international report 2 · terminal cancer, 1 month to live single household. her son and his wife...

Copyright © Daisuke WATANABE 2012 all Rights Reserved.

International Report 2 :role of professionals in terminal care setting

Seikei University, Center for Asian and Pacific Studies

Daisuke Watanabe（[email protected]）

ILC Seminar 2012/2/3

2 Copyright © Daisuke WATANABE 2012 all Rights Reserved.

Backgrounds and aims

team approach in terminal care

differences between professionals

Aims: analyzing relation between professionals and terminal care


Data

1. International survey, 2010-2011

a sample of 566 from 8 countries (Japan, South Korea, France, Australia, Czech Republic, Israel, Nederland, and USA)

physicians, nurses, and caregivers

2. Japan and Korea survey, 2011

Japan: Chuoku, Moriyama city; N=545

Korea：Seoul, Gwangju; N=670

physicians, nurses, and caregivers


Features of our research

Using two fictitious cases

Based on informant’s previous experiences, we asked two choices; one is ideal or best choice, and another is realistic or actual choice

To understand differences between countries and between professionals

To understand the gap between two choices


Two fictitious cases cancer case

Mrs. A (85 yrs old)

terminal cancer, 1 month to live

Single household. Her son and his wife live close (15 min. drive).

She prefers to spend her final days at home.

dementia case Mr. B (80 yrs old)

person with dementia who was diagnosed as pneumonia and was unable to swallow foods.

couple household

His wife wishes (terminal) care at home. But, her care ability is low.


Think about death Anxiety of death

Japan and Korea: higher rates of frequency of think about death and anxiety of death

82.3% 79.7%

19.7%

46.4%

23.6%

39.3% 42.9%

22.7%

47.7%

40.5%

13.1% 8.9%

34.5%

18.5%

10.7%

22.7%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Think about death (oftenand very often)

Anxiety (Very much &somewhat)


Cancer case: GAP between ideal and realistic practice

place: high rate of gap, ideal final place is home

response: palliative care

88.6%

44.3%

66.7%

76.4%

87.3%

50.0%

71.4%

100.0%

16.9% 16.9%

24.2%

16.4%

27.5%

14.3%

7.1% 9.1%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Japan Korea Israel Australia Czech Nederland France USA

final place

principle ofresponse


Cancer case: reason of realistic decision

Improvement QOL or respect for her dignity

Japan and USA have some ratio of “family wish”

improvement

of QOL respect for her

dignity family’s wish other

Japan 15.6% 54.1% 16.1% 14.2%

South Korea 22.1% 58.4% 9.1% 10.4%

Israel 36.1% 19.7% 6.6% 37.7%

Australia 40.4% 42.1% 7.0% 10.5%

Czech 34.5% 38.2% 1.8% 25.5%

Nederland 32.1% 57.1% 3.6% 7.1%

France 39.3% 46.4% 0.0% 14.3%

USA 5.0% 60.0% 35.0% 0.0%


Cancer case: principle of response by professionals (Japan)

ideal

realistic

0.0% 0.0% 0.0%

100.0%

0.0% 1.0% 0.0%

0.5%

96.4%

0.0% 1.6%

0.9% 2.8%

88.6%

0.9% 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

anticancerdrug

high levelmedical service

alternativemedicine

palliativecare

do nothing

physician nurse care worker

3.6% 0.0% 0.0%

96.4%

0.0% 5.2% 0.5%

1.0%

90.2%

0.5%

5.8%

1.9% 2.2%

85.0%

1.9% 0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

anticancerdrug


alternativemedicine

palliativecare

do nothing



Cancer case: principle of response by professionals (Korea)

ideal

realistic

16.7%

0.0% 0.0%

83.3%

0.0% 6.4% 11.6%

4.3%

74.2%

0.0% 11.0%

21.7%

11.0%

52.7%

0.7% 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

anticancerdrug


alternativemedicine

palliativecare

do nothing


16.7%

0.0% 0.0%

83.3%

0.0%

12.9% 10.7% 4.3%

70.8%

0.4%

12.6% 16.0% 9.5%

57.4%

1.6% 0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

anticancerdrug


alternativemedicine

palliativecare

do nothing



Dementia case: GAP between ideal and realistic practice

same tendency

Korea: small gaps, USA: big gap

66.8%

26.6%

48.4% 54.5%

70.4%

57.1%

70.4%

95.5%

36.2%

18.2%

32.8%

43.1% 45.2%

29.6%

42.9%

90.9%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%


final place

principle ofresponse


Terminal Phase? by professionals

Physicians tend to judge as “terminal phase”. (esp. Japan, Korea and Australia)

65.0%

50.0% 44.0%

90.0%

41.7%

33.3%

82.4%

73.3%

43.1%

34.9% 27.8%

77.8%

35.7% 40.0%

57.1%

100.0%

33.1%

36.8% 36.8%

53.8% 50.0%

33.3%

80.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%




Dementia Case: gap between ideal and realistic principle of response

44.5%

19.3% 27.1%

9.2%

0.0%

20.0%

40.0%

60.0%

ideal: A.N.realistic: A.N.

ideal: other thanA.N.

realistic: otherthan A.N.


realistic: A.N.

other

no gap gap

JAPAN 58.4%

23.4%

10.4% 7.8%

0.0%

20.0%

40.0%

60.0%

80.0%





realistic: A.N.

other

no gap gap

Korea

47.5%

19.7% 23.0%

9.8%

0.0%

20.0%

40.0%

60.0%





realistic: A.N.

other

no gap gap

Israel

11.8%

45.1%

29.4%

13.7%

0.0%

20.0%

40.0%

60.0%





realistic: A.N.

other

no gap gap

Australia

* A.N.: Artifical Nutrition


Dementia Case: gap between ideal and realistic principle of response

35.7%

19.0%

33.3%

11.9%

-20.0%

0.0%

20.0%

40.0%

60.0%





realistic: A.N.

other

no gap gap

Czech

29.6%

40.7%

14.8% 14.8%

0.0%

20.0%

40.0%

60.0%





realistic: A.N.

other

no gap gap

Nederland

7.1%

50.0%

10.7%

32.1%

0.0%

20.0%

40.0%

60.0%





realistic: A.N.

other

no gap gap

France

9.1% 0.0%

90.9%

0.0% 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%





realistic: A.N.

other

no gap gap

USA

* A.N.: Artifical Nutrition


dementia case: reason of realistic decision

high dispersion relative to cancer case

Japan: low rate of “QOL” and “dignity”

possibility for longer life

improvement

of QOL respect for her dignity

family’s wish other

Japan 38.8% 6.7% 16.7% 31.6% 6.2%

South Korea 42.7% 17.3% 26.7% 10.7% 2.7%

Israel 8.6% 29.3% 20.7% 10.3% 31.0%

Australia 7.8% 23.5% 49.0% 9.8% 9.8%

Czech 7.3% 41.5% 31.7% 4.9% 14.6%

Nederland 4.5% 18.2% 31.8% 9.1% 36.4%

France 10.3% 13.8% 41.4% 20.7% 13.8%

USA 4.5% 31.8% 22.7% 22.7% 18.2%


Dementia case: Correspondence analysis of ideal principle and reasons

-0.2 0.0 0.2 0.4 0.6

-0.2

0.0

0.2

0.4

0.6

Japan

Korea

Israel

Australia

Czech

Nederland

FranceUSA

-0.5 0.0 0.5 1.0

-0.5

0.0

0.5

1.0

A.Nutrition

Rehab

Keeping

Do NothingRecover

Longer LifeQOL

Dignity

Family

options principles of response 1. artificial nutrition 2. rehabilitation 3. keeping current treatment 4. do nothing reasons of the principle 1. possible recover fully 2. possibility for longer life 3. improvement of QOL 4. respect for Mr. B’s dignity 5. family’s wish


Dementia case: Correspondence analysis of realistic principle and reasons

-0.4 -0.2 0.0 0.2 0.4 0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

Japan

Korea

Israel

Australia

Czech

Nederland

France

USA

-1.0 -0.5 0.0 0.5 1.0

-1.0

-0.5

0.0

0.5

1.0

A.Nutrition

Rehab

Keeping

Do Nothing

Recover

Longer Life

QOL

Dignity

Family

options principles of response 1. artificial nutrition 2. rehabilitation 3. keeping current treatment 4. do nothing reasons of the principle 1. possible recover fully 2. possibility for longer life 3. improvement of QOL 4. respect for Mr. B’s dignity 5. family’s wish


Dementia case: principle of response by professionals (Japan)

ideal 39.3%

0.0%

14.3%

39.3%

3.6% 3.6%

56.5%

1.0% 10.4%

28.0%

1.0% 3.1%

52.7%

1.3%

19.0% 22.2%

0.6% 4.1%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

artificialnutrition

alternativemedicine

rehabilitation keep currentaly do nothing other


60.7%

0.0%

7.1%

28.6%

3.6% 0.0%

77.6%

1.0% 3.6% 16.7% 0.5%

0.5%

77.0%

0.6% 4.5% 14.9%

1.3% 1.6%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

artificialnutrition

alternativemedicine



realistic


Dementia case: principle of response by professionals (Japan)

66.7%

0.0%

16.7% 16.7%

0.0% 0.0%

65.2%

1.3% 9.9% 21.9%

0.4% 1.3%

45.8%

5.1% 10.0%

37.0%

0.9% 1.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

artificialnutrition

alternativemedicine



83.3%

0.0% 0.0%

16.7%

0.0% 0.0%

69.0%

0.9% 7.8%

22.4%

0.0% 0.0%

52.9%

4.0% 7.0%

34.7%

0.5% 0.9%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

artificialnutrition

alternativemedicine



ideal

realistic


Dementia case: reason of response by professionals (Japan & Korea)

Japan

Korea

0.0%

32.1%

3.6% 3.6%

25.0%

35.7%

0.0% 2.8%

29.4%

11.7%

1.1% 11.1%

42.8%

1.1% 1.3%

35.4%

4.7% 1.0%

18.5%

38.4%

0.7% 0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

recover fully longer life QOL Economical dignity family's wish guideline


0.0%

16.7% 16.7%

16.7%

33.3%

16.7%

0.0% 1.7%

43.7%

16.2%

0.9%

24.9% 12.7%

0.0% 0.9%

24.1% 19.7%

3.0%

41.9%

10.1% 0.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

recover fully longer life QOL Economical dignity family's wish guideline



Discussions Cancer case

Consensus between professionals

Difficulty of home-based terminal care of single household

Dementia case Less consensus between professionals than cancer

Japan, Korea, Israel and USA: high rates of artificial nutrition

Japanese professionals tend to focus on “family’s wish”

Other professionals tend to focus on “QOL” and “dignity”

Why makes the differences? In Japan, nurses and care workers empathize with the

physical and mental anguish of families.


Toward next terminal care

Decision making of dementia care has a large dispersion not only between countries but between professionals.

importance of countries’ context for good team collaboration

A feature in Japan: emphasis on family’s wish

They do not ignore patient’s dignity, but focus on it.

Keep to the balance between “dignity” and “family’s wish”

Esp. easing the burden for family member(s)


Thank you for your kindness

international report 2 · terminal cancer, 1 month to live single household. her son and his wife...

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