Establishing community-based integrated care for elderly patients through interprofessional teamwork: a qualitative analysis.

BACKGROUND: Working in multidisciplinary teams is indispensable for ensuring high-quality care for elderly people in Japan's rapidly aging society. However, health professionals often experience difficulty collaborating in practice because of their different educational backgrounds, ideas, and the roles of each profession. In this qualitative descriptive study, we reveal how to build interdisciplinary collaboration in multidisciplinary teams. METHODS: Semi-structured interviews were conducted with a total of 26 medical professionals, including physicians, nurses, public health nurses, medical social workers, and clerical personnel. Each participant worked as a team member of community-based integrated care. The central topic of the interviews was what the participants needed to establish collaboration during the care of elderly residents. Each interview lasted for about 60 minutes. All the interviews were recorded, transcribed verbatim, and subjected to content analysis. RESULTS: The analysis yielded the following three categories concerning the necessary elements of building collaboration: 1) two types of meeting configuration; 2) building good communication; and 3) effective leadership. The two meetings described in the first category - "community care meetings" and "individual care meetings" - were aimed at bringing together the disciplines and discussing individual cases, respectively. Building good communication referred to the activities that help professionals understand each other's ideas and roles within community-based integrated care. Effective leadership referred to the presence of two distinctive human resources that could coordinate disciplines and move the team forward to achieve goals. CONCLUSION: Taken together, our results indicate that these three factors are important for establishing collaborative medical teams according to health professionals. Regular meetings and good communication facilitated by effective leadership can promote collaborative practice and mutual understanding between various professions.

Problem-based learning for radiological technologists: a comparison of student attitudes toward plain radiography.

BACKGROUND: Knowledge and skill expected of healthcare providers continues to increase alongside developments in medicine and healthcare. Problem-based learning (PBL) is therefore increasingly necessary in training courses for radiological technologists. However, it is necessary to evaluate the effects of PBL to completely introduce it in our education programs. As a Hypothesis, it seems that a change occurs in the student's attitudes by participating in PBL practical training. There is the Semantic Differential (SeD) technique as a method to identify student's attitudes. We conceived that PBL could be appropriately evaluated by using SeD technique. In this paper, we evaluated PBL for plain radiography practical training using the SeD technique. METHODS: Thirty-eight third-year students studying radiological technology participated. PBL was introduced to practical training in plain radiography positioning techniques. Five sessions lasting 5 h each were delivered over a 5-week period during November to December 2012. The clinical scenario was an emergency case with multiple trauma requiring plain radiography. Groups comprising approximately eight students created workflows for trauma radiography with consideration of diagnostic accuracy and patient safety. Furthermore, students groups conducted plain radiography on a patient phantom according to created workflows and were then guided by feedback from professional radiologists. All students answered SeD questionnaires to assess views on plain radiography before instruction to provide preliminary practical training reports and after completing practical training. RESULTS: The factors were identified using factor analysis of the questionnaires, which were answered before and after each practical training session. On evaluation of the relationships between factors and question items according to factor loading, we identified "reluctance", "confidence", and "exhaustion" as the predominant attitudes before practical training. Similarly, we identified "expectation", "self-efficacy", and "realness" as the predominant attitudes after practical training. The attitudes toward plain radiography changed before and after PBL practical training. CONCLUSIONS: The attitude of self-efficacy was noted after practical training, which incorporated PBL. Student self-efficacy was thought to increase through self-directed learning, which is one of the aims of PBL. Although the influences of other lectures and training, which were performed in parallel with the PBL practice training, were not completely excluded, and although the number of study participants was small, we were able to confirm the effects of PBL.

Nepalese undergraduate nursing students' perceptions of the clinical learning environment, supervision and nurse teachers: A questionnaire survey.

BACKGROUND: Clinical practice enables nursing students to acquire essential professional skills, but little is known about nursing students' perceptions of the clinical learning environment (CLE) in Nepal. OBJECTIVES: To examine Nepalese nursing students' perceptions regarding the CLE and supervision. DESIGN: A cross-sectional questionnaire design was used. SETTINGS: Government and private hospitals in Nepal where the undergraduate nursing college students undertook their clinical practice. PARTICIPANTS: Students with clinical practice experience were recruited from years 2-4 of the B.Sc. nursing program in Nepal (n=350). The final sample comprised 263 students. METHODS: A self-administered questionnaire including demographic characteristics, latest clinical practice site, and general satisfaction was administered February-March 2014. The previously validated Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale was used in the questionnaire. The analytical approach used exploratory factor analysis, assessments of the scale and sub-dimension reliability, correlations of factors between scale sub-dimensions, and multiple regression analysis. RESULTS: Students' practicum satisfaction level at government hospitals was significantly higher than those at private hospitals (p<0.0001). Five factors explained 85.7% of the variance, with minor factorial structure differences compared with the original scale. Reliability was confirmed (Cronbach's alpha=0.93 for total scale, 0.76-0.92 for sub-dimensions). Inter-correlations between the five original sub-dimensions were 0.27-0.68 (p<0.0001). Students undertaking their practicum in private hospitals evaluated their clinical placements significantly more negatively on most sub-dimensions than those in government hospitals. Multiple regression analysis revealed a significant positive relationship between satisfaction and pedagogical atmosphere (p<0.0001). CONCLUSION: This is the first study to investigate nursing students' perceptions of the CLE in undergraduate nursing programs in Nepal. Students were satisfied with the CLE overall, but satisfaction varied by practicum hospital sector. The most influential factor explaining satisfaction was pedagogical atmosphere.

[Study of 4 patients implemented to Advance Care Planning].

This is a study of 4 patients implemented to Advance Care Planning (ACP) reflecting on the health care professionals' role and the outcomes. ACP has been defined as a process of formal decision making that aims to help patients establish their decision about future care that take effect when they lose capacity. For about two years, we tried to engage all patients who were referred to our palliative care team and their families to ACP since their first consultation. We informed their conditions at that time, how their health might change and how treatment might impact on their life goals. We also attempted to help patients' decision making and then fulfill their wishes in cooperation with patients' families and healthcare professionals. We learned three important elements: understanding patients' values and wishes, explaining prediction of the clinical course of the patients and establishing a collaborative healthcare team in order to fulfill the patients' hopes. ACP improved quality of life (QOL) not only for the patients involved, but also for the family members. ACP can play a crucial role in ensuring that patients receive the care they want throughout various stages of their lives.

What primary care physician teachers need to sustain community based education in Japan.

BACKGROUND: Community based education (CBE), defined as "a means of achieving educational relevance to community needs and, consequently, of implementing a community oriented educational program," is reported to be useful for producing rural physicians in Western countries. However, why some physicians withdraw from their teaching roles is not well known, especially in Asian countries. The aim of this study was to clarify the requisites and obstacles for taking part in CBE. METHODS: WE COMBINED TWO STEPS: preliminary semi-structured interviews followed by workshop discussions. First of all, we interviewed four designated physicians (all male, mean age 48 years) working in one rural area of Japan, with less than 10,000 residents. Secondly, we held a workshop at the academic conference of the Japan Primary Care Association. Fourteen participants attending the workshop (seven male physicians, mean age 45 years, and seven medical students (one female and six male), mean age 24 years) were divided into two groups and their opinions were summarized. RESULTS: In the first stage, we extracted three common needs from interviewees; 1. Sustained significant human relationships; 2. Intrinsic motivation; and 3. Tangible rewards. In the second stage, we summarized three major problems from three different standpoints; A. Preceptors' issues: more educational knowledge or skills, B. Learner issues: role models in rural areas, and C. System issues: supportive educational system for raising rural physicians. CONCLUSIONS: Our research findings revealed that community physicians require non-monetary support or intrinsic motivation for their CBE activities, which is in accordance with previous Western studies. In addition, we found that system support, as well as personal support, is required. Complementary questionnaire surveys in other Asian countries will be needed to validate our results.

Frequency of neurotic symptoms shortly after the death of a pet.

Some individuals manifest psychosomatic symptoms after the death of their pets. A survey was conducted at four public and commercial animal cremation service centers in Japan. In each center, a questionnaire was distributed to 100 individuals (400 in total). The questionnaire consisted of the 28-item version of the General Health Questionnaire (GHQ28), the social readjustment rating scale (SRRS) and a series of questions regarding demographic information and the circumstances of their pet's death. In total, 82 returned questionnaires were available for analysis. GHQ28 proved the existence of neurotic symptoms in 46 responses (56.1%; 95% confidence interval: 44.7%-67.0%). Analysis of the responses using the GHQ28 subscales with a Likert scoring system demonstrated more somatic dysfunction in females (GHQ-A: P=0.04). Furthermore, significant correlations were identified among the following factors: owner's age (GHQ-A: ρ=-0.60, P=0.01; GHQ-B: ρ=-0.29, P=0.01; GHQ-C: ρ=-0.32, P<0.01; GHQ-D: ρ=-0.42, P<0.01), SRRS score (GHQ-A: ρ=0.32, P<0.01; GHQ-B: ρ=0.25, P=0.02; GHQ-D: ρ=0.30, P=0.01) and animal's age (GHQ-D: ρ=-0.26, P=0.02). The death of indoor pets caused deeper depression (GHQ-D: P=0.01) than that of outdoor or visiting pets. The results revealed neurotic symptoms in almost half of the pet owners shortly after their pet's death.

Analysis of needs of patients with idiopathic osteonecrosis of the femoral head: using focus group interviews.

AIM: The current needs of patients with idiopathic osteonecrosis of the femoral head were analyzed for the purpose of seeking effective support programs that would maintain and improve the quality of life of the patients. METHODS: A focus group interview method was used to collect data. Interviewees included eight patients. They were asked about their opinions and needs with respect to medicine, health care, and welfare. RESULTS: Overall, four needs were revealed as particularly significant: information needs, decision-making in the absence of pre-established treatment, psychological support, and sufficient medical healthcare institutions. CONCLUSION: These four needs are useful for the foundation of future support systems, whose main concerns will be: counseling support for patients with idiopathic osteonecrosis of the femoral head, currently adopted institutions, and resources that may be required in the future.

Care-seeking behavior of Japanese gynecological cancer survivors suffering from adverse effects.

BACKGROUND: Post-treatment follow-up visits for gynecological cancer survivors should provide opportunities for management of adverse physical/psychological effects of therapy and early recurrence detection. However, the adequacy of such visits in Japan is poorly documented. We qualitatively explored care-seeking experiences of Japanese gynecological cancer survivors and deduced factors influencing care-seeking behaviors and treatment access. METHODS: We conducted 4 semi-structured focus groups comprising altogether 28 Japanese gynecological cancer survivors to collect a variety of participants' post-treatment care-seeking behaviors through active interaction with participants. Factors influencing access to treatment for adverse effects were analyzed qualitatively. RESULTS: Survivors sought care through specialty clinic visits when regular post-treatment gynecological follow-ups were inadequate or when symptoms seemed to be non-treatment related. Information provided by hospital staff during initial treatment influenced patients' understanding and response to adverse effects. Lack of knowledge and inaccurate symptom interpretation delayed help-seeking, exacerbating symptoms. Gynecologists' attitudes during follow-ups frequently led survivors to cope with symptoms on their own. Information from mass media, Internet, and support groups helped patients understand symptoms and facilitated care seeking. CONCLUSIONS: Post-treatment adverse effects are often untreated during follow-up visits. Awareness of possible post-treatment adverse effects is important for gynecological cancer survivors in order to obtain appropriate care if the need arises. Consultation during the follow-up visit is essential for continuity in care.

Perception of inter-professional education (IPE) among laypersons in a Japanese rural area.

Many overseas healthcare researchers have advocated the importance of inter-professional education (IPE). However, to what extent laypersons, who reside in Japanese rural areas, understand IPE is not well known. To clarify this issue, we interviewed laypersons regarding their perception of IPE. We selected one rural area in Japan, where over 40% of the residents were more than 65 years old. Participants, who had an interest in their community healthcare system, were nominated. Semi-structured interviews of approximately 60 minutes were performed and topics focused on were: 1. laypersons' perception of IPE, 2. laypersons' views on educating future medical professions, and 3. what laypersons could contribute to the educating of future medical professionals. Nine participants (58 to 88 years, 1 female and 8 males, mean 76 years) took part. We found three common themes among the interviewees. These were: 1. little knowledge about IPE, 2. positive attitudes towards educating future medical professionals, 3. original ideas concerning how to educate medical professionals. We also found that laypersons in this rural region did not fully understand IPE. As one potential educational method, we should promote IPE involving laypersons. For future study, we plan to explore medical professionals' opinions, and compare them with those of laypersons'.

[Questions that radiography students have regarding X-ray photography: a qualitative study].

OBJECTIVE: To improve lectures and training programs on X-ray photography, we aimed to determine the questions that radiography students have regarding X-ray photography. METHODS: We collected text data from questions on X-ray photography in radiography student reports after an X-ray photography training program. The text data were analyzed using content analysis. Codes were assigned to segments and they were categorized according to similarities. RESULTS: From 111 reports, 348 questions were collected. Four categories and 47 subcategories were obtained. The "Required Knowledge" category comprised subcategories concerning knowledge for the X-ray photography including X-ray radiography methodology and disease knowledge. The "Radiography Service" category comprised subcategories concerning radiographers' responsibilities in a hospital including the role of radiographer and the extent of responsibilities. The "Radiographers' Challenges" category comprised subcategories concerning unusual situations radiographers encounter at work including accurate positioning and communication with patients. The "Patient Types" category comprised subcategories concerning patients in whom X-ray photography was considered difficult including pediatric patients and patients with serious conditions. Questions related to subcategories in "Radiographers' Challenges" and "Patient Types" were interrelated. Radiography students had concerns regarding whether they would be able to handle difficult patients efficiently in clinical situations. CONCLUSION: We were able to suggest the re-orientation of radiography education according to students' intellectual appetite regarding X-ray radiography.

What rural physicians need to engage in community based education: a qualitative interview survey.

There is systematic evidence that community-based education is effective in the recruitment of rural physicians to remote communities. However, various obstacles may exist that prevent rural physicians from sustaining their mentoring activities. The aim of this study was to explore ways for rural physicians to overcome such adversities and continue their mentoring activities. We interviewed four nominated physicians (all male, mean age 48 years) based in Hokkaido, Japan, who practiced in an area with less than 10,000 inhabitants. Semi-structured interviews of approximately 60 minutes were performed and focused on topics rural physicians' found necessary for their teaching activities. All interviews were tape-recorded and transcribed, the verbatim transcripts were analyzed and repeated themes were identified. Three themes that emerged as needs were 1. sustained significant human relationship, including the formation of a network between students and university faculty, as well as developing partnerships with many community relationships, or other medical professions; 2. intrinsic motivations and satisfaction, including pleasure in mentoring the younger generations; and 3. rewards, including financial compensation. Rural physicians as preceptors require nonremunerative, intrinsic motivational factors, such as a sense of satisfaction regarding the education of medical students and being able to relate to residents and others health-care professions, when pursuing their educational activities. To support them, focusing only on monetary facets may be unsuccessful in encouraging them to continue their educational work.

Survey of patient and physician satisfaction regarding patient-centered outpatient consultations in Japan.

OBJECTIVE: The purpose of this study was to show the difference in consultation satisfaction between patient and physician in rural settings, and identify the variables affecting their satisfaction regarding these encounters. METHODS: We collected data by administering questionnaires that included questions regarding satisfaction for a patient-centered approach to patients and physicians, transcribing data from medical records, and observing consultations in person. We then modeled cumulative logits of patient and physician satisfaction scores by performing ordered logistic regression using the proportional odds model. PATIENTS: Seven physicians and 122 patients participated in the study. RESULTS: Both patients and physicians expressed high satisfaction with their consultation sessions. Patient satisfaction tended to be higher than physician satisfaction. Physicians were satisfied with longer consultations but patients were not. Moreover, the long waiting times dissatisfied patients. In cases of multiple healthcare episodes (courses of treatment for a different condition) during a single visit, patient satisfaction decreased, while physician satisfaction increased. Physician satisfaction for interactions in general was less when they checked the same patient who had previously visited them. CONCLUSION: Our findings suggest that if physicians feel satisfied with their consultation, patients also feel satisfied regardless of the physician's opinion. The variables that affect patient and physician satisfaction include prior visits with the same physician, consultation length, longer waiting times, and number of episodes. These findings from Japanese clinics are consistent with those previously reported for other countries.

Psychiatric investigation of 18 bereaved pet owners.

This survey explores the grief associated with the loss of a pet, and was carried out using a self-administered questionnaire. The questionnaires were handed out to 50 bereaved pet owners attending a public animal cremation service, and we received 18 responses. Participants responded within 0 to 44 (median 4) days of the death of their pet. Although most mental health problems immediately following mourning are presumed to be normal grief reactions, on the basis of several psychiatric scales, 8 of the 16 valid responses indicated depression and/or neurosis. Statistical analyses showed that the following factors were significantly associated with grief reactions: age of owner, other stressful life events, family size, age of deceased animal, rearing place, and preliminary veterinary consultation.

Factors in the awareness of depression, focusing on perceptual dissimilarities between PCPs and patients: an exploratory and qualitative research.

Primary care physicians (PCPs) are said to play a leading role in the early diagnosis of depression. Sometimes however, symptoms can be overlooked or misdiagnoses may occur, and this may be due to differences in the way that PCPs and patients perceive depression. The aim of this study is to clarify factors that may contribute to suspicions, or awareness of depression, focusing especially on perceptual dissimilarities between PCPs and patients. We conducted our research using qualitative methodology, with individual interviews being conducted with five experienced primary care physicians working in a rural area, and five patients who had been in consultation with PCPs. The main interview topic of this study was the triggers for their, or their patients', depression. From our interviews we discerned five categories of factors: "mental manifestations," "physical manifestations," "events in the patient's private life," "social environment and conditions" and "others." Our findings suggest that a critical difference in the perception of depression may exist between PCPs and patients. PCPs should be more alert to uncommon conditions of depression, as well as the more prevalent symptoms. We found that PCP's latent abilities and attitudes, such as "intuition," "subjectivity," and "experience", are often cues in the diagnosis of depression. This is in accordance with existing research on the subject. On the patients' side, sometimes sufferers do not notice the symptoms of depression by themselves, which may also be a serious problem. In conclusion, we, as medical professionals, must take care to be aware of these distinctions in order to swiftly detect depression, and to better treat our patients.

Incidence of Community-associated Methicillin-resistant Staphylococcus aureus Infections in a Regional Hospital.

BACKGROUND AND OBJECTIVE: Since the early 2000s, the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections among the community of people lacking known healthcare risk factors has increased. This MRSA infection is referred to as community-associated MRSA (CA-MRSA) infection and is distinct from hospital-associated MRSA (HA-MRSA) infection, which occurs among people with known healthcare risk factors. Understanding the epidemiology of CA-MRSA infections is critical; however, this has not been investigated in detail in Japan. Our objective was to investigate the incidence of CA-MRSA infections in a regional hospital. PATIENTS AND METHODS: We investigated CA-MRSA isolates and infections in a rural regional hospital by reviewing medical records of one year. Infections were classified as CA-MRSA if no established risk factors were identified. RESULTS: During 2008, 31 Staphylococcus aureus (S. aureus) isolates were detected in 29 unique patients, with 1 methicillin-sensitive S. aureus (MSSA) isolates obtained from 19 patients (66%) and MRSA obtained from 10 patients (34%). In the 10 patients with MRSA, the number of HA-MRSA and CA-MRSA cases were nine (32% of patients with S. aureus isolates) and one (3%), respectively. The patient with CA-MRSA was diagnosed with cellulitis due to CA-MRSA. All nine patients with HA-MRSA exhibited colonization. CONCLUSION: We observed a CA-MRSA case in a regional hospital in Japan, suggesting that incidence trends of CA-MRSA should be considered in future research and treatment.

An interview survey on factors influencing the career choice of primary care physicians in rural areas.

BACKGROUND: The lack of primary care physicians working in rural areas is a major problem both in Japan and worldwide. Particularly in Japan, healthcare provision in the community is seriously deteriorating, due to the absence of a regulated instructional system for primary care physicians in rural areas. Understanding what influences the career choice of rural primary care physicians is vital, and this study aims to examine those factors. METHODS: Qualitative research methodology with semi-structured interviews and content analysis was used. All interviews were conducted in interviewees' rural clinics over three days in September 2007 and 2008; each interview lasted for 60 minutes. All interviews were recorded, transcribed verbatim, and analyzed thematically by two independent researchers, then the preliminary results were presented to the third and fourth authors. All authors were in agreement with the final results. RESULTS: Fourteen physicians (13 males and 1 female; mean age 43-years-old) agreed to participate in the interviews, and four themes emerged: "existence of role models for younger primary care physicians," "affinity with rural backgrounds and culture," "understanding the importance of a holistic approach," and "internal motivation for challenging and rewarding work as a doctor." DISCUSSION & CONCLUSIONS: Our research results were similar to those of previous overseas studies, regardless of differences in cultural background. We could explain our themes with the concept of the "rural pipeline into medical practice" by JP Geyman et al. according to the time frame described therein. Taking some potential limitations like generalizability and translation into account, we could utilize our research results to indicate how the number of rural primary care physicians may be increased.

A case of community-associated methicillin-resistant Staphylococcus aureus infections in a community hospital.

Infections caused by methicillin-resistant Staphylococcus Aureus (MRSA) have recently occurred in communities in people lacking known healthcare risk factors. This MRSA infection is referred to as community-associated MRSA (CA-MRSA) infection, and is distinct from hospital-associated MRSA infection, which occurs in people with risk factors. We experienced a patient diagnosed with CA-MRSA cellulitis, as culture of pus revealed MRSA and he had not been exposed to healthcare environments for the past year. The patient was a previously healthy 38-year-old man with suppurative cellulitis in his right index finger following injury to the finger at his worksite. The cellulitis was successfully managed with incision and drainage (I&D), followed by cefazolin during a 10-day clinical course, although the patient's MRSA strain was resistant to cefazolin. There are several reports that suggest that I&D followed by antibiotic treatment for CA-MRSA skin infection produces equivalent clinical outcomes, whether the antibiotic prescribed was effective or not. Given that MRSA emerged in an outpatient setting, CA-MRSA should be considered a possible etiology of skin infection in healthy individuals with no classical risk factors for acquisition of MRSA.

A Japanese case of familial Mediterranean fever with a MEFV gene mutation.

A 17-year-old Japanese male with a three-year history of recurrent episodic chest pain and fever, each lasting for one to three days, was diagnosed with familial Mediterranean fever (FMF) because of the following: 1) short attacks of chest pain and fever recurring at varying intervals; 2) no symptoms with a sense of well-being between attacks; and 3) identification of the Mediterranean fever gene (MEFV) mutation demonstrating M6941. Although FMF has been described primarily in several limited ethnic groups, a limited number of cases have been reported in Japan. No specific diagnostic tests are commercially available for FMF so identifying the characteristic clinical picture of FMF is important.

The perception of the hidden curriculum on medical education: an exploratory study.

BACKGROUND: Major curriculum reform of undergraduate medical education occurred during the past decades in the United Kingdom (UK); however, the effects of the hidden curriculum, which influence the choice of primary care as a career, have not been sufficiently recognized. While Japan, where traditionally few institutions systematically foster primary care physicians and very few have truly embraced family medicine as their guiding discipline, has also experienced meaningful curriculum reform, the effect of the hidden curriculum is not well known. The aim of this study is to identify themes pertaining to the students' perceptions of the hidden curriculum affecting undergraduate medical education in bedside learning in Japan. METHODS: Semi-structured interviews with thematic content analysis were implemented. Undergraduate year-5 students from a Japanese medical school at a Japanese teaching hospital were recruited. Interview were planned to last between 30 to 60 minutes each, over an 8-month period in 2007. The interviewees' perceptions concerning the quality of teaching in their bedside learning and related experiences were collected and analysed thematically. RESULTS: Twenty five medical students (18 males and 7 females, mean age 25 years old) consented to participate in the interviews, and seven main themes emerged: "the perception of education as having a low priority," "the prevalence of positive/negative role models," "the persistence of hierarchy and exclusivity," "the existence of gender issues," "an overburdened medical knowledge," "human relationships with colleagues and medical team members," and "first experience from the practical wards and their patients." CONCLUSIONS: Both similarities and differences were found when comparing the results to those of previous studies in the UK. Some effects of the hidden curriculum in medical education likely exist in common between the UK and Japan, despite the differences in their demographic backgrounds, cultures and philosophies.

Families' acceptance of near death: a qualitative study of the process for introducing end-of-life care.

AIM: Providing effective end-of-life (EOL) care for the elderly with severe brain damage is difficult because patients' families find it hard to accept the condition of their loved ones as "near death". In Japan, this has become an urgent social problem. Although health-care teams sometimes expect that the elderly with severe brain damage should be treated as terminal, many find that patients' families cannot accept the condition as near death. As a result, they are not able to appropriately introduce any EOL services. It was the aim of the present study to develop a comprehensive understanding of the process by which families accept the elderly with severe brain damage as near death. METHODS: Qualitative methodology with focus groups and semi-structured interviews were used. Twenty-three participants in two sets of male and female focus groups were interviewed in a semi-structured format. Ten participants (five men and five women) who made important medical decisions were then interviewed separately. RESULTS: Eleven categories emerged: (i) family affection with wishes for continued survival; (ii) vacillation of desire for death with dignity; (iii) family members' hierarchy; (iv) awareness that others may make different decisions; (v) family members' discussion overcoming discordance; (vi) satisfaction with physicians' explanations; (vii) impressions of life-sustaining measures; (viii) entrusting important decisions to hospital physicians; (ix) significance of family members' previous experiences; (x) patient's age; and (xi) duration of medical treatment. CONCLUSION: We developed a conceptual model that is useful for evaluating which stage of the process families are currently experiencing as well as introducing EOL care in a timely manner.