滋賀県における在宅ホスピスケアの実態 : 開業医のアンケート調査から
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(2) 8 6. 1 I n t r o d u c t i o n The r e p o r to f NHPCO ( N a t i o n a lH o s p i c e and P a l l i a t i v eCareO r g a n i z a t i o n )，2 0 0 3，s t a t e st h a tt h e r e a r e3 ，2 0 0i n s t i t u t i o n sc a r r y i n go u th o s p i c eprogram i nt h eUnitedS t a t e ss oa st os u p p r e s ss k y r o c k e t i n g m e d i c a le x p e n s e s .Approximately8 8 5， 0 0 0p a t i e n t su s e s u c hf a c i l i t i e s .Accordingt od e a t hr e c o r d si nt h eU . S .， more than o n eq u a r t e ro ft h e 2， 4 0 0， 0 0 0d e a t h s r e c o r d e dr e c e i v eh o s p i c ec a r e . Thea d v a n t a g e so fh o s p i c ehomec a r ea r et ok e e p downm e d i c a le x p e n s e sandh e a lt h ep a i no faf a m i l y t h a t has n u r s e dt h e i rl o v e d one u n t i lt h e end o f h i s / h e rl i f e .A r e p o r e )i n d i c a t e st h a tab e r e a v e d f a m i l yf e e l salmostnor e g r e to v e ru s i n gh o s p i c ehome c a r e .Yetd e s p i t eo ft h ea d v a n t a g e s，h o s p i c ehomec a r e i sn o ta sp o p u l a ra si ts h o u l db e .Theb i g g e s tr e a s o n i st h ep h y s i c a lande m o t i o n a lp r e s s u r ee x p e r i e n c e dby d o c t o r sandn u r s e si nah o s p i c eteamwhot a k ec a r eo f t e r m i n a l l yi l lp a t i e n t s .I nc a r r y i n go u th o s p i c ehome c a r e，i ti sr e q u i r e df o rateamo fhomed o c t o r sand n u r s e sn o to n l yt op r o v i d em e d i c a lc a r ef o radying p a t i e n t，b u ta l s ot oh e l phim/hert ob ep r e p a r e df o r t h ecomingd e a t h;v i s i tt h ep a t i e n t ' shomej u s tb e f o r e d e a t h ;d e a l with t h e postmortem t r e a t m e n t ; and p r o v i d e companionship and c o n s u l t a t i o n sw i t ht h e b e r e a v e df a m i l y . Whereasd o c t o r swhoc a r r yo u thomeh o s p i c ec a r e a r er e q u i r e dt ohaves u i t a b l eknowledge，i ti smore importantf o rn u r s e st ob et r a i n e dt od e a lw i t ha v a r i e t yo f emergency s i t u a t i o n s and t ob ea b l et o make p r o p e rjudgments when p r o v i d i n ge m o t i o n a l c a r et odyingp a t i e n t sandt h e i rf a m i l i e s . F i n a n c i a lp r oblems and s h o r t a g e so fe x p e r t sa r e c i t e da sr e a s o n sf o rt h et r o u b l e di m p l e m e n t a t i o no f t h es y s t e m .Biggapsi nt h em e d i c a lenvironmentand systemb e t w e e nl a r g e rc i t i e swherep o p u l a t i o n sa r e c o n c e n t r a t e dandr u r a la r e a swhered e p o p u l a t i o nand t h eagingp r o c e s so ft h ep o p u l a t i o ni sa c c e l e r a t e d，and t h eaddedp r e s s u r eonhomed o c t o r sandn u r s e s，a s w e l la st h ed e l a y e ds p r e a do ft h ei n f o r m a t i o nandt h e low d e g r e eo fr e c o g n i t i o na r ea l la f f e c t i n gt h e promotiono fhomeh o s p i c ec a r e . Althoughc o o p e r a t i o nont h ep a r to fl o c a lg e n e r a l p r a c t i t i o n e r si se s s e n t i a lf o rt h ee s t a b l i s h m e n to f homeh o s p i c ec a r es e r v i c e，s u r v e y so fd o c t o r sont h e i r a t t i t u d e towards h o s p i c ec a r e and t h ec u r r e n t. 竹村節子. s i t u a t i o nhass of a rb a r e l yb e e nc o n d u c t e d .Ast ot h e e n t i r e Shiga P r e f e c t u r e，no s u r v e yr e s u l to ft h i s n a t u r ee x i s t s . I nShigaP r e f e c t u r e，wheret h ep e r c e n t a g eo ft h e agingp o p u l a t i o nc o m p r i s e s1 7 . 3 % 2 )，andt h ep r o c e s so f agingi sadvancing，witht h eaimt oe s t a b l i s hh o s p i c e homec a r es e r v i c e，wehavec a r r i e do u tt h ef i r s ts u r v e y whichc o v e r sa l ln i n el o c a lm e d i c a la s s o c i a t i o n s .' T h e q u e s t i o n n a i r e was answered by home d o c t o r s who t a k ec a r eo ft e r m i n a l l yi l lp a t i e n t sandt h ef a m i l yand g e n e r a lp r a c t i t i o n e r s who a r et h ep i l l a ro fl o c a l m e d i c a ls e r v i c e s .Web e l i e v et h a tt h i ss u r v e yi sa b l et o c l a r i f yt h ea c t u a ls i t u a t i o n，problemsando b s t a c l e s wheni tcomest ot h ep r a c t i c eo fh o s p i c ehomec a r e s e r v i c ei nShigaP r e f e c t u r e .. I I D e f i n i t i o no ftheterminology Witht h er e f e r e n c et ot h efundamentalp r i n c i p l eo f h o s p i c ehomec a r es e r v i c e se s t a b l i s h e dbyt h eHome 3 H o s p i c eA s s o c i a t i o n nt h i ss u r v e y we d e f i n e d ) ，i h o s p i c ehomec a r es e r v i c ea sb e i n gasystemwhereby c a r ef o rt h edyingi sp r a c t i c e di nt h ehomes ot h a t t e r m i n a l l yi l lp a t i e n t s( c a n c e rp a t i e n t s ) can b e r e l e a s e d from p h y s i c a l， e m o t i o n a l， s o c i a ， l and s p i r i t u a lp a i n sandl i v ebothm e n t a l l yandp h y s i c a l l y a te a s ew h i l em a i n t a i n i n gt h ed i g n i t ya s ahuman b e i n gt i l lt h e end o ft h e i rl i f e . The fundamental p r i n c i p l eo ft h eHomeH o s p i c eA s s o c i a t i o ni n d i c a t e s t h a tahomes h o u l db eap l a c ewhereadyingp a t i e n t and t h e i rf a m i l yc a nb er e l a x e d most and t h e i r i n t e n t i o n sc a nb ee x e r c i s e dm o s t .T h e r e f o r e，h o s p i c e homec a r ei sa l s oc o n s i d e r e dt ob eac a r esystemt o p r o v i d et h en e c e s s a r ya i df o ra dyingp a t i e n t and t h e i rf a m i l yt of u l f i l lt h e i rwisht os p e n dt h er e s to f t h e i rl i f ea thome.. I I I The担urposeo fther e s e a r c h Throughc l a r i f i c a t i o no ft h ec u r r e n th o s p i c ehome c a r es i t u a t i o ni nt h er e g i o n，t h i sr e s e a r c hw i l lstudy t h eproblemsandi s s u e st h ei m p l e m e n t a t i o no fhome h o s p i c ec a r ei sf a c e dwithi no r d e rt op r o v i d ed a t af o r t h ef u t u r ee s t a b l i s h m e n to ft h es y s t e m ..
(3) 8 7. 滋賀県における在宅ホスピスケアの実態. I VThes u b j e c t sandmethodo fthesurvey The s u b j e c t so ft h es u r v e y were 7 7 2g e n e r a l p r a c t it i o n e r swhowerer e g i s t e r e dwit ht h eM e d i c a l A s s o c i a t i o no fShigaP r e f e c t u r ea so fJune2 0 0 2 .The p u r p o s eandc o n t e n t so ft h eq u e s t i o n n a i r eweref i r s t e x p l a i n e dt ot h e chairmen o fn i n el o c a lm e d i c a l a s s o c i a t i o n s and a l s oa te a c hr e s p e c t i v e board o f d i r e c t o r s meetingt o 0b t a i n. t h e i ra s s i s t a n c ei nt h e s u r v e y，and t h e n with t h e i rc o n s e n t，p r a c t i t i o n e r s from t h ee a c ha s s o c i a t i o n were n o t i f i e do ft h e upco 立l1n gs u r v e y . Thes u r v e ywasc a r r i e do u tfromJulyt oAugusto f 2 0 0 3 . Theq u e s t i o n n a i r ewasm a i l e dt oe a c hp r a c t i t i o n e randt h e ywerer e q u e s t e dt om a i li tbacka f t e r havingk e p ti tf o rtwow e e k s . The c o n t e n t so ft h eq u e s t i o n n a i r ec o v e r e dt h e backgroundo fe a c hf a c i l i t ysucha st h enumberso f y e a r so fp r a c t i c e，b e d s，and s t a f f，an o c c u p a t i o n a l c a t e g o r y，t h e name o fm e d i c a la s s o c i a t i o nh e / s h e b e l o n g st o，whethert h e r ei sana d j o i n i n gf a c i l i t yt o c o n d u c tv i s i t i n gn u r s i n gs e r v i c ei nh i sp r a c t i c e .I ta l s o a s k e dwhethero rn o tt h e ya r ei n t e r e s t e di nh o s p i c e homec a r eandhowmucht h e yunderstandt h es e r v i c e . I nt h ec a s eo fap r a c t i t i o n e r who has c o n d u c t e d h o s p i c ehomec a r es e r v i c e，t h em o t i v a t i o n，t h enumber o fp a t i e n t s，s p e c i f i cm e d i c a ls e r v i c e s，o t h e rs e r v i c e s， and o b s t a c l e s were a l s oa s k e d .I nt h ec a s eo fa p r a c t i t i o n e rwhohasn e v e rc a r r i e do u tt h es e r v i c e，t h e r e a s o n s were h e / s h e was a s k e dt ot i c ka p p l i c a b l e r e a s o n si nt h eq u e s t i o n n a i r eanda l s od e s c r i b ed e t a i l s i nh i s / h e rownw o r d s .I na d d i t i o n，f r e ed e s c r i p t i o no f opmlOn s were sought r e g a r d i n g t h e n e c e s s a r y r e q u i r e m e n t sandt h eimportantf a c t o r st oc o n d u c t t h es e r v i c e，t h eo r g a n i z a t i o n st h e yt h i n ks h o u l dp l a y ac e n t r a lr o l ei ni m p l e m e n t a t i o nande x p a n s i o n，and t h er e a s o nf o rt h ed i f f i c u l t yi na c t u a li m p l e m e n t a t i o n i nShigaP r e f e c t u r e，a sw e l la sanyo t h e rs u g g e s t i o n s .. V. E t h i c a lc o n s i d e r a t i o n s. I nc a r r y i n go u tt h es u r v e y，t h ef o l l o w i n gp o i n t s werec l a r i f i e di nw r i t i n g :Thei n f o r m a t i o ng a t h e r e d wouldo n l yb eu s e df o rt h i sr e s e a r c handwouldnotb e u s e df o ranyo t h e rp u r p o s e s . Thed a t awasanonymousandh a n d l e dbynumber.Noanswerf o rt h e q u e s t i o n n a i r es h o u l db ef o r c i b l y made. No d i s a ι. v a n t a g ewouldb ec a u s e dduet ot h es u r v e y .. 羽. γher e s u l t so fthes u r v e y .. Oft h e7 7 2p r a c t i t i o n e r s2 9 7o r3 8 . 5 %r e s p o n d e d .The p e r c e n t a g e so ft h e9m e d i c a la r e a sw e r e :3 7 . 7 %from O t s u C i t y，3 2 . 8 %fromK u s a t s u R i t t oa r e a，3 5 . 8 %from Moriyama City-Yasu County， 3 8 . 2 % from KogaCounty， 必 4 5 . 5 % from 01 m 立 m 工出 h邸a chi n 工 man C α i t y 陶 . トG County， 5 0 . 0 % from Y o k a i c h i C i t y， 5 2 . 4 % from H i k o n e .3 8 . 1 % from Kohokl トa r e a . and 3 7 . 9 % from Takashima-County.Thesef i g u r e sshow，wewere a b l et or e c e i v ealmostt h esamenumbero fr e s p o n d e n t s around t h ee n t i r e Shiga P r e f e c t u r e . Among them，2 9 4 answers were t a k e na sv a l i d with t h e e x c l u s i o n so ft h r e ed o c t o r swhosea f f i l i a t i o nt ol o c a l m e d i c a la s s o c i at i o n swereu n c l e a r( t h ep e r c e nt a g eo f v a l i danswerswas3 8 . 1 % ) . 旬 旬 句句. 1 . 8ackgroundo ff a c i l i t i e s 1 ) Whent h e ys t a r t e dh o s p i c ec a r e. Oft h er e s p o n d e n t s，1 0 8f a c i l i t i e s，whichc o m p r i s e s t h el a r g e s tp a r t，weres e tup from 1 9 9 0 9 9( 3 6 . 7 % )， f o l l o w e dby6 0f a c i l i t i e swhichweree s t a b l i s h e dfrom 1 9 8 0 8 9( 2 0. 4 % ) ， and t hen 5 2f a c i l i t i e s which were openedb e f o r e1 9 6 9( 1 7 . 7 % )( T a b l e 1 ) . However，t h er a t i oo ft h ee s t a b l i s h m e n tb e f o r e1 9 6 9i s shown t ob eh i g h e r by some m e d i c a la s s o c i a t i o n s ; 3 5 . 5 %i nKohokum e d i c a la s s o c i a t i o n( r a n k e dt h ef i r s t i nt h eKohokur e g i o n )，25%i nKogaCountym e d i c a l a s s o c i a t i o n， 3 4 . 1 %i n Hikone m e d i c a la s s o c i a t i o n， 2 7 . 3 % i n Takashima 心o unty m e d i c a l a s s o c i a t i o n ( r a n k e dt h es e c o n di ne a c hr e s p e c t i v er e g i o n ) . 2 )Thet y p eo ft h ej o bandnumbero ft h es t a f fi nt h e f a c i l i t i e s Ther e c o r dshowst h et o t a lnumbero f2 8 4f u l l t i m e and5 3p a r t t i m ed o c t o r swithsomee x c e p t i o no fno number o fd o c t o r sm e n t i o n e d . On a v e r a g e， t h e numbero fd o c t o r swasonef u l ltimeand0 . 2p a r tt i m e p e rf a c i l i t y .Thenumbero fn u r s e swas1 4 6f u l lt i m e， 1 0 4p a r t t i m e，8 7f u l l t i m ep r a c t i c a ln u r s e s，and5 3 p a r t t i m ep r a c t i c a li nt o t a l .Ona v e r a g e0 . 5f u l l t i m e and0. 4p a r t t i m en u r s e s，and0 . 3f u l l t i m eand 0 . 2 p a r tt i m ep r a c t i c a ln u r s e s work p e rf a c i l i t y . As a d d i t i o n a ls t a f f， p h y s i c a lt h e r a p i s t s， o c c u p a t i o n a l.
(4) 竹村節子. 88. T a b l e1 Theo p e n i n gy e a r A numberof samples. Thet o t a l Otsu-City Kusatsu/ R i t t o MoriyamaC i t y / YasuCounty TheAreaofeachKoga-County medical OhmihachimanC i t y / a s s o c i a t i o na GamoCountv doctori s Y o k a i c h i C i t y r e g i s t e r e dw i t h Hikone Kohoku Takashima-County. B e f o r e 2000 n w a r d s N.A. 1 9 6 9 :1970-79 1980-89:1990-99:o. 294. 5 2 : 29 ( 1 7 . 7 % ) ( 9 . 9 % ) 1 2 : 88 7 ( 1 3 . 6 % ) ( 8 . 0 % ) 35 3 ( 2 . 9 % ) ; ( 8 . 6 % ) 24 2 8 . 3 % ) ( 4 . 2 % ) ! ( 5 ; 3 20 ( 2 5 . 0 % ) ! ( 1 5 . 0 % ) 2 : 4 23 4 % ) ( 8 . 7 % ) ! ( 1 7. 15 j ( ( 1 3 3 % 2 ) 1 6 . 7 % ). f i g u r e 1 H o s p i c er e l a t e df a c i l i t i e sp r o v i d i n g homec a r es e r v i c e. 33 ( 1 1 . 2 % ) 10 ( 1 1. 4 % ) 5 ( 1 4 . 3 % ) 5 ( 2 0 . 8 % ) 4 ( 2 0 . 0 % ). 12 ( 4 . 1% ) 3 ( 3. 4 % ). ( 4 . 3 % ). ( 0 . 0 % ). 。 。 。 。. ( 0 . 0 % ). ( 0 . 0 % ) ( 0 . 0 % ). ( 2 6 7 % 4 ) i i ( 4 0 . 0 % 6 ) : : ( 6 . 7 % ) 6 . 7 % ) ( 7 : 1 1: 2 3 1 5 : 6 6 . 8 % ) ( 3 4 . 1 % ) ! ( 1 3 . 6 % ) ( 1 5 . 9 % ) ; ( 2 5 . 0 % ) ( 4 . 5 % ) ( 4 3 1 1 1 : 3 ( 1 2 . 9 % ) ( 3 5 . 5 % ) ! ( 9 . 7 % ) ( ( 0 9 0 7 % % 3 O ) ) 1 i i i ( ( 2 5 2 4 . 5 B % % 7 e ) ) i i ( 1 [ 9 8 7 2 % % Z 3 ) 1 1 ( 0 . 0 % ) lp7d(OJ. 3 ) Thenumbero fh o s p i c ec a r ef a c i l i t γ t h a tp r o v i d e s homec a r es e r v i c e . T h i r t y s e v e nf a c i i i t i e s hadar e l a t e df a c i l i t yt h a t p r o v i d e sh o s p i c e home c a r e( 1 2 . 6 % ) whereas 2 4 3 f a c i l i t i e sd i dn o thavei t( 8 2 . 6 % )( F i g u r e1 ) . Among. N . A .. 1 0 8 : ( 3 6 . 7 % ) ; 3 1 : ( 3 5 . 2 % ) ! 2 1 : ( 6 0 . 0 % ) ! 1 3 : ( 5 4 . 2 % ) : 6 : ( 3 0 . 0 % ) : 6 : ( 2 6 . 1% ). 44. t h e r a p i s t s and s o c i a l workers were c i t e dt ob e o l u n t e e rworkers workingf o rsomef a c i l i t i e s，andv werem a r g i n a l l ya c c e p t e d .. 4.8%. 6 0 : ( 2 0 . 4 % ) ; 2 5 : 4 % ) ! (28. 5 : ( 1 4 . 3 % ) ! 3 : ( 1 2 . 5 % ) : 2 : ( 1 0 . 0 % ) : 1 0 : ( 4 3 . 5 % ) :. 。. them，i nt h eKohokur e g i o n( n3 1 )，9f a c i l i t i e s( 2 9 . 0 % ) c a r r i e do u th o s p i c ehomec a r e . 口. 2 .R e c o g n i t i o n and u n d e r s t a n d i n g towards h o s p i c e homec a r e Fort h eq u e s t i o na st owhethero rn o tt h e yh a v e e v e rh e a r do f" H o s p i c ehomec a r e "，2 4 7d o c t o r sa n s weredY e s ( 8 4 . 0 % )，and4 6d o c t o r sN o ( 1 5 . 7 % )( F i g u r e2 ) . h er e c o g n i t i o no ft h ee x i s t i n g Ont h eo t h e rhand，t N . A . 0 . 3 %. f i g u r e 2 R e c o g n i t i o ntowardsh o s p i c ehomec a r e.
(5) 8 9. 滋賀県における在宅ホスピスケアの実態. T a b l e 2 R e c o g n i t i o nt oh o s p i c ehomec a r e Have you ever heard about hospice home care ? A numbero f. samples. YES. N. A .. NO. 294. 247. ( 8 4 . 0 % ). 4 6 :. ( 1 5 . 7 % ). ( 0 . 3 % ). Before1 9 6 9. 52. 48. ( 9 2 . 3 % ). 3 :. ( 5 . 8 % ). ( 1 . 9 % ). τhetotal. 1 9 7 0 7 9. 29. 26. ( 8 9 . 7 % ). 3 :. ( 1 0 . 3 % ). 0 :. ( 0 . 0 % ). The opening year 1 9 8 0 8 9. 60. 46. (76 . 7 % ). 1 4 !. ( 2 3 . 3 % ). O !. ( 0 . 0 % ). 1 9 9 0 8 9. 108. 89. ( 8 2. 4 % ). 1 9 :. ( 1 7 . 6 % ). 0 :. ( 0 . 0 % ). 2 0 0 0onwards. 33. 26. (78 . 8 % ). 7 :. ( 2 1 . 2 % ). 0 :. ( 0 . 0 % ). Otsu-Citv. 88. 72. ( 8 1 . 8 % ). 1 6 :. ( 1 8 . 2 % ). 0 :. ( 0 . 0 % ). Kusatsu/Ritto. 35. 29. ( 8 2 . 9 % ). 6 :. ( 1 7 . 1% ). 0 :. ( 0 . 0 % ). 24. 2 1. ( 8 7 : 5 % ). 3 :. ( 1 2 . 5 % ). 0 :. ( 0 . 0 % ). 20. 15. (75 . 0 % ). 5 !. ( 2 5 . 0 % ). O !. ( 0 . 0 % ). 23. 2 1. ( 9 1 . 3 % ). 2 :. ( 8 . 7 % ). 0 :. ( 0 . 0 % ). 0 :. ( 0 . 0 % ). An areaof MorivamaCitv/YasuCountv medical Koga-County associations OhmihachimanCity/Gamo a doctor i s Countv registered Yokaichi-Citv with Hikone て. 15. 13. ( 8 6 . 7 % ). 2 :. ( 1 3 . 3 % ). 44. 39. ( 8 8 . 6 % ). 4 :. ( 9 . 1 % ). Kohoku. 3 1. 27. ( 8 7 . 1% ). 4 :. ( 1 2 . 9 % ). 0 :. ( 0 . 0 % ). γakashima-Countv. 1 1. 9. ( 8 1 . 8 % ). 2 :. ( 1 8 . 2 % ). 0 :. ( 0 . 0 % ). ( 2 . 3 % ). The name oftowns，cities andcounties aretakenfrom a l i s tofmedicalassociation i n Shiga prefecure 002(The name ofcountyandcitieswaschangedin 2003，so howcan 1explain it?) In June，2. f a c i l i t yv a r i e sbyt h ey e a ro ft h e i rcommencingo ft h e s e r v i c e .9 2 . 3 %d o c t o r s answered " y e s " when t h e i r h er e c o g n i t i o nl e v e li s s e r v i c es t a r t e db e f o r e1 9 6 9，andt s l i g h t l yl o w e ramongd o c t o r swhosef a c i l i t i e ss t a r t e d t h es e r v i c ea f t e r2 0 0 0 and 7 8 . 8 %d o c t o r s answered y e s . Ther a t eo fr e c o g n i t i o nbye a c hm e d i c a la s s o c i a t i o n b a s e showed t h a ti n Ohmihachiman City-Gamo County，91 .3%d o c t o r sknewo ft h es e r v i c e，andont h e c o n t r a r y，i nKoga-County，o n l y7 5 . 0 %d o c t o r sknew t h es e r v i c e( T a b l e2 ) . 3 .I n t e r e s t stowardshomeh o s p i c ec a r e 3 6d o c t o r s showed t h e i r Of t h er e s p o n d e n t s， 1 i n t e r e s ti nt h es e r v i c e( 4 6 . 2 % )，and4 7d o c t o r sd i dn o t showanyi n t e r e s ti nt h es e r v i c e( 1 6 . 0 % ) . Then，1 0 9 d o c t o r swereu n c l e a raboutt h e i rp o s i t i o no fi n t e r e s t e r v i c e( F i g u r e3 ) .Whencombiningt h ed o c t o r s m 土hes whoshowednoi n t e r e s t sw i t hd o c t o r swhoweren o t s u r e，aboutt h eh a l fo ft h ed o c t o r s( 5 3 . 1 % )showedno i n t e r e s ti nt h es e r v i c e .Comparedw i t ho t h e rm e d i c a l a s s o c i a t i o n s，t h o s ed o c t o r swhob e l o n gt ot h em e d i c a l. a s s o c i a t i o n s which a r el o c a t e di nt h ea r e a where p u b l i ch o s p i t a l sa r eo f f e r i n gh o s p i c e and p a l l i a t i v e c a r ei nt h e i ra d j o i n i n gu n i t s，showedl e s si n t e r e s ti n. N . A .. 0 . 7 %. f i g u r e 3 I n t e r e s ti nh o s p i c ehomec a r.
(6) 9 0. 竹村節子. Ta包括 3 I n t e r e s ti nh o s p i c ehomec a r e. A numberof "，_~mpk'!. 47， (16.0%). 109!( 3 7 . 1 % ). (12.5%). 39!( 4 4 . 3 % ). 12， (34.3%). 1 2 !( 3 4 . 3 % ). 294. 136. (46.2%). Otsu-City. 88. 37. ( 4 2 . 0 % ). : 11. i くusatsu/Ritto MoriyamaCity/ Yasu Count. 35. 1 1. ( 3 1. 4 % ). Thet o t a l. An areaof medical associations a doctori s γegistered with. Are you ever interested in hospice home care? Notsurewhether beingi n t e r e s t e dor not YES NO N.A. 24. 9. ( 3 7 . 5 % ). 4 !. (16.7%). 1 1 ;(45.8%). Koga-County OhmihachimanCity/Ga moCountv. 20. 7. ( 3 5 . 0 % ). 5 ;. (25.0%). 8 ;(40.0%). 23. 12. ( 5 2 . 2 % ). 4 '. 4 % ) (17.. 7 ;(30.4%). Y()k< li c b l = Q i t : Y '. 15. 14. ( 9 3 . 3 % ). ( 6 . 7 % ). 0 ; ( 0 . 0 % ). Hikone. 44. 22. ( 5 0 . 0 % ). 5， ( 1 1. 4 % ). 1 7 ;(38.6%). Kohoku. 3 1. 18. ( 5 8 . 1 % ). 2， ( 6 . 5 % ). 1 1 ;(35.5%). Takashima-County. 1 1. 5. ( 4 5 . 5 % ). 2 !. (18.2%). 3 ;(27.3%). 2. 。 。 。 。 。 。 。. ( 0 . 7 % ) ( 1 .1 %). ( 0 . 0 % ) ( 0 . 0 % ) ( 0 . 0 % ) ( 0 . 0 % ) ( 0 . 0 % ) ( 0 . 0 % ) ( 0 . 0 % ) ( 9 . 1 % ). m p l e m e n t a t i o no fh o s p i c ehomec a r eandt h ed e g r e e h o s p i c e home c a r e a s f o l l o w s : Hikone ( 5 0 . 0 % )， i fI n t e r e s ti nh o s p i c ehomec a r ewerecomparedu s i n g Moriyama C i t y Y a s u County ( 3 7 . 5 % )， O t s u C i t y o X2t e s t，showingas i g n i f i c a n c ed i f f e r e n c ea tp < O . 01 . ( 4 2 . 0 % )( T a b l e3 ) . Analyzinghed a t abyt h ey e a ro fe s t a b l i s h m e n t，i t 4 .R e a l i t yo fh o s p i c ehomec a r e h a to n l y1 2 . 1 %f a c i l i t i e sp r o v i d eh o s p i c e S e v e n t y f i v ed o c t o r sp r o v i d eh o s p i c e home c a r e wasfoundt 1 9d o c t o r shaven e v e rdones o( 7 4 . 5 % ) ; homec ( 2 5 . 5 % )，and2 a r eamongt h o s ewhocommencedt h es e r v i c e n l yo n eq u a r t e ro ft h et o t a lnumbero f a i s t e di nt h eform f t e r2 0 0 0 .Ther e a s o n s，whichwerel t h e r e f o r e，o d o c t o r sc a t e rt ot h es e r v i c e( F i g u r e4 ) . o ff r e ed e s c r i p t i o nc a nb esummarizeda s"Undert h e Amongt h ed o c t o r swhop r o v i d eh o s p i c ehomec a r e， p r e s e n tc i r c u m s t a n c e s，t h es t r u c t u r eo ft h es e r v i c e h a sy e tt ob ep r e p a r e d . "I nt h eK u s a t s u R i t t or e g i o n， 6 3d o c t o r ss p e c i a l i z emainlyi ni n t e r n a ldepartment i t slowr a t i oo fp r o v i s i o n ( 11 .4 % )c a nb ee x p l a i n e dby ( 8 4 . 0 % )，ando n l y1 2d o c t o r ss p e c i a l i z eo t h e rd e p a r t ment( 1 6 . 0 % )，s u c ha s4d o c t o r ss u r g e r y，4 d o c t o r s p e d i a t r i c s， 1 o r t h o p e d i c s， 1 T a b l e4 P r a c t i c e o fh o s p i c ehomec a r e r eunknown. a n e s t h e s i o l o g y，and2a Neverpracticedbefore? Based on t h ed a t aa b o v et h ea c t u a l 何. A number ofsamples. 14. ( 2 6 . 9 % ). 38:. (73.1%). 7. ( 2 4 . 1 % ). 2 2 :. (75.9%). 60. 10. ( 1 6 . 7 % ). 5 0 :. (83.3%). Before 1 969. 52. 1970-79. 29. Theopening 1980 89 year. 1990 99. 108. 34. ( 3 1 . 5 % ). 7 4 :. (68.5%). 2000onwards. 33. 4. ( 1 2 . 1 % ). 29:. (87.9%). Otsu-Citv. 88. 24. ( 2 7 . 3 % ). 6 4 :. (72.7%). Kusatsu/Ritto MoriyamaCity/ Y Anareaof asuCountv medical Koe : a-Countv associations OhmihachimanCity/ adoctori s GamoCountv registered Yokaichi-Citv with. 35. 4. ( 1 1. 4 % ). 3 1:. (88.6%). 24. 5. ( 2 0 . 8 % ). 1 9 :. (79.2%). 20. 5. ( 2 5 . 0 % ). 1 5 :. (75.0%). 叩. f i g u r e 4 P r a c t i c eo fh o s p i c ehomec a r e. 219:. 75. 叩. ( 74.5%). ( 2 5 . 5 % ). 294. Thet o t a l. NeverPracticed b e f o r e. YES. 23. 6. ( 2 6 . 1 % ). 1 7 :. ( 7 3 . 9 % ). 15. 4. ( 2 6 . 7 % ). 1 1 :. (73.3%). Hikone. 44. 9. ( 2 0 . 5 % ). 35:. (79.5%). Kohoku. 3 1. 15. (48. 4 % ). 1 6 :. (51.6%). τakashima-Countv. 1 1. 3. ( 2 7 . 3 % ). 8 i. ( 72.7%).
(7) 9 1. 滋賀県における在宅ホスピスケアの実態. 7f a c i l i t i e sf o rnone f a c i l i t i e sf o r2p a t i e n t s( 1 4 . 7 % )，1 and 4 f a c i l i t i e sw i t h no a n s w e r . On a v e r a g e one f a c i l i t yp r o v i d e dt h es e r v i c ef o r2 . 3t e r m i n a l l yi l l p a t i e n t s . Thenumberso fm e d i c a ls t a f fwhohade x p e r i e n c ei n p r o v i d i n gh o s p i c ec a r e were a sf o l l o w s :z e r oi n2 2 f a c i l i t i e s( 2 9 . 3 % )，o n ei n1 9f a c i l i t i e s( 2 5. 4 % ) ， twoin1 0 f a c i l i t i e s( 1 3 . 4 % ) and t h r e eo r more i n1 3f a c i l i t i e s ( 1 7 . 2 % ) .Amongthemwaso n ef a c i l i t ywhere1 0s t a f f membershads u c he x p e r i e n c e .Nod a t awereo b t a i n e d e r e l y1 .3m e d i c a l frome l e v e nf a c i l i t i e s .Ona v e r a g e，m 1 )A boutt h ef a c i l i t i e sp r o v i d i n gh o s p i c ehomec a r e s t a f fp e rf a c i l i t yhadt h ee x p e r i e n c e . ( n口 7 5 ) ( 2 )Ther e a s o nwhγtheγstartedh o s p i c ehomec a r e ( 1 )A chievementi nt h ep a s toneγear Ther e s u l to fp l u r a lanswers u r v e yshows6 3s t a r t e d I nt h ep a s to n ey e a r，1 1f a c i l i t i e sp r o v i d e dh o s p i c e b e c a u s eo fr e q u e s t sfromap a t i e n t ' sf a m i l y( 8 4 . 0 % )， homec a r ef o rmoret h a n f i v et e r m i n a lc a n c e rp a t i e n t s and3 8fromah o s p i t a l( 5 0 . 7 % )，and2 6fromapa 七i e n t ( 1 4 . 7 % :o n ef a c i l i t yp r o v i d e dt h es e r v i c ef o r1 3 h i m s e l f( 3 4 . 7 % )，andt h e r ewereo n l yafewr e q u e s t s p a t i e n t s ) .Threef a c i l i t i e sp r o v i d e dt h es e r v i c ef o rf o u r fromp r a c t i t i o n e r so rl o c a la d m i n i s t r a t i o ns u c hast h e e v e nf a c i l i t i e sf o r3 s o c i a lw e l f a r eo f f i c e( F i g u r e5 ) . t e r m i n a lc a n c e rp a t i e n t s( 4 . 0 % )，s p a t i e n t s( 9 . 3 % )，ande a c h1 5f a c i l i t i e sr e s p e c t i v e l yf o r ( 3 )C o n c r e t ec o h t e n t so ft h es e r v i c e twoandf o ro n ep a t i e n t s( 2 0 . 0 % ) .Twenty-onef a c i l i t i e s. The r e s u l to fp l u r a l answer s u r v e y shows that p r o v i d e df o rnone( 2 8 . 0 % )andt h eanswersfromt h e manyo fs e r v i c e sp r o v i d e dwerem e d i c a lt r e a t m e n t . r e s tt h r e ef a c i l i t i e sweren o ta v a i l a b l e .Ona v e r a g e1 .9 The h ouse c a l l ranked t h ef i r s tw i t h7 3( 9 7 . 3 % )， t e r m i n a l c a n c e rp a t i e n t s p e ro n ef a c i l i t y were f o l l o w e d . b yi n t r a v e n o u st r a n s f u s i o nw i t h5 6( 7 4. 4 % ) . p r o v i d e dw i t hh o s p i c ehomec a r e .Ont h eo t h e rhand， F o r t y n i n es a i di ti smainlyp a l l i a t i v ep a i nc o n t r o l 1f a c i l i t i e sp r o v i d e d ( 6 5 . 3 % )，and4 8answeredemergencyt r e a t m e n t( 6 4 . 0 % ) . e x c e p tf o rc a n c e rp a t i e n t s， 1 h o s p i c ehomec a r es e r v i c ef o rmorethanf i v eo t h e r O t h e r sa r e ;3 3p r o v i d ep r e s s u r eu l c e r ' s treatment 7c a t e rt ohomeoxygent h e r a p y( 3 6 . 0 % )，2 2 t e r m i n a l l yi l lp a t i e n t s( 1 4 . 7 % : Onef a c i l i t yp r o v i d e d ( 4 4 . 0 % )，2 s e r v i c ef o rf o u r t e e np a t i e n t s，and a n o t h e rf o r2 0 p r o v i d et u b ef e e d i n g( 2 9 . 3 % )， and o n l y1 1p e o p l e p a t i e n t s ) .Fourf a c i l i t i e sp r o v i d e dt h es e r v i c ef o rf o u r p r o v i d e dn u r s i n gc a r es u c ha ss a n i t a t i o nandc l e a n i n g a c i l i t i e sf o r3p a t i e n t s( 8 . 0 % )，1 1 body( 1 4 . 7 % )( F i g u r e6 ) . p a t i e n t s( 5 . 3 % )，6f. t h ef o l l o w i n g :r e l a t i v e l y new s e r v i c e commencing 4 . 3 %a f t e ry e a r y e a r s ;60%between1 9 9 0and9 9，and1 2 0 0 0，andt h ep o p u l a t i o ni n c r e a s ewithalowr a t i oo f agingp o p u l a t i o n1 1 1 3 %( T a b l e4 ) .Ont h ec o n t r a r y，i n t h e f a c i l i t i e s t h a t b e l o n g t o Kohoku m e d i c a l 8. 4 %o ff a c i l i t i e sp r o v i d eh o s p i c ehome a s s o c i a t i o n，4 c a r e ;t h er e a s o n sa r ec i t e da sf o l l o w s : Thel a c ko f mainh o s p i t a l sp u tthemi nap o s i t i o nn o tt ob ea b l et o d e c l i n et h er e q u e s t s .Homeh o s p i c ec a r ei sp o s i t i o n e d w i t h i nt h es c o p eo ft h e i rhomem e d i c a lc a r e .. ( s. 「 Requestr r o maf 誼m i l yofa戸a t i e n t. 8 4 . 0. Re時u e s t骨omah o s p i t a l. 5 0 . 7. ヤ omap a t i e n t Requestf. Requestr r o map r a c t i t i o n e r. 3 4 . 7. 圏2.7. 色r eo f 官c eanda d m i n i s t r a t i o n Requestr r o mas o c i a lw e l. O t h e r s. n=75. 調2.7. 。. 20. 40. 60. f i g u r e 5 The r e a s o nf o rs t a r t i n gh o s p i c ehomec a r e. 80. 100%.
(8) 9 2. 竹村節子. ( 4 )Strategγands t r u c t u r e (selectedp l u r a l answers) i np r o v i d i n gh o s p i c e home Visit 7.3 c a r e Intervenetransfusion 7417 Fromt h er e s u l to fp l u r a l Palliativecare 65.3 a n s w e r s .6 6 answeredt h a t Criticalcare 64.0 t h e y made t h e m s e l v e s Pressureulcer'scare 44.0 r e a c h a b l e anytime f o rt h e Homeoxygentherapy Tubefeeding 1 p a t i e n t s 'n e e d s( 8 8 . 0 % )， 6 S a n i t a t i o n andcleaning t r a v e lo u tt oap a t i e n t ' s Others home e v e n on h o l i d a yo r N. A. d u r i n g n i g h t when 20 80 40 60 100% .3 % )，2 5had2 4 r e q u e s t e d( 81 f i g u r e 6 C o n c r e t ec o n t e n t so fh o s p i c ehomec a r es e r v i c e h o u r s aroundt h e c l o c k system( 3 3 . 3 % )( F i g u r e7 ) . ( 5 )H a r d s h i p si no r d e rt o (selectedp l u r a lanswers) p r o v i d eh o s p i c e home c a r e 8 8 β anytimereachable s e r v l c e 81 . 3 The p a r t i c i p a n t so ft h e Visitinghomeatnightandonholidayifrequested s u r v e ywerea s k e dt oc h o o s e Arrangingahospitalforemergency 7 . 3 two s u i t a b l e a n s w e r s . 3 3 . 24hourson-duty T h i r t y f i v eo f them p o i n t Bringapatienti nforc r i t i c a lcare 目1 . 3 o u t p h y s i c a l e x h a u s t i o n Increasinganumberofstaff 1 0 . 0 ( 4 6 . 7 % )，3 5o fthemanswers t h a tt h e yc a n n o ts e tup2 4 Others h o u r ss e r v i c e .Botho fthem N .A . rankedt h ef i r s t .f o l l o w e d 20 40 60 8 0 100首 by2 8whoc l a i m e dp s y c h o l o g i c a l p a i n ( 3 7 . 3 % )， and f i g u r e 7 Treatmentwhenp r o v i d i n gh o s p i c ehomec a r e t h e n1 6c o m p l a i n e das h o r ( s e l e c t e dp l u r a la n s w e r s ) t a g eo ft h eteamandt h es t a f f .3 % )， 1 3c i t e dt h el a c ko f ( 21 4 6 . 7 P h y s i c a ls t r e s s mutualu n d e r s t a n 4 6 . 7 Notb e i n ga b l et od o24 houson-duty d i n g between t h e team o f 3 1 . 3 E m o t i o n a ls t r e s s m e d i c a ls t a f f，andap a t i e n tand 2t h e t h ef a m i l y( 1 7 . 3 % )，and 1 t a g eo fs t a f f . 3 Sh r 21 l a c ko f mutual u n d e r s t a n d i n g M u t u a lu n d e s t a n d i n gbetweenm e d i c a ls t a ap a t i e r 、 t ， andh i s f a m i l y between a p a t i e n t and t h e M u t u a lu n d e s t a n d i n gbetweenp a t i e n tandh i sf a m i l y f a m i l y( 1 6 . 0 % ) . Other o p i n i o n s a r e ;5o fthemfoundi td i f f i c u l t Seekh o s p i t a l st op r o v i d ec r i t i c a lc a r e t ol o o kf o remergencyh o s p i t a l Noc o r p o r a t i o nf r o mf a m i l y fthem whenn e c e s s a r y( 6 . 7 % )，4o M u t u a lu n d e r s t a n d i n gbetweend o c t o r sando t h e rm e d i c a ls t a f f 膨勿 2 . 7 s a i dap a t i e n t ' sf a m i l yi sn o t a t t e n t i v eandd o e sn o tg i v eany L ia s i o nw i t ho t h e rm e d i c a li n s t i t u t e 院予司 2 . 7 a s s i s t a n c e( 5 . 3 % )( F i g u r e8 ) . Others n=75 ( 6 )E s s e n t i a lc o n d i t i o ni no r d e r N.A t op r o v i d eh o s p i c ehomec a r e I np r o v i d i n gh o s p i c e home 20 40 60% h e p a r t i c i p a n t s were c a r e， t f i g u r e 8 D i f f i c u l t i e si np r o v i d i n gh o s p i c ehomec a r e. 。. r '. 0. 汗 ".
(9) 9 3. 滋賀黒における在宅ホスピスケアの実態. (selectedtwo answer) Strongw i l lofapatientandhisfamily. 8 2 . 7. Alwayssomeoneathometo lookafterapatient. P a l l i a t i v e controli sablc athome. Readyforc r i t i c a lcarewhen necessary. 24 hourson-dutyi sable. Informed-consenttowardsapatientandhisfamily Havingwellexperiencedstafffornursingacancerpatientand cannceγtherapy Havingenough membersofstaffforthe care. 、. T0 l i mi tthe d i s t a rcebetweenapatient's home andanursingstation. n=75. Others. 。. 20. 40. 60. 80. 100%. f i g u r e 9 E s s e n t i a lc o n d i t i o nt op r o v i d eh o s p i c ehomec a r e. a s k e dt oc h o o s etwos u i t a b l ea n s w e r s .S i x t y t w oo f themc h o s et h eanswert h a tap a t i e n tandh i sf a m i l y musthaveas t r o n gw i l lt os p e n dt h er e s to fl i f eandt o d i ea t home ( 8 2 . 7 % ) .T h i r t y o n eo f them c h o s ea c o n d i t i o nt h a tsomeonealwaysh a st ol o o ka f t e ra p a t i e n ta thome( 41 .3 % )，2 4o fthemp o i n to u tt h a t p a l l i a t i v ec o n t r o lc a nb ea c t u a l i z e da thome( 3 2 . 0 % ) .I n 0o ft h er e s p o n d e n t s( 1 3 . 3 % )c o n s i d e r e d t h es u r v e y，1 ( 4 . 0 % ) t h a ti n f o r m e dc o n s e n ts h o u l db eo b t a i n e d，3 c o n s i d e r e dt h a tm e d i c a ls t a f fa r er e q u i r e dt oh a v e e x p e r i e n c ei nt r e a t i n gandn u r s i n gc a n c e rp a t i e n t s， i n d i c a t i n gt h a tt h e s ef a c t o r sa r en o te s s e n t i a l( F i g u r e 9 ) .. 2 )F a c i l i t i e st h a tdon o tp r o v i d eh o s p i c ehomec a r e s e r v i c e( n = 2 1 9 ) ( 1 )Ther e a s o nt h e ydon o tp r o v i d eh o s p i c ehome c a r e Of t h e2 1 9r e s p o n d e n t s，1 0 6p a r t i c i p a n t so ft h e s u r v e yansweredt h a tnoo n eh a sr e q u e s t e dt h es e r v i c e ( 4 8. 4 % ) ， 1 0 2o fthemc o n s i d e r e dt h a ti ti sd i f f i c u l tt o p r o v i d et h es e r v i c ed u et os h o r t a g eo fs t a f f and burdent h eteamo ft h em e d i c a ls t a f fh a v et os h o u l d e r. ( 4 6 . 6 % )， 2 7 answered t h e r e was no r e q u e s t from h o s p i t a l s( 1 2 . 3 % )and2 0o fthemp o i n t e do u tt h a tthey don o th a v ee x p e r tn u r s e swhoh a v ep r o v i d e dhome c a r es e r v i c etowardsc a n c e rp a t i e n t s( 9 . 1 % )(Figure 1 0 ) . S i xp a r t i c i p a n t sansweredt h a tt h e ya r eunablet o st h e yh a v ej u s te s t a b l i s h e dt h e. u n i t embarkoni t，a ( 2 . 7 % )，andmosto fthema r el o c a t e di nt h ef a c i l i t i e si n MoriyamaC i t y -Yasu Countya r e aw i t h5f a c i l i t i e s o p e n e da f t e r2 0 0 0 .Anothero n ee s t a b l i s h e dbetween 1 9 9 0 9 9 .Other5 0p a r t i c i p a n t s( 2 2 . 8 % )g a v et h ereason a sf o l l o w s ;2 3o fthema r en o ts p e c i a l i z e di nh o s p i c e fthema r et o oo l dt o andp a l l i a t i v ec a r e( 4 6 . 0 % )，5o p r o v i d e t h e s e r v i c e ( 1 0 . 0 % )， 6 o f them c i t e d s y s t e m a t i c a limpedimentss u c ha st h el a c ko fmedical l i c e n s et oh a n d l en a r c o t i c s( 12 . 0 % ) .Threeo fthems a i d t h a tt h e yhadp r o v i d e dt h es e r v i c e，butn e v e rthought t h a ti twash o s p i c ehomec a r e，t h e yj u s thad done whatt h e yc o u l ddo( 6 . 0 % ) . ( 2 )Needst op r o v i d eh o s p i c ehomec a r e Tot h eq u e s t i o nt h a twhetherh o s p i c ehomec a r ei s n e c e s s a r yi nt h ef u t u r e，1 1 6o f them a r ep o s i t i v e ( 5 3 . 0 % )，2 7o fthema r en e g a t i v e( 1 2 . 3 % )and7 3o fthem.
(10) 9 4. 竹村節子. (selectedp l u r a l answers). Norequestsfroma patientandafamily. 48. 4. Shortageofstaffandthevarious burdens. Norequestsfrom a hospital. Nothavingexperiencednurseforprovidng a cancerpatienttheservice. Notlongenoughtothinkabouttheservice as thepracticei s prettynew. Others. N. A.. o. 20. 40. 60%. f i g u r e 1 0 Ther e a s o n so fn o tc a r r y i n go u th o s p i c ehomec a r e a r en o ts u r e( 3 3 . 3 % )(F i g u r e1 1 ) . Among2 7p a r t i c i p a n t swhoc o n s i d e rt h es e r v i c en o t 7o f them s a i dt h a tt h e ya r en o t n e c e s s a r y， 1 s p e c i a l i z e di nt h eh o s p i c e and p a l l i a t i v ec a r ea sa d o c t o r and t h e y do n o t have a p a t i e n tw i l l i n gt o r e c e i v et h es e r v i c e( 6 3 . 0 % )，3o fthemc o n s i d e rt h a ti t w i l lb eo n l ye s t a b l i s h e d with u n d e r s t a n d i n g and s t r o n gw i l lo fap a t i e n tandh i sf a m i l y( 11 .1 % )，and t h e n，2o fthema r et o oo l dt op r o v i d et h es e r v i c e ( 7. 4 % ) . 5 .P r e p a r a t i o nt oc a r r yo u th o s p i c ehomec a r e( N = 2 9 4 ) Tot h eq u e s t i o n，whatk i n do fp r e p a r a t i o nh a st ob e donet op r o v i d eh o s p i c ehomec a r e .Ther e s p o n d e nt s werea l l o w e dt oc h o o s etwoo ft h ea n s w e r s .Oft h e2 9 4 r e s p o n d e n t s， 1 5 8p e o p l ep o i n t e do u tt h a ti ti s importantt os e tupac l o s el i n k a g eamongd o c t o r s s u c h a s h o s p i t a l s， p r a c t i t i o n e r s， l o c a l m e d i c a l a s s o c i a t i o n( 5 3 . 7 % )， 1 3 9o f them c o n s i d e r e ds o c i a l w e l f a r es h o u l db emoreimproveds ot h a tt h ep h y s i c a l andf i n a n c i a lburdeno fhomec a r ewouldb er e d u c e d ( 4 7 . 3 % )，8 3o fthemc o n s i d e r e dt h a tthroughi n c r e a s i n g h eu n i t ss h o u l da l s o t h enumbero fh o s p i c eu n i t s，andt b ead r i v i n gf o r c et op r o v i d eh o s p i c e home c a r e. N .A .. 1 . 4 %. n = 2 1 9. f i g u r e 1 1 Whetherh o s p i c ehomec a r ei sn e c e s s a r y ( 2 8 . 2 % )，7 1o fthemc o n s i d e r e dt h a tt h enumberand t h eq u a l i t yo fahomec a r es t a t i o ns h o u l db ei n c r e a s e d ( 2 4 . 1 % )，3 5o fthemb e l i e v e dt h a tpromotingi n f o r m e d c o n s e n t and i n s p i r i n gp a t i e n t ' s mind a r et h et o p p r i o r i t y( 11 .9 % ) and 3 4o fthemthoughtt h a ti ti s.
(11) 9 5. 滋賀県における在宅ホスピスケアの実態. ( s e l e c t e dt w oa n s w e r ) 7. L iaisonbetweenh o s p i t a landp r a c t i t i o n e r s. Promotingq u a l i t yofw e l f a r esothatburdenofhomecarei sl i g h t e n e d. Alsop r o v i d i n gtheservicefromhospicecareu n i t. Increasingq u a l i t yoftheserviceandanumberofhomecares t a t i o n s. Promotinginiformed-consenttowardsacancerp a t i e n t，andreforming ofp a t i e n t ' smindtowardssickness. D i s c l o s i n gi n f o r m a t i o ntoap a t i e n tandh i sf a m i l y. Others. N.A. 6 . 5 60. 80. 4. 40. nu/O nuo-. 20. ・ ・ ・. 。. Nヱ294. f i g u r e 1 2 N e c e s s a r yc o n d i t i o ni nc a r r y i n go u th o s p i c ehomec a r e. n e c e s s a r yt op r o v i d et h en e c e s s a r yi n f o r m a t i o nf o ra 6 .Whats h o u l db ep r i o r i t i z e dwhenp r o v i d i n gh o s p i c e p a t i e n tandh i sf a m i l y( 11 .6 % )( F i g u r e1 2 ) . homec a r e ?( N = 2 9 4 ) Of t h e7 5d o c t o r s who have a l r e a d yp r o v i d e d Twoanswerswerea s k e dt oc h o o s e .Themajorityo f h o s p i c ehomec a r e，4 8d o c t o r ss u g g e s t e dt h a ts o c i a l t h er e s u l ta r ea sf o l l o w s ;2 1 9d o c t o r sc o n s i d e r e di ti s w e l f a r es h o u l db e improved ( 6 4 . 0 % ) ;3 1o f them p a l l i a t i v ec a r et oe a s ea p a t i e n t ' sd i s c o m f o r t and r e g a r d e dt h el i n k a g eamongh o s p i t a l，p r a c t i t i o n e r s -s e v e r ep a i n( 7 4 . 5 % )，1 7 4o fthemb e l i e v e dt h a ti ti s and l o c a lm e d i c a la s s o c i a t i o na sav e r y important companionship and s u p p o r tf o rat e r m i n a l l yi l l f a c t o r( 41 .3 % ) ;and1 8d o c t o r sc i t e dt h a tt h enumber p a t i e n ti nr e a l i z i n gh i sownwayo fd e a t h( 5 9 . 2 % )and andq u a l i t yo fhomec a r es t a t i o n shavet ob ei n c r e a s e d 1 3 3o fthemc o n s i d e r e dt h a ti ti st op r o v i d eadying ( 2 4 . 0 % ) . p a t i e n tC t ndh i sf a m i l ywitht h ec o n v i n c i n gmedical There was a s i g n i f i c a n td i f f e r e n c e between t h e t h e r a p yand t h en u r s i n g( 4 5 . 2 % ) . On t h e contrary， o p i n i o n so fd o c t o r swhoc a r r yo u th o s p i c ehomec a r e t h e r ea r eo n l y two d o c t o r s who c o n s i d e r e di ta s andt h o s eo fa r ed o c t o r swhodon o t( p < O . 0 1 ) .Other2 2 a g g r e s s i v et h e r a p yandm e d i c a lt r e a t m e n t( 0 . 7 % )and d o c t o r sc o n s i d e r e dt h a ti ti sn e c e s s a r yt o reform t h eo n l yoned o c t o rt h i n ki ti sam e d i c a ltherapyt o m e d i c a li n s u r a n c esystems，t oimprover e g u l a t i o n s， aim a tp r o l o n g i n gl i f e( 0 . 3 % )( F i g u r e1 3 ) . Other andt os e c u r ef i n a n c i a lr e s o u r c e s( 7 . 5 % ) . o p i n i o n sa r et or e s p e c twhatap a t i e n tandh i sf a m i l y ' s.
(12) 9 6. 竹村節子. Cselectedtwo answer). . 5. Reliefto discomfortandto provide palliative care. Providing supportand campanionshipto a dying patient to choose howto die with dignity as he i s. Providing medical therapy and nursingthata family also understands. Providing aggressive cancertherapy. Medical careforprolonging l i f e. 10.3. Others. N=294. 6.8. N. A .. 。. 20. 40. 60. 80. 100. %. f i g u r e 1 3. Whats h o u l db ea c c o u n t e dt h emosti np r o v i d i n gh o s p i c ehomec a r e ?. wantandt h e i rw i l l . Cselected plural answers). 7 . Wheret h ec e n t e ro fh o s p i c ehomec a r e s h o u l db e ?( N = 2 9 4 ) 0 2 d o c t o r s Of t h e 2 9 4r e s p o n d e n t s， 1 c o n s i d e ri twould b e ah o s p i t a ， l a d j o i n i n g h o s p i c e and p a l l i a t i v e c a r e u n i t s， and department o fhome c a r es e r v i c ew i t h i na h o s p i t a l( 3 4 . 7 % )，6 9o fthemc o n s i d e rt h a ti t would b eb e t t e rn o tt oc h o o s e where t h e 6o fthem c e n t r a lo r g a n i z a t i o ni s( 2 3 . 5 % )，4 t h i n ki ti sp r a c t i t i o n e r s( 1 5 . 6 % )，4 1o fthem t h i n ki ti s ahome n u r s i n gc a r es t a t i o n( 1 3 . 9 % )，and2 8of .themr e g a r dah o s p i t a la s 4 . 7 % t h ec e n t e r( 9 . 5 % )( F i g u r e1 4 ) .However，3 o fd o c t o r s who have a l r e a d yc a r r i e do u t h o s p i c ehomec a r e ;b e l i e v et h a ti ti sb e t t e r 0 . 7 % n o tt od e c i d ewheret h ec e n t e ri s，and3 ofthemt h i n ki ti sap r a c t i t i o n e r .E i g h t y n i n ed o c t o r s，whodon o tp r o v i d et h es e r v i c e，. Home care departmentwithin a. 34.7. hospital ora unit Betternotto choose wherethe central organization. Practitioners. Home nursing care station. A hospital. Others. N.A.. 。. 20. 40略. f i g u r e 1 4 r e g a r d a h o s p i t a l and t h e a d j o i n i n g IW h : r ' e ' "s h o u l db et h ec e n t e ro fp r o v i d i n gh o s p i c ehomec a r e ? p a l l i a t i v ec a r eu n i tandhomec a r es t a t i o na s.
(13) 9 7. 滋賀県における在宅ホスピスケアの実態. Cselectedplural answers) Onlya fewhospitals havinghospiceand palliative care units. 48.6. Nonetolookaftera patientathome. しackofi nterests amongdoctors and medical staff. 34.. Difficulttolook aftera patientonlywithelderly family. 33.3. Citizens do notknowtheservice. 33. Needstogivetrainingandeducationtoa staff Difficulttosecurenecessarymembers ofstaffi n af a c i l i t y Financially d i f f i c u l t. DuetoHousingconditions. Geographical d i f f i c u l t y. Others. N=294 N.A.. 。. 20. 40. 60%. f i g u r e 1 5D i f f i c u l tr e a s o n si np r a c t i c i n g homec a r ei nS h i g ap r e f e c t u r e t h ec e n t e r ( 4 0 . 6 % )，4 3o fthemc o n s i d e ri ti sb e t t e rn o t t od e t e r m i n ewheret h ec e n t e ri s( 1 9 . 6 % )，3 1o fthem t h i n ki ti shomec a r es t a t i o n ( 1 4 . 2 % )，2 3o fthemt h i n k i ti sap r a c t i t i o n e r( 1 0 . 5 % ) . Therewasas i g n i f i c a n t d i f f e r e n c ebetweent h etwogroups( p < 0 . 0 1 ) . 8 .D i f f i c u l t yi np r o v i d i n gh o s p i c ehomec a r ei nS h i g a P r e f e c t u r e Ther e s p o n d e n t swerea s k e dt os e l e c ta l lt h a ta p p l y andt h er e s u l t sa r ea sf o l l o w s( F i g u r e1 5 ):Ofa l lt h e r e s p o n d e n t s， 1 .1 4 3answeredt h a tt h e r ea r eafewh o s p i t a l shaving h o s p i c eandp a l l i a t i v ec a r eu n i t( 4 8 . 6 % ) . 2 .1 0 9answeredt h a ti ntermso fn u r s i n g，ap a t i e n t d o e sn o thaveaf a m i l yt ol o o ka f t e rhima l lt h et i m e ( 3 7 . 1 % ) . 9 8answeredt h a tt h e r ea r emanyf a m i l i e si nShiga P r e f e c t u r ewhosemembersa r eo n l ye l d e r l ys ot h a t t h e ycannotl o o ka f t e rap a t i e n ta thome( 3 3 . 3 % ) .. 3 .1 0 1answeredt h a tmanym e d i c a ls p e c i a l i s t sa r enot i n t e r e s t e di nt h es e r v i c ei nShiga( 3 4. 4 % ) ，b uta l s o9 7 s a y st h a tc i t i z e n so fShigadon o tknowwhatt h e s e r v i c ei s，e i t h e r( 3 3 . 0 % ) . 4 .5 0i n d i c a t e dt h a te d u c a t i o n and t r a i n i n go ft h e m e d i c a ls t a f fi sn e c e s s a r y( 1 7 . 0 % )，3 6answeredthat i ti sd i f f i c u l tt os e c u r et h e number o ft h es t a f f ( 1 2 . 2 % ) . 5 .3 5i n d i c a t e dt h a tl i v i n gc o n d i t i o no ft h epa 七i e n t makesi td i f f i c u l t( 11 .9 % ) .3 6p o i n t e do u tf i n a n c i a l d i f f i c u l t y( 1 2 . 2 % )， and 5 p o i n t e do u t geographic d i f f i c u l t y( 1 .7 % ) . Twenty-eighto fthemwrotedownt h e i ro p i n i o n s ; i n c l u d i n g no f i n a n c i a la d v a n t a g e s ;t h e needs o f expanding a range o f work by n u r s e s through r e l a x i n gr e g u l a t i o n s ;r e d u c t i o ni nt h e governmentalbudgetf o rm e d i c a li n s u r a n c e s，m e d i c i n eand w e l f a r e ; and l a c ko fknowledge and information aboutap a t i e n tandh i sf a m i l y .Somep e o p l es t i l l.
(14) 9 8. f i n d t h e s e r v i c e d i s r e p u t a b l e i n t h e l o c a l community. 9 .P r a c t i t i o n e r ' st h o u g h t stowardsh o s p i c ehomec a r e . 9 4r e s p o n d e n t s，1 5 7( 5 3. 4 % )foundi td i f f i c u l t Oft h e2 t op r o v i d e home h o s p i c ec a r ef o rt h ef o l l o w i n g r e a s o n s( i nt h eo r d e ro fnumberso fr e s p o n d e n t ) : 1 .P h y s i c a l l yande m o t i o n a l l yi m p o s s i b l e 2 .I ti sn e c e s s a r yf o rap a t i e n tandh i sf a m i l yt ok e e p s t r o n gw i l landt ou n d e r s t a n dandc o r p o r a t ee a c h o t h e rw i t ht h eteamo fm e d i c a ls t a f f . 3 .I ti sn e c e s s a r yt oh a v eac l o s ec o n t a c twi t ho t h e r m e d i c a lf a c i l i t i e s . ti sd i f f i c u l tt od e a lw i t hap a t i e n tw e l le n o u g h . 4 .I ti sn e c e s s a r yt oh a v emutualt r u s tandr e s p e c t 5 .I betweent h eteamo fd o c t o r sandap a t i e n tandh i s f a m i l y . 6 . Ap a t i e n tandh i sf a m i l yp r e f e rt ob ei nah o s p i t a l . 7 . Nots p e c i a l i z e di nh o s p i c eandp a l l i a t i v ec a r e . 8 .D o c t o rs h o u l dchangeandimprovet h e i rc o n s c i o u s n e s stowardsm e d i c a lt h e r a p y . 9 .I ti si m p o s s i b l eundert h ec u r r e n tm e d i c a ls y s t e m . 1 0 . Thef a m i l yh a st os h o u l d e rab i gburdent ol o o k a f t e rt h ep a t i e n t .. V I I Consideration I nJapan，c a n c e r( m a l i g n a n to r g a n i s m )t r e a t m e n t h a sb e e na d v a n c i n gdaybydayw i t ht h ei n v e n t i o no f newdrugsandd e v e l o p m e n t so fm e d i c a lt e c h n o l o g i e s . h es u r v i v a lr a t eh a sb e e n B e c a u s eo ft h i sp r o g r e s s，t d r a m a t i c a l l yi n c r e a s e d . On t h eo t h e r hand，P e o p l e ha v eg o t t e nmorei nt e r e s t e di nt h ei d e ao fh o s p i c e c a r e，whiche v a l u a t e sQOL( Q u a l i t yo fL i f e )，r a t h e r thana g g r e s s i v et r e a t m e n taimedo n l ya tp r o l o n g i n g t h ep a t i e n t ' sl i f e . 4 0h o s p i c e sandi n p a t i e n tp a l l i a t i v ec a r e Asar e s u l t，1 u n i t s have b e e ne s t a b l i s h e di n Japan s i n c eA p r i l 2 0 0 54)，andi ti sc o n s i d e r e dt h a tt h enumberw i l lgrow s t e a d i l y . Witht h ei n c r e a s eo fi n ω p a t i e n tp a l l i a t i v ec a r eu n i t s， i ti sr e p o r t e dt h a tfromat e r m i n a lc a n c e rp a t i e n t ' s i sownhomei samores u i t a b l ep l a c et o p o i n to fv i e w，h l i v et h er e s to ft h e i rl i f e than s p e n d i n gt i m ei na 5 h o s p i t a lu n i t )) 6. I nf a c t，f o rt h es u r v e y sa s k i n gwhere t h e ywouldp r e f e rt os t a yandd i e，al o to fanswersa r e somethingl i k e" w o u l dl i k et os p e n dt h er e s to fmyl i f e " o r" w o u l dl i k et od i ea th o m e " 7 ) -14l. a t home，. 竹村節子. N e v e r t h e l e s s， d e s p i t et h e i n c r e a s i n g number o f h o s p i c ehomec a r er e p o r t s，t h er e a l i t yi st h a tl a r g e numbero ft e r m i n a lc a n c e rp a t i e n t ss t i l ld i ei nt h e i n s t i t u t i o n mainlyi nah o s p i t a F5). Thep a t i e n t swho were a b l et od i ea tah o s p i c e j p a l l i a t i v ec a r eu n i t s 6 1 ，a ndt h e amountedt oo n l y4%o ft h et o t a ld e a t hr a t e) numbero ft h o s ewhoc a nd i ea thomei ss t i l lminima l . Therea r ec a s e swhereap a t i e n tandt h ef a m i l yw i s h e d t ob ec a r e df o ra thomeb u te n d e dupdyingi nan i n s t i t u t i o nb e c a u s eo ft h em i s s e dc h a n c e . T h i ss u r v e yr e s u l ti n d i c a t e st h a to b s t a c l e si nc a r r y i n g o u th o s p i c ehomec a r ew i t h i nShigaP r e f e c t u r ea r ea s f o l l o w s : I nt h er e g i o nt h enumbero fh o s p i t a l st h a th a v e a d j o i n i n gi n p a t i e n th o s p i c eandp a l l i a t i v ec a r eu n i t s i sl i m i t e d .Therea r eo n l yafewmainstayh o s p i t a l s whichc a na c c e p tp a t i e n t si m m e d i a t e l yf o rt h ec a s eo f emergency and f o rt h et r e a t m e n tt h a ts u i t st h e ti sa l s on e c e s s a r yt os e tupan d i s e a s ea d v a n c e m e n t .I e d u c a t i o n a lo r g a n i z a t i o nt h a tc a nt e a c h and t r a i n m e d i c a lworkerst oimplementh o s p i c ehomec a r eand an o r g a n i z a t i o nt h a tc a np l a yac e n t r a lr o l ei n p r o v i d i n gt h es e r v i c ef o rt h o s ewhon e e di t . Toc o n d u c th o s p i c ehomec a r es e r v i c e，•t h ef o l l o w i n g t h r e ea b s o l u t ec o n d i t i o n sw i l lb er e q u i r e do fap a t i e n t andh i sf a m i l y 1 7 ): 1 .A t e r m i n a l l yi l lp a t i e n t ' ss t r o n gw i l l( t os t a yand d i ea th o m e ) . . 2 .T h e i rf a m i l y ' ss t r o n gw i ll 3 .T h e i rf a m i l y ' sc a p a b i l i t yt ot a k ec a r eo ft h e p a t i e n tc o n s i s t e n t l yu n t i lt h ee n d . Ther e s u l t so ft h i ss u r v e ya l s oi n d i c a t e st h a tt h e a b o v et h r e ec o n d i t i o n sa r ec o n s i d e r e dn e c e s s a r yf o r 2 . 7 %o ft h e t h ed o c t o r st oc a r r yo u tt h es e r v i c es i n c e8 r e s p o n d e n t sb e l i e v et h a tat e r m i n a l l yi l lp a t i e n tand t h e i rf a m i l yh a v et oh a v eav e r ys t r o n gw i l l，41 .3%o f g e n e r a lp r a c t i t i o n e r sp o i n to u tt h a tsomeonemustb e 2 . 0 %o f a thomet on u r s eap a t i e n ta l lt h et i m e，and3 themr e g a r dp a l l i a t i v ec o n t r o la thomea sane s s e n t i a l f a c t o rt oc o n d u c th o s p i c ehomec a r es e r v i c e . Other opmlOn sa r et h a ta l lm e d i c a ls t a f f who p r o v i d e h o s p i c ehomec a r emusth a v et h eenergyandp a s s i o n n e c e s s a r yt op r o v i d eadyingp a t i e n tw i t he m o t i o n a l s u p p o r tandc o n s i d e r a t i o na sw e l la smakeane f f o r t t omeett h ep a t i e n t s 'r e q u e s t sandn e e d s .Ort h es t a f f h a st omakeadyingp a t i e n tandh i sf a m i l yu n d e r s t a n dw e l la b o u tt h ef a c tt h a tt h e r ei sal i m i to fwhat h o s p i c ehomec a r ec a nd o .A p a t i e n t ' shomeh a st ob e.
(15) 滋賀県における在宅ホスピスケアの実態. f u l l ye q u i p p e di nsuchamannert h a th ei sa b l et o r e c e i v ei n t e r v e n e st r a n s f u s i o n so fhomei n t r a v e n o u s h y p e r a l i m e n t a t i o n( I V H ) and c o n t i n u o u s morphine i n j e c t i o n s .T h e r e f o r e，a sp o i n t e do u ta sa b o v e，t o c a r r yo u th o s p i c ehomec a r es e r v i c e，i ti sr e q u i r e dt o meetv a r i o u sc o n d i t i o n sa sw e l la st ohaveamuch h i g h e rl e v e lo fm e d i c a lt r e a t m e n t . Ont h eo t h e rhand，c o n c r e t em e d i c a la c t sperformed i nh o s p i c e home c a r ea r ei n t r a v e n o u st r a n s f u s i o n， p a i nc o n t r o landt h et r e a t m e n ti nc a s eo femergency s i t u a t i o n，i na d d i t i o nt oar e g u l a rhousec a ll .E s p e c i a l l y， r e g a r d i n gt ot h ei n t e r v e n e st r a n s f u s i o n， a m e d i c a ls t a f fd e d i c a t e dt ot h es e r v i c ei sunderg r e a t p r e s s u r e .Theya r ek e p tl o n ghoursa tt h ep a t i e n t ' s home， c o o r d i n a t i o n and s c h e d u l i n g with v i s i t i n g n u r s e s，p h y s i c a ld i s t a n c e(7kmi st o of a r )t og e tt oa p a t i e n t ' s home，and t e c h n i c a la n x i e t yo fp r o v i d i n g IVH. Japanesem e d i c a ll a w sr e g u l a t ewho c a nm e d i c a l t r e a t m e n t s such a si n j e c t i o n s， and manage and p r e s c r i b ep a i nc o n t r o la g e n t s，i n c l u d i n gn a r c o c t i c s .At p r e s e n t，an u r s ei sa l l o w e dt og i v eap a t i e n ti n j e c t i o n o ri n t e r v e n e st r a n s f u s i o no n l yw i t hm e d i c a ld o c t o r ' s d i r e c t i o n . However i ti sp r o h i b i t e df o ran u r s et o c o n d u c tthembyh e rownjudgmentd e p e n d i n gona p a t i e n t ' sc o n d i t i o n .I nEuropeandt h eU . S .，t h er o l eo f t h en u r s e(whohasaM a s t e r ' sD e g r e e )，whop r o v i d e s h o s p i c ec a r ehasb e e nexpandedi nt h er e g u l a t i o ns o t h a ts h ei sa b l et op r o v i d eap a t i e n tm e d i c a lt r e a t m e n t withouthavingam e d i c a ld o c t o r s 'd i r e c t i o n18). 1b e l i e v e t h a ti ti st i m ef o rJapant od i s c u s sp r o v i d i n gn u r s e s withs p e c i a lt r a i n i n gande d u c a t i o nt ob r i n gthemup t ob ee x p e r t s and l e g a l l y expanding h o s p i c e home c a r e . Ther e s u l to ft h i ss u r v e ya l s oi n d i c a t e st h a tp r i v a t e p r a c t i t i o n e r ss t a r t e dh o s p i c ehomec a r es e r v i c e，a sa f a m i l yo fadyingp a t i e n tp r e f e r st h es e r v i c emore thant h ep a t i e n th i m s e l f，andi tshowst h a tt h ei s s u e i sl i n k e dwit ht h ei s s u eo fwhomt ob en o t i f i e do ft h e name o ft h ei l l n e s s . On onehand，at e r m i n a l l yi l l p a t i e n ti sa b l et ol i v el i f ef u l l ywhenheh a sh o s p i c e homec a r e，i ta l s or e q u i r e st h ei n d e p e n d e n c eont h e p a r to ft h ep a t i e n tandh i sf a m i l y .T h e r e f o r e，p r i o rt o t h es u r v e y，i twasassumedt h a ti twouldb ee s s e n t i a l f o rad o c t o rt oinformap a t i e n to ft h enameo ft h e i l l n e s s ;namely，c a n c e randt h ec o n d i t i o n .However， l o o k i n ga tt h er e s u l t，o n l y1 3 . 3 %o fd o c t o r sanswered t h a tinformedc o n s e n ti se s s e n t i a lt op r o v i d eh o s p i c e. 9 9 homec a r e .Manyd o c t o r sc o n s i d e ri ti sp o s s i b l ef o r themt op r o v i d eh o s p i c ehomec a r es e r v i c ef o radying p a t i e n t and h i sf a m i l y when he i se l d e r l y . Yet，a reform o ft h en a t i o n ' sm e d i c a l measurements i s a n o t h e rf a c t o rt h a th o s p i c e home c a r eh a s been s t a r t e d，a sl o c a lh o s p i t a l sandhomed o c t o r sbecome c o n n e c t e dwithe a c ho t h e rmuchc l o s e r，andap a t i e n t s t a y sl e s sa tah o s p i t a lthanb e f o r ef o rt h esakeo f r e f o r m . 2 1 9d o c t o r s( 7 4 . 5 % )，whohaven o tp r o v i d e dh o s p i c e homec a r e， c i t e dt h er e a s o n sa sf o l l o w s : No r e q u e s t from a p a t i e n t， t h e i rf a m i l y and a l o c a lh o s p i t a l y e t . Shortageo fm e d i c a ls t a f f，andf i n a n c i a lb u r d e n ; no e x p e r i e n c ewitht h es e r v i c e ;t h em e d i c a ldepartment t h e ys p e c i f yi sd i f f e r e n t ;t h ed o c t o ri st o oo l d . Without knowing t h ec o n c e p to ft h es e r v i c e， t h e p r a c t i t i o n e r has a l r e a d yt a k e ni tf o r granted t o p r o v i d ep a t i e n t switht h es e r v i c e .I thasn o tb e e nlong enoughs i n c ead o c t o rs t a r t e dh i sp r a c t i c es ot h a tt h e systemhasnotb e e nreadyt oc o p ewithh o s p i c ehome c a r e . He has n e v e r heard o ft h es e r v i c e .1 ti s i m p o s s i b l et oc o p ewithi tundert h ec u r r e n ts y s t e m . Thes e r v i c es h o u l db ep r o v i d e dwit hs p e c i a li n s t it u t i o n s j f a c i l i t i e s .Ont h eo t h e rhand，1 1 6d o c t o r s( 5 3 . 0 % ) c o n s i d e ri tn e c e s s a r yt oc a r r yo u th o s p i c ehomec a r e . Therea r e2 7d o c t o r s( 1 2 . 3 % )，whodon o tc o n s i d e ri t n e c e s s a r yt op r o v i d eh o s p i c e home c a r e， b u tt h e r e a s o nt h e ya r en o tkeenont h es e r v i c ei st h a tthey a r en o tane x p e r tonh o s p i c ec a r e .Theydon o thav ea p a t i e n t who h o p e st or e c e i v et h es e r v i c e .I t only d e p e n d sons t r o n gw i l landu n d e r s t a n d i n go fapat i e nt andt h e i r 、f a m i l y，Thed o c t o r st h e m s e l v e sa r es oo l d t h a tt h e ya r en o ta b l et op r o v i d et h es e r v i c e .Fromt h e answers，i ti sassumedt h a tp r a c t i t i o n e r sg e n e r a l l y hope t op r o v i d eh o s p i c e home c a r es e r v i c ei f both t e r m i n a l l yp a t i e n t sandh i sf a m i l ya r ek e e n . Thes u r v e yr e s u l ta l s or e v e a l e dt h a tt h e r ea r emany problemsando b s t a c l e sf o ras i n g l ep r a c t i t i o n e ror f a c i l i t yt oc a r r yo u th o s p i c ehomes e r v i c ei n d e p e n d e n t l y .I ti sthoughtt h a th o s p i c ehomec a r es e r v i c e s h o u l db ec a r r i e do u twitht h ef u r t h e rpromotiono f l i n k i n gamongd o c t o r sworkinga th o s p i t a l s，p r i v a t e p r a c t i t i o n e r s， and l o c a lm e d i c a la s s o c i a t i o n s . For examplet h ei nt r o du c t i o ns o c a l l e dOpenSystemwit h t h ei n c r e a s eo fb e d sa ti n p a t i e n th o s p i c e j p a l l i a t i v e c a r eu n it s and house c a l l so fm e d i c a l work e r s i n c l u d i n gn u r s efromt h es t a t i o nwhichi sbaseda t.
(16) 1 0 0. 竹村節子. t h o s ef a c i 1 i t i e st op r o v i d em e d i c a 1c a r ef o rp a t i e n t s s t a y i n ga thomec o u 1 d1 e a dt oasmootht r a n s f e rt o h o s p i c ehomec a r e .I ti sa 1 s oimportantt oi n s p i r e1 0 c a 1 p e o p 1 eandt os e c u r et h enumbero fe x p e r t sthrough s p e c i a 1 i s te d u c a t i o nandt r a i n i n g . 1havedonea n o t h e rs u r v e ytowardsp r a c t i t i o n e r andh o m e v i s i t i n gn u r s e si nWakayamaP r e f e c t u r ei n 2 0 0 019) 2 0 ) 21). Thebackgroundo ft h ep r e f e c t u r ei ss i m i 1 a r with 8higa P r e f e c t u r e .I n Wakayama，t h er a t eo f agingp o p u 1 a t i o ni nt h ea r e awas2 0 . 0 %a tt h a tt i m e . Themaini n d u s t r yo ft h e1 0 c a 1a r e awasa g r i c u 1 t u r e ( o r c h a r d s )， f i s h e r y， f o r e s t r y， and t h e r ea r e some d e p o p u 1 a t e dtownsandv i l l a g e s . From t h er e s u 1t o ft h es u r v e y answered by 2 3 8 p r a c t i t i o n e r si n Wakayama ( 5 3 . 0 %a n s w e r e d )， 9 7 p r a c t i t i o n e r s( 41 .0 % )p r o v i d e dh o s p i c ehomec a r e，and 1 4 1p r a c t i t i o n e r s( 5 6 . 0 % )d i dn o tp r o v i d et h es e r v i c e . A1thought h er e s u 1 ti ss i m i l a rt ot h a to f8higaa sa who1e， t h e number o fp r a c t i t i o n e r s who p r o v i d e h o s p i c ehomec a r ewas1 .6t i m e smorethant h a to f 8higaP r e f e c t u r e . Theprob1emst h a tWakayamaP r e f e c t u r ehadwere a sf o l l o w s : 1 . Lacko fknow1edgetowardst h es e r v i c eamong p a t i e n t s，t h e i rf a m i 1 yandm e d i c a 1s t a f f . 2 .Weak1 i n k samong1 0 c a 1r e s i d e n t s，1 0 c a 1a r e a s， andm e d i c a 1s t a f f . 3 .Therei snoc o r ei n s t i t u t i o nf o rt h es e r v i c e( i n 2 0 0 1，a p a l l i a t i v ec a r eu n i t was e s t a b 1 i s h e di n WakayamaP r e f e c t u r eH o s p i t al ) . 4 .Therei snomember 、o ft h ef a m i l yt on u r s et h e p a t i e n ta thome. 5 . Lacko ft r a i n i n gands t u d yprograms f o rt h e s e r v l c e . 1havec o n s i d e r e dt h a t1w i l ln o tb ea b l et og e ta d e f i n i t eansweru n t i 11g e tar e s u 1 to fas u r v e yi nan urban a r e a . However，i ti st r u et h a tt h e two p r e f e c t u r e sf a c es i m i 1 a rp r o b 1 e m s . Thoseprob1emsa r e s t i l l1 e f tu n s o 1 v e d .801b e 1 i e v et h a tu n 1 e s st h ec o r e prob1emsa r en o ts o l v e d，t h ep r a c t i c eo fh o s p i c ehome c a r es e r v i c ew i l lb ei nad i f f i c u l ts i t u a t i o n . At a p r e s e n t，t h e r ea r et h eo n l yt h r e eh o s p i t a 1 st h a thavea p a l l i a t i v ec a r eu n i t :8higaM e d i c a 1C e n t e rf o rA d u l t s， Hikone M u n i c i p a 1H o s p i t a ， l and Otsu M u n i c i p a 1 H o s p i t a l .1b e 1 i e v et h a ti fa t1 e a s tonep a l l i a t i v ec a r e u n i te x i t si ne a c hm e d i c a 1t e r r i t o r yi nt h ep r e f e c t u r e， y2 t h esystememp10yedbyOtsuC i t )whiche n a b 1 e st h e l i n k i n go fah o s p i t a 1andap r a c t i c ec a nb es e tupi n 司. o t h e ra r e a s，andi n t oi t sframeworki n s t i t u t i o n sand o r g a n i z a t i o n sr e 1 a t e dt o home h o s p i c ec a r ec a nb e i n t e g r a t e d . I n8higaP r e f e c t u r e，3 0 . 5 %o fp e o p 1 ed i eo fc a n c e r andi ti srankedt h ef i r s ta st h ec a u s eo fd e a t h .Yet t h e r ea r e3 0townsandv i l l a g e swheret h er a t eo ft h e agingp o p u 1 a t i o ni sh i g h e rthan2 0 % 2 ). T h e r e f o r e，i ti s p r e d i c t e dt h a tt h er e g i o nh a sab a s i so fi n c r e a s ei nt h e numbero fp e o p 1 ewhowou1dn e e dh o s p i c ehomec a r e s e r v i c e，and1hopet h a tt h e1 0 c a 1governmenta sa who1ew i l lengagei ne s t a b l i s h i n gh o s p i c ehomec a r e s e r v i c es o o n . 四. Conclusion. Ac o n d it i o nt oc a r r youth o s p i c ehomec a r ei sa s f o l l o w s : 1 . Tos e tupah o s p it a 1p r o v i d i n gemergencys e r v i c e anda c c o r d i n g1 i n k i n gbetweenap r a c t it i o n e rand h o s p i t al . 2 .Toi n c r e a s et h enumbero fh o s p i c eandp a l l i a t i v e c a r eu n i t sandh o s p i t a l si nt h ep r e f e c t u r e . 3 .Top r o v i d eas p e c i a 1t r a i n i n gande d u c a t i o no f h o s p i c ehomec a r ef o rm e d i c a 1s t a f f . 4 . To f a c i 1 i t a t e a mutua1 u n d e r s t a n d i n g among m e d i c a 1s t a f fandap a t i e n tandh i sf a m i 1 y . 5 . To i n s p i r e1 0 c a 1p e o p 1 e about h o s p i c e and p a l l i a t i v ec a r e， and t od i s c l o s e and p r o v i d e i n f o r m a t i o naboutt h es e r v i c e . Top r a c t i c eh o s p i c ehomec a r e，i ti sn e c e s s a r yt o d i s c u s showmainh o s p i t a 1 si nt h eworkinga r e a so r t h ep r e f e c t u r eandt h e1 0 c a 1governmentsg e ti n v o 1 v e d i nt h e program， and how c o n c r e t ee a c hm e d i c a 1 o r g a n i z at i o nc a n1 i n kupwit he a c ho t h e rs i n c et h e r ei s a1 i m i tf o ronep r a c t i t i o n e rt op r o v i d eh o s p i c ehome c a r es e r v i c e .Ont h eo t h e rhand，i ts h o u 1 db ed i s c u s s e d whethero rnotap a t i e n tandt h e i rf a m i 1 yr e a l l yn e e d h o s p i c e home c a r ei nc o n s i d e r a t i o no ft h ei s s u e s r e 1 a t e dt oap r e f e r e n c eont h ep a r to fap a t i e n tandh i s f a m i 1 ytowardsai n h o s p i t a 1t r e a t m e n t，n u r s i n gc a r e c a u s e d by aging， and t h e p s y c h o 1 o g i c a 1 and e d u c a t i o n a 1s t a t u so fp a t i e n t sandt h ef a m i 1 ytoward h o s p i c ehomec a r e . Acknowledgment 1wou1d1 i k et othankt h echairmano fe a c hm e d i c a 1 a s s o c i a t i o nandt h ememberso f8higaP r e f e c t u r ef o r.
(17) 1 0 1. 滋賀県における在宅ホスピスケアの実態. t h e i rd e d i c a t e ds u p p o r tanda d v i c ei nc o n d u c t i n gt h i s s u r v e y .S p e c i a lt h a n k st oP r o f e s s o rKimieF u j i t af o r h e renormoush e l pandp r o f e s s i o n a la d v i c e .. s i t u a t i o no fm e d i c a li n s t i t u t e si nt h eP r e f e c t u r e， Terminal Care 3 ( 3 )， 2 6 1，Sanwashoten C o r p . 1 2 ) HatanoS .( 1 9 9 3 ) :C h o i c eo v e rWhereandHowt o u b l i ch e a l t h5 7( . 9 )，6 0 46 0 9，TheJournalo f d i e，P Ja p a n e s eM e d i c i n e 1 3 )N a t i o n a lF e d e r a t i o no fH e a l t hI n s u r a n c eS o c i e t i e s ( 1 9 9 3 ) :Ther e p o r to fr e s e a r c hands t u d yone x p a n ω 2 . s i o nandimprovemento fh o s p i c ec a r e，9 1 4 )Ano p i n i o np o l lo fc a n c e randh o n o r a b l ed e a t h . 2 5 t ho fJune，t h eYomiuriEveningNews，1 9 9 6，The YomiuriS h i n b u n . 1 5 )S t a t i s t i c sandI n f o r m a t i o nDepartmenti nHealth ( 2 0 0 3 ) : V i t a lS t a t i s t i c so fJapani n2 0 0 2，2 2 6，Labour andW e l f a r eS e c r e t a r i a tO f f i c e . 1 6 )TsunetoS .( 2 0 0 4 ) :Thep r e s e n ts i t u a t i o no fh o s p i c e andp a l l i a t i v ec a r eu n i t si nJapan，WhitePapero f H o s p i c eandp a l l i a t i v ec a r ei nJapan2 0 0 4E d i t i o n， 1 4，JapanH o s p i c eP a l l i a t i v eCare 1 7 ) Hinohara S .( 1 9 9 5 ) : Caring o fl i f e and death， I g a k u s h o i nLtd，9 8 7 . 1 8 )AmericanN u r s e ' sA s s o c i a t i o n( 19 7 3 ) :Standardso f i t y，Mo: TheA s s o c i a NursingP r a c t i c e，KansasC t i o n . 1 9 )T s u j iA.&TakemuraS .( 2 0 0 0 ) :TheAnnualr e p o r t 4 2 1 4 7， Sasakawa o fs t u d ya c h i e v e m e n t1 6( 1 )， 1 Studyonh o s p i c ec a r eH e a l t hS c i e n c eF o u n d a t i o n . 2 0 )T s u j iA .& TakemuraS .( 2 0 0 1 ) :Studyonr e a l i t yo f h o s p i c ehomec a r ei nWakayamaP r e f e c t u r e .From as u r v e yonHomev i s i t i n gn u r s i n gc a r es t a t i o n( t h e f i r s tr e p o r t ) 5， A b s t r a c t from t h e1 4 t h Japan Nursing R e s e a r c h Committee i nK i n k ir e g i o n j c o n f e r e n c e i n Hokuriku， Chugoku， Shikoku r e g i o n s . 2 1 )T s u j iA .& TakemuraS .( 2 0 0 1 ) :Studyonr e a l i t yo f h o s p i c ehome c a r ei nWakayamaP r e f e c t u r e .From as u r v e yonH o m e v i s i t i n gn u r s ec a r es t a t i o n sand l o c a lp r a c t i t i o n e r s( t h es e c o n dr e p o r t )，Journalo f J a p a n e s eS o c i e t yo fNursingR e s e a r c h2 4 ( 3 )， 3 4 3 . 2 2 )NishiyamaJ .( 1 9 9 7 ) :Thep r o s p e c t i v esupporto f l o c a lm e d i c a ls e r v i c ei nl i a i s o nw i t hh o s p i t a l s， m e d i c a l a s s o c i a t i o n， g e n e r a l p r a c t i t i o n e r， and p a t i e n t .T a c t i c st o work t o g e t h e r， SCHERING LETTER2 2，YutoburainL t d . “. References 1 )MakitaH .( 1 9 9 0 ) :A Studyonr e g r e t f u l n e s so ft h e f a m i l i e s who t o o kc a r eo ft h ed e c e a s e de l d e r l y . 8 5 5 . S o c i a lg e r o n t o l o g y3 3，4 2 )AnnualP o p u l a t i o nE s t i m a t e s，Thef i r s to fO c t o b e r 8 1 9，Department o fP o l i c y and Planning 2 0 0 3， 1 ( S t a t i s t i c a lS t a n d a r d so fShigaM u n i c i p a lG o v e r n m e n t ) . 3 )Understandingo fc a n c e r，AFLAC，H o s p i c eHome 0 01 . H o s p i c e Home c a r e Care A s s o c i a t i o n， 2 o s p i c ehomec a r e . A s s o c i a t i o nHomePage，Abouth h t t p:jjwww.hoken-pa l .c o .j pj g a n n a n d e i nj z a i t a kujzaitaku.htm 4 )N a t i o n a lC a n c e rC e n t e r Homepage. The l i s to f h o s p i t a l sh a v i n gap a l l i a t i v eCareU n i t . h t t p: jj w w w . n c c . g o . j p j j p j n c c c i s j p u b j i n d e x j h o s p i t a lk . h t m l 5 ) Kawagoe A .( 1 9 9 1 ) : Looking A f t e rat e r m i n a l c a n c e rp a t i e n ta t home I n t r o d u c t i o no fH o s p i c e HomeC a r e .M e d i c a lF r i e n dP u b l i c a t i o n . 6 )KawagoeA .( 1 9 9 2 ) :Wisht od i ea thome-ad i a r yo f ac a n c e rp a t i e n t and h i sf a m i l y -，Hokendojinsha C o r p . 19 9 1 ) : 7 ) H e a l t h and W e l f a r eS t a t i s t i c sA s s o c i a t i o n( Trend i nh e a l t h and w e l f a r e( n u r s i n gc a r e and m e d i c a lt h e r a p yf o re l d e r l y )，4 0，A s t a t i s t i c sand r e s e a r c hdepartmenti nt h eM i n i s t r yS e c r e t a r i a to f H e a l t handW e l f a r e . 8 ) Kuroda T .( 1 9 9 1 ) :A s u r v e yo fa w a r e n e s s when l o o k i n ga f t e rat e r m i n a l l yi l lp a t i e n ta thome( w h a t t heythoughtwhent h el a s tmomentc a m e )，2 1 2 4， OsakaGasGroupW e l f a r eF o u n d a t i o n . 9 )WhitePaperbyM i n i s t r yo fH e a l t handW e l f a r e e a l t handW e l f a r eS t a t i s t i c sA s s o c i a t i o n， ( 1 9 9 5 )，H 41 . 1 0 )I n s t i t u t ef o rH e a l t hEconomicsandP o l i c y( 1 9 9 7 ) : 1 9 9 6JapanM e d i c a lPlanning，2 0 7 . 1 1 ) Survey o ft e r m i n a lc a r et oc i t i z e n s( 1 9 9 3 ) : Summaryo fr e s u l to fs u r v e ya st oc u r r e nt. 句.
(18) 竹村節子. 102. (Summary) The Research on the Condition of Home Hospice Care in Shiga Prefecture - From a questionnaire to general practitioners Setsuko. School. of. Human. Nursing,. Takemura. The. Background The majority of terminal cancer patients still die in general wards of hospitals; those who die in hospices and palliative care wards account for only some four percent of the total. It is considered the most appropriate for terminal cancer patients to receive care at home, enabling them to live out their remaining days in a meaningful way. In order to fulfill such patients' wish to die at home and their families' wish to care for them at home, a home hospice care system must be established that encompasses pain management and sufficient personal care for the patients, as well as support for their families, who are present at the death. The establishment of such a system requires understanding of physicians' views on this issue, identifying problems regarding physicians' cooperation with hospitals, and shedding light on other issues that should be addressed. bjectives To clarify the current situation of home hospice care in Shiga Prefecture, where the aging rate is 17.3%, as well as to review issues and problems to be addressed in establishing a home hospice care system in local communities, by analyzing the results of a questionnaire survey of general practitioners, who should play a leading role in supporting home care. Method A questionnaire survey on home hospice care was conducted of 772 general practitioners in Shiga Prefecture by postal delivery and collection. Results Of the 294 respondents, only 75 (25.5%) actually provided home hospice care services. Of the remaining 219, however, 116 (53.0%) admitted the need for such services. The 75 practitioners see 1.9 patients. each on average,. mostly. in response. -. to. University. of. requests. Shiga. Prefecture. from patients'. families. and hospitals.. They. generally visit the patient's home to administer fluid replacement, provide pain management and respond. to emergencies.. own contact that. systems. Although. they. for emergencies,. it is impossible. to prepare. have their. some replied. for response. to their. patients' needs around the clock, and that even if they could, it would be too much of a burden, both physically and mentally. The respondents feel that home. hospice. phy. sicians'. care services capability,. further. promotion. of. requires,. in addition. to. strong. demand. from. patients and their families, and sufficient numbers of caregivers, as well as close linkage among practiti oners, associations. Some hoped that nurse. departments. role.. These. shortage local. hospitals. and. palliative. care wards. of hospitals. respondents. of hospices. hospitals. home. hospice. medical. and visiting. could play a leading. felt. and. contributes. in promoting. local. that. the. current. palliative. care wards. partly. to the difficulty. in. care.. Conclusion The survey revealed that the following factors are essential in establishing a home hospice care system: accept tion;. core hospitals. patients education. showing and. that. are always. sudden. change. training. facilities. ready. to. in condifor medical. professionals; facilities that provide integrated services for home hospice care; and palliative care wards. and. hospices. that. practitioners. Key Words Home hospice terminal. cancer. patients. cooperate care, general. with. general. practitioners,.
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