer patients and patients informed of their cancer who chose to coexist with the cancer and live together with their families. At home, the words and facial expressions of the patients and their families are clear expressions of their humanity. At times, such, feelings are also directed frankly and unaffectedly toward us, the visiting nursing staff. When considering the early case in which we were unable to continue home care, we could see various problems: on the part of the medical staff including primary physician and nurses, the welfare service, the patient and family, and neighboring informal social resources. These included problems in informing the patient of his cancer and his remaining days. In home treatment of patients with terminal cancer, death at home assisted by a physician from the same medical facility is not emotionally all it might appear to be. Nurses, for example, do not provide religious comfort; therefore, they can not provide home hospice services. Or so it is said. However, in supporting community home care, there is an exchange between humans and the communication of genuine feelings; thus, the nurturing of warm care makes possible the kind of death the person wishes. In fact, we can not deny that that is the path we are taking. In the present report, we explore the issues that make home terminal care possible from the viewpoint of visiting nurses.     

Present situation of home care and roles of nurses at Tokyo Women's Medical University Hospital--through the 5-year home care support activities

Diseases, details of interventions, medical cares provided and the condition of use and services of local medical institutions were investigated in the home care support activities during the period from November 1997 to March 2003. We intervened in 1,309 patients. 70% of them were terminal patients with malignant tumor. Interventions were mostly consultations about the life under medical care, guidance about HPN/tube feeding, consultations about nursing and coordination with local medical institutions. 422 of them were under care of family doctors. 502 of them used visiting nursing. 70% of the patients under care of the hospital required high-tech home care and home hospice care. The 5-year activities indicate that nurses who support home care at the hospitals providing acute medical care are expected to 1. serve as the consultation contact for patients and families, 2. support the life under medical care in consultation with internal and external related professionals, 3. use social resources, 4. serve as the contact for providing the logistic support under an emergent situation or under the lack of care-giving capabilities, 5. provide guidance for the safe use of high-tech home medical care by patients/families at the discharge, 6. communicate or coordinate with local medical institutions for continued care/nursing and 7. develop/support the flexible and convenient distribution system of medical equipment and medical materials/drugs or the 24-hour healthcare support system jointly with private enterprises.     

Assessment of quality of care in an oncology institute using information on patients' satisfaction

OBJECTIVE: To evaluate the feasibility of conducting a patient satisfaction survey in the oncology hospital setting, using a multidimensional patient satisfaction questionnaire to be completed at home. METHODS: Socio-demographic and clinical data were collected for 133 consecutive patients. Patients were asked to complete the European Organisation for Research and Treatment of Cancer QLQ-C30 (version 2.0) just before hospital discharge and the Comprehensive Assessment of Satisfaction with Care at home 2 weeks after discharge. RESULTS: Respondents (73% of patients approached) were younger, hospitalized for a shorter time and presented less appetite loss, nausea and vomiting and better physical and role functioning than non-responders. The aspects of care for which patients wanted the most improvement were associated with the provision of medical information. In multivariate analyses, longer hospital stay was associated with higher satisfaction with all aspects of medical and nursing care, most probably because patients discharged early were not assured of continuity of care and lacked information regarding self-care at home. Higher global quality of life was associated with higher satisfaction with all aspects of care, suggesting the potential contribution of patient satisfaction to the patients' well-being. CONCLUSIONS: Conducting a patient satisfaction survey in an oncology hospital setting proved feasible; however, further surveys should attempt to obtain the opinion of patients with more severe physical conditions. The assessment of the patients' satisfaction provided indications for improvement of care in a particular hospital. Although the results of this study are specific to one hospital, the methods could be reproduced in other hospital settings, but may possibly lead to other conclusions.     

The verification of effectiveness of home medical care workshop for hospital nurses: the result was based on before/after questionnaire survey

Since 2006, the department of home nursing care at Tokyo Women's Medical University Hospital has held a half year long 6-courses home medical care workshop for our hospital nurses by inviting local medical and welfare specialists as their lecturers. The objective of the workshop was to gain a wider range of knowledge and understanding of hospital discharge support system and home medical care services. In order to evaluate the level of understanding and achievement obtained from the workshop, a questionnaire survey was conducted in 2010 asking the participants to fill out a self evaluation form before and after the course. In addition to that, a class evaluation form was handed out after each class to evaluate a level of understanding of each lecture. The result showed that all aspect of the evaluation levels went up(p<0. 05). Some of the free comments were summarized in the followings: 1 ) Positive results were obtained by working together, and we learned how to coordinate with the regional medical specialists through specific case studies. 2 ) It was a good opportunity for the nurses to receive a direct advice from facilitators(visiting nurses)on cases at hand. 3 ) The lectures' talks based on their experiences brought us a feeling of closeness in the regional home medical care. After the course was concluded, the following issues were raised by hospital ward nurses in the area of difficulties at the time of patient's discharge from the hospital: 1 ) The coordination between doctors and other medical specialists, 2 ) Handling of different requirements among the different family members, 3 ) Timing of patient discharge planning, and 4 ) Lack of knowledge in social resources and medical health insurance system. Hence, we would like to incorporate these survey findings.     

Progress of introduction of artificial respirator at home--the knowledge I have gained from a 19 year-old patient requiring a home respiratory management care and through the friendship with his family members

The patient developed right cerebellar hemorrhage at the age of 15 and spent four years at hospital. The patient and the family members had a strong wish to bring the patient back home and the patient was admitted to the hospital to undergo guidance about home medical care. The patient had paralysis of right upper and lower extremities and generalized strong ataxic motion and was under gastric feeding and had underwent tracheotomy to cope with hypoventilation, which required use of an artificial respirator at night hours. Since the patient was still as young as 19, we want to have the patient "go home" as they wanted. Fortunately, the mother who had to play key roles was still young and the parents worked at home. It didn't take long for them to master the techniques though they had various anxieties. It is considered important in the guidance on home medical care to what degrees the caregivers accept the condition of the patient and can imagine the long lasting care at home. We provided assistance while repeatedly interviewing with the patient and family members considering the significance to confirm their willingness and psychological condition. As a result, the patient was discharged from the hospital in two months. Now, two years have passed, and the patient is still cared at home and the possibility of the patient is sought for. The progress is reported here in this article.     

Discussion on care management operation of a visiting nurse--a case of increased ADL by the support of independent life

In addition to the visiting nursing service conventionally provided, the Department of Long-term Care Insurance Service of this hospital inaugurated the home care supporting service in April 2000. Senior citizens rated higher in the degree of necessity of care in the initial accreditation and in the renewal accreditation of the Long-term Care Insurance tend to have fewer changes in the services for the last two years. At present, care managers of various professions are involved in the home care supporting services and have no choice but to provide care in non-specialty areas. Under the situation, care management by the visiting nurse helped an elderly increase ADL and live on his own, and the case is introduced in this article. Mr. K.T. developed angina pectoris at the age of 76, had recurrences of complications and repeated transfers of hospitals and was eventually admitted to the hospital. Though he had declined muscular strength and ADL because of the long bed-ridden life, he was discharged from the hospital. Nursing services centered on visiting nursing were provided as the home care supporting service when home medical care for the patient was started. Since Mr. K.T. required medical management, he and his family members were not sure whether it is possible to provide care for him at home and required guidance about health/life and mental supports. Therefore, visiting nursing care was provided by a nurse to assess needs or condition of the person, which reduced anxiety and encouraged the person. As a result, ADL increased and the degree of necessity of care decreased from 4 to 2. This success is attributed to the visiting nurse's appropriate care management based on the medical expertise from the perspective of nursing and the introduction of necessary services at the necessary time based on the appropriate assessment of changes in the physical condition or willingness and the nursing condition of family members. Coordination with the staffs engaged in each service also contributed to the success. As shown by this case, it may be necessary for care managers who can exercise their specialty to be engaged in the service or to change care managers depending on the condition of the care service receiver or considering the specialty of care managers for the benefit of the care service receiver and for the improvement of the efficiency of the operations.     

Factors leading to home care of patients in the terminal stage of malignant diseases--a study of 10 cases

In order to clarify the factors that lead patients in the terminal stage of malignant diseases to home care, we interviewed ten families of such patients. Among factors involving patients, a strong desire to stay at home and to spend time at home with the family were initially required. Adequate understanding of the patients and their diseases was also needed by families. Other factors include guaranteed medical services in emergencies and/or 24 hours/day 7 days/week care. Patients requested referrals to family physicians, visiting nurses or community health services to cover outpatient clinic functions. It is concluded that a strong desire to stay at home, adequate understanding by the family and guaranteed medical services in emergencies were three significant factors leading to home care of patients in the terminal stage of malignant diseases.     

Involvement of Daikou Sunabashi Clinic in home care to home death

Daikou Sundabashi Clinic provides continuous advanced medical treatment and visiting nursing services for patients with serious diseases till their death at home. The clinic has been involved in home care of 72 patients in total during the period from April 2002 to July 1 of 2003. Of the patients, 40 patients died to date and 71% (32 patients) of them died at home. 49 of the 72 patients (70%) had terminal cancer and mostly required advanced home care. The clinic provides services according to the following principles till the death of the patients: 1. All of our medical staff pool their information and stay in very close communication with one another. 2. The attending physician gives a complete explanation of the patient's condition to his/her family. 3. The staffs respond to emergency calls around the clock using 2 cell phones. Under this very meticulous and fast-response system, seriously ill patient can receive continuous and high-quality treatment at home and die at home even if the family is not adequately capable of providing care.     

Perceptions of terminally ill patients and family members regarding home and hospice as places of care at the end of life

To enable demand-based palliative care, it is important to know the perceptions of terminally ill patients and their family members regarding home and hospice as places of care at the end of life. Eight women and five men suffering from cancer and with a life expectancy of 3 months or less were interviewed. In each case one of the family members was also interviewed. Four patients spent their last phase of life at home, nine in a hospice. This paper provides further insight in the patient perspective in palliative care. The results reveal that a cohabiting partner seems an important prerequisite for terminally ill patients to stay at home. For spouses it is an obvious choice to facilitate the patients' stay at home, even when it becomes too demanding, something not discussed between spouse and patient. When sufficient care at home seems impossible and the negotiation between patients and family members results in the opinion that living at home is no longer an option, it is decided that the patient moves to a hospice. The choice for the specific setting of the patients' new residence seems to be random; one possibility is pointed out to them and seems appropriate.     

The present situation of home infusion therapy (HIT) and the problems of coordinated service

Fujisawa Pharmaceutical Co., Ltd. established its home care business division in April, 1995. On the assumption that the patients have the final say in decision making, we aim at smooth operation of home care, adjusted to each patient's needs, which will lead to improvements in quality of life (QOL). Approximately 700 patients took advantage of our pharmacy service between April, 1995 and March, 1999; of them, almost 80 percent had a malignant tumor in the terminal stage and were receiving home parenteral nutrition (HPN). Patient ages ranged from the 50s to the 80s. The number of patients with a malignant disease who take advantage of medical treatment by family doctors or a visiting nurse station is less than that of patients with a benign disease. Following are the problems of coordination for HIT patients: 1) difficulty in understanding the patient's or their family's actual thoughts about home care, 2) insufficient information from the medical staff to the patient or their family for decision making, 3) insufficient coordination in the medical organization, and 4) failure of information exchange between the medical organization's staff and the home-care staff. In order to operate a home care service which can improve QOL, information exchange and cooperation among the members of the home care team is essential.     

Problems in home medical care of elderly diabetics

In recent years, reflecting our aging society, the prevalence in the elderly population of diabetics has been gradually increasing. In our hospital, 221 diabetics are registered, and 106 (45 males, 65 females) of whom are elderly patients above 65-years old. The support of family or medical care providers is necessary for patients who have difficulties in "self-management" of diabetes. The main causes of the problems in their home medical care are thought to be as follows: 1) poor glycemic control, 2) diabetic complications, 3) arteriosclerotic diseases, and 4) psychotic disorders (dementia). Hereafter, the number of elderly patients who require home health care or medical supports will increase. Now, we must tackle the important problem of the management of elderly diabetic patients through the induction of a "Long term care insurance system".