[Home Medical Care Promotion for Multidisciplinary Cooperation].

It may be said that the effective functioning of an integrated community care system depends entirely on home medical care. "Cooperation"is necessary in pushing home medical care forward and it is vital to advance as a system. In Iwaki-city, the municipal government and the medical association have been sponsoring many types of multidisciplinary cooperation workshops for home medical-care promotion. There was administrative participation, and cooperation became the main workshop focus. We hold workshops 2 times a year. The Iwaki City Medical Association holds lectures on home medical care in the town. Doctors who work in medical offices and hospitals attend the lectures, with topics such as family medicine, understanding dementia, advice for the acceptance of medical examination, cancer screening in the local community hall, and gaining a favorable reception. In our hospital, I hold many types of workshops on home medical care in southern Iwaki-city and on facilitating cooperation. These contribute to collaboration, as they facilitate face-to-face interaction in an important area. I also report the actions taken in our hospital.

[End-of-Life Home Care for a Young Patient].

We report the case of a young patient(under 40 years)with a malignant tumor; this is an age when a person is involved in social activity and is productive. A variety of activity largely has a negative influence on family at death of such a patient. After fighting this illness for a long time, home medical care was administered, and I experienced a case of a 31-year-old patient with malignant melanoma who was administered end-of-life home care. He had a diagnosis of right leg malignant melanoma approximately 5 years ago. Palliative medical care was decided, after aggressive treatment for approximately 5 years, including an operation, and home medical care was hoped, after this was introduced at our department of surgery. I performed pain control in this patient after hospitalization at approximately one week and the patient was shifted to home medical care. The patient could only swallow water, and oral medication could not be ingested because the patient was bedridden. The mother who was the main caregiver quit her work and devoted herself for care. I performed pain control mainly by administering oxycodone and a steroid and an anti-inflammatory, which were given intravenously along with the antianxiety drug. During home medical care, I focused on pain control, but the patient expressed gratitude for the main caregiver that was witnessed by the family. The patient died 26 days after the initiation of at-home care. Nursing care insurance is not available for young patients, and home help is limited. I quit work for the caregiver, and including contrivance of the future life, there is much limitation with the aspect of the income. A younger patient experiences temper, as well as physical pain, enough for mental and social pain is necessary.

[Assessment of our home care and home palliative care].

We conducted home care and home palliative care from the department of home care. We provided home care services to 190 patients(105 men, 85 women)in October 2013. Their average age was 78.7(range: 32-102)years old, and home care had been underway from 1 day to 8 years, 10 months. Among all participants, 168(88.4%)suffered from malignant diseases, 168 patients had died, and over half of deceased patients(88 out of 168)had died at home. We used opioids for control of cancer pain, carried out home parenteral nutrition(HPN), home enteral nutrition(HEN), percutaneous endoscopic gastrostomy( PEG), and removed pleural effusion and ascites during home care. In order to facilitate the practice of palliative care by the palliative care team, which consists of various medical staff in the hospital, we are giving high priority to education and enlightenment in the hospital. To provide enlightenment, education, and cooperation between regional home care and home palliative care, we are also conducting educational lectures in the regional party of the Iwaki city medical associate, and providing combined educational-medical training for home care and home palliative care by various medical staff.

[A questionnaire survey of medical cooperation by the Iwaki Medical Association].

It has been pointed out that currently, Iwaki City faces an insufficiency of doctors working at hospitals, compared with before. Such an insufficiency became more remarkable after the 2011 Tohoku Earthquake and Fukushima Nuclear Disaster, as about 30,000 people relocated to Iwaki City from the evacuation areas. In this regard, the Iwaki Medical Association conducted a questionnaire survey to investigate the problems of medical cooperation and utilize the data to improve medical cooperation within hospitals and clinics. A total of 159 doctors answered the questionnaires: 64% were community physicians, 36% were doctors working at hospitals, and 42% were physicians. About 60% of the doctors were satisfied with the present medical cooperation. Home health care was performed by 25% of the doctors working at hospitals and 45% of the community physicians. Approximately 80% of the doctors felt the need for additional physicians to perform home health care, although more than half of the doctors answered that they do not perform it. Various problems exist in the context of medical cooperation, but many doctors still hope for its improvement, according to the answers in the questionnaires. Efforts have to be exerted further in order to enhance medical cooperation among the health care team.

[Review of our home nutrition therapy cases].

The provision of home care service, 20 years since it was established, is becoming more important. The aging population is now at its highest ever level, and the number of patients in need of nutrition therapy is increasing. We have provided a home care service since 1996, mainly for the provision of home palliative care. Home care service has been provided to 168 patients, about 90% of which suffered from malignant disease, and about 80% of the malignant disease patients were in the terminal stage. The patients included 151 on home parenteral nutrition(HPN)and 7 on home enteral nutrition(HEN)using percutaneous endoscopic gastrostomy(PEG). Six patients with gastrostomy underwent drainage of malignant digestive obstruction. For HPN of malignant terminal stage patients, we considered whether the HPN menu was available for malignant cachexia. We primarily considered the intent of the patients with malignant cachexia and their families.

[Current status of home palliative care].

In order to push forward with home palliative care under the regional alliance in Iwaki city, we worked toward building a medical network. The current main four actions are: 1 ) Educational medical training course for palliative skill-improvement in the regional party of Iwaki city medical associate, 2 ) Combined educational and medical training for home palliative care and an assembly of regional alliance, 3 ) Critical path for the regional alliance of palliative care, and 4 ) Iwaki palliative therapy research. However, the present status of these actions has not been working well in supporting of home palliative care under the hospital-clinic cooperation. On the other hand, we actually felt that the regional alliance called face to face cooperation between doctors and many paramedics was proceeding well. In our department as a whole, the palliative cases with the help of regional alliance have been increasing. We also experienced with home palliative care under the hospital clinic cooperation. The most important action is to notify the medical offices of clinics and hospitals to let them acknowledge that we have been actively providing home palliative care and services. Moreover, it is also necessary to introduce our palliative care and services to medical offices when a patient is in the early stage of the disease.

[For the betterment of home palliative care].

The problems we have identified to overcome for a betterment of home palliative care were as follows:(1) Staffs' low level of knowledge and a lack of interest in home care, (2) Lack of cooperation between hospital and clinic, (3) Hard to keep the medical and caregiver staffs employed in the home care settings and a technical training is behind, (4) Insufficient cooperative networks for elderly care and welfare in the region, and (5) Misunderstanding of home palliative care by patient, family and people in the region. It is important to solve these problems one by one for a betterment of home palliative care. In this paper, we reported these problems through actual activities of our hospital and Iwaki city, and we propose to deal with them.

[Present status of home palliative care and its future perspectives].

We provided home care and home palliative care services to 129 patients from December 1996 to March 2009. One hundred thirteen of 129 patients (87.6%) suffered a malignant disease. 113 patients of the 129 had died, and 57 of the 113 patients (50.4%) died at home. We tried a continuous/seamless practice of palliative care up to acute phase. We could make a smooth transition of a terminal cancer patient from hospital to home medical care and to a discharge planning. Since 1992, Iwaki palliative therapy research has started and been contributed largely in enlighten, development and local communication between hospitals and clinics in Iwaki city. However, the present status of the palliative research has not been working well in support of home palliative care under the hospital-clinic cooperation. So, we took three important actions: (1) construction of medical network, (2) educational medical training course for skill-improvement and (3) critical path for local alliance of palliative care in order to push forward with home palliative care, and we are now carrying forward these three projects under the cooperation of Iwaki city medical associate.

[Review of our home nutrition therapy cases].

We provided a home care service to 118 patients from December 1996 to December 2007. One hundred three of 118 patients (87.3%) suffered from malignant disease. We had 90 patients on HPN and 4 patients on HEN using PEG. Home anti-cancer chemotherapy was performed for 29 patients. Most of the patients in our home care suffered from malignant disease, and they were maintained to protein-calorie malnutrition (PCM), so it is important to continue a home care nutrition therapy for survival and QOL advantages. Also, it is important for patient undergoing anti-cancer chemotherapy to maintain a good nutrition for avoiding a complication and to have a continuous chemotherapy. In our home nutrition therapy cases, HPN consisted of large number because of many digestive cancer patients existed, so HEN could not be used. In the case of HEN practicable that is first choice in home care nutrition, the other HPN was suitable for a pain control of terminal state patients. It is important for HPN to educate and to teach how to manage a patient cleanly and to teach a caregiver how to use a portable pump. We intended to simplify the content of infusion for patients, and to change the volume according to the patient status. HEN cases could be performed safely and for a long-term practice by a caregiver.

[Our outpatient cases for home anti-cancer chemotherapy using a CV port and a portable pump system].

We report our outpatient cases for home anti-cancer chemotherapy using a CV port and a portable pump system. A total of 119 patients with advanced and recurrent cancer were performed at an outpatient clinic or provided home anti-cancer chemotherapy since December 1996 until December 2005. Of these patients, 18 patients were provided home anti-cancer chemotherapy using a CV port and a portable pump system (5 with gastric, 4 colonic, 2 rectal, 1 lung, 1 hepatic, 1 duodenal, 2 breast, and 2 pancreatic). Fifteen patients had died, and 3 patients are alive and undergoing continuous therapy. The response revealed 3 cases with partial response, 13 cases with no change and 2 cases with progressive disease. No severe side effects were seen, and no troubles of catheter and port were experienced as well. Not only the treatment of outpatients for home anti-cancer chemotherapy was effective and maintained the patient's QOL, but also contributed to a marked decrease of medical costs compared to admission therapy.

[Our outpatient cases for home anti-cancer chemotherapy].

We report our outpatient cases for home anti cancer chemotherapy. A total of 97 patients with advanced and recurrent cancer (22 with breast, 20 gastric, 29 colonic, 12 rectal, 1 hepatic, 3 cholangio, 4 pancreatic, 2 duodenal, 2 ovarian and 2 malignant lymphomas) were performed at an outpatient clinic or provided home anti-cancer chemotherapy since December 1996. Of these patients, 9 patients were provided home anti-cancer chemotherapy, 56 patients had died, and 41 patients are alive and undergoing continuous therapy. The response rates revealed effective results in these diseases. No severe side effects were seen, and they underwent treatment at an outpatient clinic easily. The treatment of outpatients for home anti-cancer chemotherapy was effective and maintained the patient's QOL. However, it was important to establish early an exclusive therapy room, training of expert nurses and good staff.

[Current status of our home care].

We report a current status of our home care cases. Our home care has provided for 76 patients (46 men, 30 women) since July 1996. The average age was 73 (range 32-92) years old. The shortest period of home care was for 1 day, and the longest period of home care was achieved for 5 years and 5 months. 70 of the 76 patients suffered from malignant diseases. Of these patients, 53 patients were terminally ill cancer patients. 63 patients of the 76 had died, and over half of them (35 out of the 63 patients) had died at home. 14 of the 76 patients who were treated by other hospitals and clinics came to our hospital by means of referral, and we provided them our home care with the cooperation of these hospitals and clinics. No problems existed in our hospital with issues regarding discharge planning and nursing cooperation.

[Review of our home parenteral nutrition (HPN) and home enteral nutrition (HEN) cases].

We reviewed our cases of HPN and HEN after percutaneous gastrostomy. We had 38 patients (26 men, 12 women) on HPN. Of them, 23 (17 men, 6 women) had an implantable subcutaneous infusion port. The average age of HPN cases was 69 (range 40-92) years, and 34 patients (89%) suffered from a malignant disease. The mean duration of HPN was 104 (range 2-543) days. Home anti-cancer chemotherapy was provided for 2 patients. Percutaneous gastrostomy was performed for 7 patients (4 men, 3 women) by endoscopy (PEG, 6 cases) and 1 patient needed an open laparotomy. Their average age was 60 (range 40-83) years. 5 patients with a malignant disease who were in HPN underwent gastrostomy for decompression drainage of a digestive tract obstruction. 2 patients had a benign disease and were on HEN for a long time. We experienced 2 cases of skin complications, one under HPN and the other under HEN, but no severe complication experienced. HPN and HEN contribute to improve the patients' QOL.

[Review of our home parenteral nutrition (HPN) and home enteral nutrition (HEN) cases].

We reviewed our cases of HPN and HEN after percutaneous gastrostomy. We had 38 patients (26 men, 12 women) on HPN. Of them, 23 (17 men, 6 women) had an implantable subcutaneous infusion port. The average age of HPN cases was 69 (range 40-92) years, and 34 patients (89%) suffered from a malignant disease. The mean duration of HPN was 104 (range 2-543) days. Home anti-cancer chemotherapy was provided for 2 patients. Percutaneous gastrostomy was performed for 7 patients (4 men, 3 women) by endoscopy (PEG, 6 cases) and 1 patient needed an open laparotomy. Their average age was 60 (range 40-83) years. 5 patients with a malignant disease who were in HPN underwent gastrostomy for decompression drainage of a digestive tract obstruction. 2 patients had a benign disease and were on HEN for a long time. We experienced 2 cases of skin complications, one under HPN and the other under HEN, but no severe complication experienced. HPN and HEN contribute to improve the patients' QOL.