Death education in home hospice care in Japan Hiromi Kawagoe Journal of Palliative Care: Autumn 2000; 16, 3: ProQuest Health and Medical Complete Death Education in Home Hospice Care in Ja apan MI KAWAGOE, Community Nursing, St. Luke's Nursing College, and KOH KAWAGOE, Home Care Clinic goe, Tokyo, Japan Abstract /In the practice of home hospice care, or one third of all deaths were due to cancer. In death education for both patient and family is ex- 1999, 92% of deaths from cancer occurred in the iremely important, although little information on its general hospital, 2% in an institutional hospice usefulness is available. In this study, the effects of or palliative care unit, and 6% at home. This death education under home hospice care were trend to having death take place in institutions analyzed for 16 patients who died at home. Death has meant that the general public has becom at least once in each phase of care, and at least four isolated from dying and ignorant of methods for times in total. The acceptance of death by the patients dealing with imminent death was judged according to the way they spent their Death education in home hospice care was es- emaining time, to their attitudes, and to their hope for tablished as a realistic and practical method for a life after death. Fourteen of 15 patients appeared to a patient and her /his family to live out their accept their own death. An autopsy was performed in remaining days in ways acceptable to 16 cases. In one case, the doctor recom- therefore involves not only medical care,but mended an autopsy to the family, in the other cases, also education. Using death expected in the it was performed in accordance with the patients or family's wish As the goal of death education in home short term as educational material results in hospice care is the acceptance of death by both pa- death education itself. However, the content tient and family, our methods of death education ap- must be practical and individualized, and the coals are different from those of death educatior n general. Although important, death educatio Resume Lorsqu'on dispense des soins palliatifs a in home hospice care has not been widely stud- domicile, il est extremement important que le patient et sa famille soient renseignes sur la mort et sur tous ied in Japan( 1 ). This is mainly due to doctors' peu de litterature sur I'utilite de le faire. Dans cette few home hospice care services, and the diffi etude nous analysons les resultats de cette formation culty of evaluating its effects objectively sur la mort aupres de 16 patients qui sont decides a In the present study, we examine 16 terminally la maison. Nous avons eu au moins quatre fois des ill cancer patients who received home hospice conversations sur la mort avec chaque patient durant care, and discuss the theory of death education les diverses phases de la maladie. C'est a partir de la While such studies tend to be subjective and liter- facon dont ils ont vecu leurs derniers jours, de leurs attitudes face a la mort, de leur espoir d'une autre vie ary, we have attempted an objective analysis avons juge s'ils acceptaient la mort. Des 15 based on accurate data. Conversations with the patients, 14 semblaient accepter leur tient or the family were recorded and evalu autopsies a ete pratique dans 5 des 216 cas Dans un ated In 10 out of 16 cases, death conferences with cas c'est le medecin qui l'avait recommandee a la the bereaved families were held to confirm famille, dans les 4 autres cas c'est a la demande de whether or not our assessments were correct Us la famille et selon les volontes exprimees par les g this information, the goals of death education patients qu'elles ont ete pratiquees. Dans le cadre in home hospice care in Japan are evaluated des soins a domicile, le but de notre formation sur la ort etait que le patient et sa famille puissant ac CASES AND METHODS cepter la mort; il semblerait donc que notre methode de preparer les patients et les familles a la mort soit Cases The subjects were 16 incurable cancer patients INTRODUCTION selected from registered home hospice care. The criterion of selection was that the death educa In Japan, cancer has been the leading cause of tion be delivered in certain ways, as will be de death since 1983. In 1999, about 270,000 people scribed. All the patients died at home Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Death education in home hospice care in Japan Hiromi Kawagoe Journal of Palliative Care; Autumn 2000; 16, 3; ProQuest Health and Medical Complete pg. 37
8535g86工 Table 1/ CASES Duration of Home Hospice (chief caretaker 二 mother, father, sister 0548 fe, parents, 2 daughters, 2 sisters husband, son, daughter 3456789 Uterus FFMM wife, daughter wife, 2 daughters, sons-in-law, granddaughter vife, son, daughter, mother, 3 sisters 23456 daughter, grandson, granddaughte 79 Uterus on, daughter-in-law, daughter, housekeeper MMM rife, daughter, 2 grandsons Prostate ife, daughter and son-in law, son and daughter-in-lay Abbreviations: M= male, F= female Nine patients were male and seven female. the current medical care needed and how it The average age was 60.8 years(range: 20-86 could be provic ed at home years).The primary cancer sites were the nursing care of the dying(for the family only) gastrointestinal tract in four, liver in two, pan introduction to similar cases and books con creas in two, lung in two, ovary in one, uterus in home hospice care two, breast in one, prostate in one, and bone in ng phase, death eaucation was was 106.1 days(range: 20-425 days)(Table 1). given to the family members who were involved Death Education family to take care of the patient without medi- Death education in home hospice care involved cal staff involvement. The following points were truth-telling", providing the patient and family discussed with information regarding the disease, such as things to note while caring for the patient iagnosis and the fact that the disease was incur- ocess able, and the life expectancy. Death education was how to confirm the patient's death carried out at least four times in each case: during the introductory phase, the stable phase, the d ing phase, and the bereavement phase During the introductory phase, the education Death education after death was given to was provided to both patient and family. The sig the following e grief. The education included family to man nificance of their final time together at home was explained. Education covered the following areas: support for the family in preparing for the the differences in medical treatment at the hospital and in home care home visits by the doctor and nurse to care the current medical care needed and how it for the body with the fa uld be provided at home final explanation of the course of the disease including autopsy results In the stable phase, education was also given a conversation with the family to both patient and family. The goals here were to provide support for an acceptance of death Evaluation of Death Education to live with hope until death. The following To assess the effect of death education, precise docu- points were discussed mentation was used, including recorded conversa the state of the disease ons between patient, family members, and medical the estimated time of death, with any expla- staff. a record of the death conference, in which the nation necessary family discussed their memories, was also made Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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Table 2/"TRUTH TELLING"IN HOME HOSPICE CARE Incurable State Remaining Days Who? Y/N Time Who? Time Who? exceptional N B 67890 YYYYYY BBBA AAAAAAAA mDDDDD 12 N ABABBBBBABB B NYYNN YYYNYYYYYNNYYNN Dr N: no Y: yes B: before initiation of home hospice care D: daughter H: husband W: wife Table 3/ PATIENTS ATTITUDE TOWARDS DEATH death","I shall be in the same gra Living Actively shall meet my family again"were considered Judgement In Days Remaining For The Future indicative of belief in an afterlife The efficacy of death education was evaluated 14 8 based on how the final care was performed, and Exceptional case whether or not the patients or families consented to an autopsy. Assessment of final care included review of persons who attended the death whether or not a doctor was present, and other "Truth-telling"was analyzed based on three conditions. Regarding the autopsy, who consented points: disease diagnosis, its incurable state, and to the autopsy and stage of illness were analyzed the predicted life expectancy. In one case, this nalysis was not performed because the patient RESULTS was mentally handicapped The results of death education were judged Truth-telling for each case by studying the process of death Ten patients were told the name of their illness, acceptance in the patient and family during cancer, before home hospice care began Five pa home hospice care, and by analyzing how the tients( Patients 2, 5, 12, 15, and 16)were not in- death was accepted. Whether or not the de- formed Of the 10 patients who were informed ceased accepted his/her death was judged ac- seven were told by the doctor in charge and the cording to two criteria remaining three were told by a family member (Table 2). Eleven patients were told that their con- how the patient had spent his/her last days dition was incurable. Eight of these were told be whether or not the deceased believed in an fore initiation of home hospice care, four by the the three cases told after the initiation of home hos The first was assessed based on the way the pice care, two were told by a doctor and one by a patient had arranged social matters, if they had family member. In 10 cases, the time remaining to made arrangements for a funeral service or them was discussed with the patients. Except in grave, and if they had expressed gratitude to the one case, this information was provided by the bereaved.Whether or not the deceased believed author after the initiation of home hospice care in and dreamed of an afterlife was judged by There were many problems associated with what he/ she said before death. For example, " I Patient 2. The patient was a 36-year old man shall always be with my family even after my with stomach cancer. He was not correctly in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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formed of his illness and believed that his condi- Two days before her death she said tion was curable. As a result, he did not want to go home from the hospital. Complying with a I will have all your seats reserved in Heaven, so strong request from his family, however, his please put many handkerchiefs in my coffin home hospice care began. Concerning"truth- After her death her husband remarked telling", there were serious discords among his family members, especially his mother and his The intensity of our married life during the last six 8a工iE9rs5 wife. Without naming his illness, we told the 25 years. I feel sorry for her but I am convinced she patient that his condition was incurable and his remaining time was limited We judged that this patient has accepted the The Acceptance of Death by Patients Based on how the patient lived during their re- Patient 5: The subject was a 51- year-old woman maining days, death was accepted by 14 patient with cancer of the uterus. At her husband's re and one(Patient 5)was unclear(Table 3). Patient quest, she was not told that her cancer was in- 1 is omitted from the review of death education because of the patient's lack of understanding. naturally became restless at times; she was calm Judging from the hope for an afterlife, acceptance when in good condition, but plained of of death was observed in eight cases(Patients 2, 3, great restlessness when in poor condition. She 4, 6, 10, 12, 13, and 15)and six cases were obscure. appeared to be stable about two weeks before The process of acceptance was reviewed for each her death and said, "Things will take their natural Itient, and eight are discussed he course."Fifteen days before her death, however she reported severe pain and her anxieties in patient 2: As mentioned previously, this patient creased because she had not been well informed was not told the name of his disease, however, of her illness. Her husband strongly wished to he was told that his disease was incurable. Four take care of her at home but the patient was anx- days before his death he said to his four-year- ious because she was not in the hospital. Ten days old child, "Papa will be disappearing, "and to before her death, she was moved to the hospital his wife, " We have been married only eigl ht and remained there until two days before her years. Thank you. "Three days before his death death when she was taken home again. Arrange he said to his father ments were made one day before her death for a Thank you for everything, father. Let me pay my baptism. She was baptized a Catholic after which, score in Heaven. Please look after by wife and son. according to her husband, she completely recov- ered her composure. In this case, the auth He was baptized on his deathbed. Although he cluded that the acceptance of death did not take r con was only 36 years old, he accepted his death, pre: place until she was baptized Patient. 6: This was a 54- year-old woman with Patient 4: The subject was a 49-year-old woman ovarian cancer. Twenty days before her death she with stomach cancer. Thirteen days before death I have made up my mind, because of the explana tion I heard yesterday. However, I do not wish to hospital for medical research. I wonder if the be in a coffin all alone as I will feel lonely. What pathological autopsy is much more significant. I worries me now is that I mig ted in do not wish to receive any medical treatment after I become unco Heaven. However, Ms. Takana's(visiting nurse My life n Gods will. If possible, I wish to avoid the time Ten days before death she said Nine days before death she said My husband read me a book titled I Want to Die at I am aware of my limited life, still I am worried ome(pt A week before her death, all of her family members got together to talk. The following Two days before death she wrote a haiku(17. syllable poem) expressing the joy of being ac- order he heaven and her gratitude to all iss. My regret is that I shall have to The aut leave so soon after I see my family in an ideal way death and arranged her life in her own way. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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Case no 8: The patient was a 59-year-old man nothing at all to worry about or regret. "He with liver cancer who was discharged from the chose to stay at home. Six months before death, hospital. He was a company worker and had left he stated that he would sign the necessary docu a lot of unfinished work when he was taken to ments to allow an autopsy. Four months before the hospital. He thought he could not manage death he said his work in the hospital but could at home Thus, he agreed to go home from the hospital In January of this year I was told that I would live He handed over his job to a colleague, and set for only six months without hospital care but I tled his financial affairs. He was thoughtful to have survived 10 months since then. I am very satisfied that I chose home care his family members especially to his wife and spent his remaining days at home in pe e. The Twenty-three days before death, stretchin author judged that this patient accepted death. out three fingers, he said"I think I shall be all However, his attitude toward an afterlife could right for another three days. "The author judged not be determined that this patient accepted death and lived his remaining days as pla Acceptance of death Patient 9: This was a woman, 62 years of age, was very active. His belief in an afterlife could with lung cancer. She was preparing for her last not be confirmed days at home. She read a book entitled Katei de mitoru gan kanja or Terminally Ill Cancer Patients Patient 16: This boyear-old man with cancer of being Cared for at Home(Publisher: Medical the pancreas stated eight days before death that Friend Co. At the time of my first visit to her he thought he could live a little longer, but it she said: was fate after all. This patient was not given adequate information regarding his disease, yet not care even if i die tomorrow providing that he seemed to be aware of the ousness of his I can avoid the last agony condition and accepted death his own way The following is the report of a conversation The Acceptance of Death by the Family between the patient and doctor three months before her death. While looking at a hand mir- Generally it took some time for family members ror, she seemed to be happy. She said: to accept the death of the patient. This accept For only a few days, I have been taking steroids ance took place gradually during home care markably fat. If I continue like and, in most cases, the family appeared to be this, do you think I shall be all right for another relieved when the patient died. During the proc year or so, doctor? ess of death acceptance by the family there were two unusual cases, Patients 1 and 2. As your sickness is rather serious, let's make a plan for every three months to begin with. You will be In Patient 1, due to lung metastasis from an quite all right for three months from now, I think. osteosarcoma, imminent death was predicted After the first three months is over, let,'s make a However, the patient appeared well. His family, especially his mother, could not accept his con dition, At the time of my first visit, hi I told her about another patient who had similar experiences was emotional and refused to accept the infor- A conversation a month and a half before hey mation provided by my predecessor: There is death: " Is your husband all right? "He seems to no means to cure your sons disease. "We be having a hard time and I feel sorry for him." thought that the best way to convince this to show her X-rays of his chest taken et saying, "I fear that I shall not be able to stand up month. Four months later, with the four X-rays and my husband likewise. She was worried about the health of her husband and her son's in front of her, she at last began to realize that profession bu It she had lived out her life at her son was going to die. At that time, she re- gained her peace of mind and decided to care home. Acceptance of death was judged to be for her son, who was becoming weaker day by adequate but whether or not she believed in an afterlife was not known day, and so prepare for his death( 2) A male patient, 36 years of age with stomach Patient 14: This was an 80-year-old man with cancer(Patient 2), was not given accurate infor ancer of the rectum. When his doctor detected mation regarding his disease at the time of his that the cancer had spread to the liver about 13 return home from the hospital. As his condition months before his death, the patient refused worsened, the patient became anxious about not treatment and said, "I am 80 years old now. I receiving hospital care. At this time, there was a have done everything I believed right and I have dispute between his mother and his wife over Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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whether to tell him the truth. We followed his designed to allow individuals to choose the wife's wishes, but also complied with his moth- own way to spend their last days by providing ers wish that he not learn the name of his dis- them with issues to consider( 3) ease. We told him only that he was very seri- As death is inevitable in all human beings, it ously ill. The patient knew that he would die, is important to provide education in harmony and left a will for his children, wife and parents. with the state of growth and development of the He was baptized into the Christian faith in his dying person. This involves not only medical taff, but reli His mother, however, was troubled by the cists, and educators, and is an interdisciplinary E=55 truth-telling"even after death, and bereave- field. Death education can be carried out in vari ment care was difficult ous places and under various circumstances(3) Family members were with the patient at the using many teaching materials time of death in all cases except those of Patients In Japan, " death"is widely thought to be a 4 and 9(Table 4). In the case of Patient 3, the taboo topic and death education in this country visiting nurse arrived at the patient's house, by lags behind that in the USA and European coincidence, at the time the patient passed away. countries. However, it was recently reported to be in a provisional curriculum in school educa- DISCUSSION tion(4). In comparison with general death edu- Object and Person in Charge of Death Education cation, that given in home hospice care is en- ely different since the education is designed Education in general supports the growth and for persons confronted with death. The object development of kind Death education is and contents method and effects of death edu Table 4/FAMILY IN ATTENDANCE AND CIRCUMSTANCES AT DEATH Patient No. Attendant Family Attendant Staff Circumstances At Death Parents, sis Calm death in fathers arms watched by his family. Wife, pi 2 sist None Death dunng violin music which he liked, He shed tears just before his last breath, with mouth care carred out by his seven-year-old pand, son, daughte None ently nd son were drinking sake at the bedside Husband aughter Nurs Family gathered at the bedside due to a sudden change in breathing No one noticed her last breath Husband, sister-in Despite disquietude till then she became peaceful following a baptism friends at the bedside. she died calmly with her husband holding her hands N Calm death during a hymn lead by her daughter who testified that she was conscious at the time of he Wife, daughter None Several hours before his death, he called his daughter who rubbed his lighters and their None About half an hour before death his facial expression became peace- nds, granddaughter ful with a faint smile which continued until death d, son Visiting nurse was called due to husbands anxiety about a sudden change in breathing. Death was like falling asleep on, daughter, moth death watched by all family members. Daughter sisters, priest and his wife mother to grasp his hands which were held by the priest Just before his last breath, he tumed off the Tv by himself. Entering the room, his wife found that he had just gone rangr ghter, grandson None I fall asleep? "the patient asked her granddaughter. shortly after daughter he died but no one knew when she breathed her last daughter, None eath. the granddaughter, housekeeper Wife, daughter None Calm death surrounded by family and relatives son, daughter-in- None His death was attended by his B1-year-old wife. With a gentle voice e told us by phone that everything was over. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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cation are, as a matter of course, different from this criterion. However, home hospice care is not necessarily the best program for every cancer pa As family members of the patient are in tient at the terminal stage. It was concluded that olved with home hospice care in Japan(1), they home hospice care is an exclusive right given only develop relationships with the dying patient in- to patients and their families who wished to dependently. Therefore, the object of death edu- spend their remaining days together at home cation is not merely the dying patient but also the caretakers, the patient's family. Death educa- Change in Death Education According to the tion for the family is no less important than it is Condition of the Patient for volunteers who are involved as team mem- In home hospice care, the curriculum of death pers in hospice care(5). Participation of the fam- education should change with the condition of ily in providing care is important in terms of the patient. It is necessary to educate the patient manpower and for bereavement care after the and family to reach the goals set for each stage patient's death(6). The death education in home of the dying process hospice reported here was performed through At the initial stage we must understand the trial and error and we examined the way in wish of the patie lent correct ctly and, at the same which the deceased and the bereaved spent their time, an objective assessment of the ability of the remaining time together. Our death education family to provide care is important. At this nethods involved many problems and should stage, the significance of hospice care(7, 8)and be further improved through daily practices. especially of its application at home should be Establishment of a universal system of death ained in detail to the patient and family. The education will use information collected by doc- goal of education at the stable stage should be for the patient and family to accept death as a Goals of Death Education natural phenomenon and to understand ciousness of the remaining days of life so that the Deeken(3)reported 15 goals concerning death patient can live in peace. In the final stage,the education. However, some such as the sixth doctors and nurses should explain that death is goal, which was related to suicide and the 12th inevitable. However, the family often told the goal which was related to the art of death were patient the significance of life and how wonderful not included in death education for home hos- it was. Thus, during death education in home pice care. hospice care, the medical attendants were not Among goals considered important for home merely specialists and teachers but also students hospice care were When the patient's condition is stable and the dying process family is self-possessed (3), young family mem preparation for death(2nd) bers or grandchildren can learn about life and grief education(3r) death. For example, Patient 14's grandson said, elimination of fear of death(4 h) n response to a question during a TV interview: understanding the preciousness of the re As my grandfather was at home I could see him etting weaker day by day. Home hospice care is hard work all right, but it is an experience that one Some other educational goals were unsuitable should have once in life for home hospice care or too complex for gen eral death education These included: When a doctor knows that death is approach removal of the taboo concerned death (5th) g, he/she must inform the family so that other matters relating to the right to know for a relatives can be told and arrangements such as the funeral service, death costume, and portrait terminal cancer patient (7th) moral matters on death( 8th) can be made. When death is imminent, educa- tion regarding the process of death, possible autopsy (9th) preparation for funeral service(10th) changes, and how to care for the patient should death philosophy(13 th) be provided We explained that the medical staff religious matters(14 could be reached at any time, so the family the possibility of an afterlife(15) ould feel comfortable about providing the final one if poss For successful home hospice care, both the pa An important point of education at this stage tient and family must choose and support this was to let them know that the patient would be service. Death education in home hospice care is free from agony, but their consciousness would provided for the patient and family who fulfill be retained until the last moment. Accordingly, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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we reminded attendants not to make careless method of"truth-telling"differed from case to remarks. As reported by Segri-Swinehart (9), it case. Generally, aged patients (70 years or more) is important for the family to be near the death- were aware of their length of life so it was not EUga bed until the very last moment necessary to follow to the fundamental rules in " Truth-te most cases. Younger patient ver, were not aware of their confrontation with death unless Acceptance of death by the patient in hospice they were informed by doctors accurately. Fur care was closely related to providing the patient thermore, they had a lot of matters to organize with accurate information regarding their condi- before death. We therefore told such patients the tion. to choose one's home as a final residence truth, providing conditions were acceptable the patient must precisely understand his/her In home hospice care, the doctors and ondition. The name of the disease, its stage, and nurse's contact time with the patient and famil he time remaining must therefore, be discussed especially with the patient, was extensive. Dur th the patient in detail ing every visit, we talked with the patient and In Japan, in most cases, the decision whether family for a least 30 minutes. Care and support or not to tell the patient the truth is made by the after"truth-telling"were provided. with such doctor or medical staff. This must be reviewed preparation, it was possible to carry out"truth with the patient's"right to know"(10) telling"and necessary explanations in most 1. the information must be given clearly comply with all of the opinions of the family 2. the patient must accept the truth within a limited time. Such situations have yet to be studied and the best way to deal with fam a relationship of mutual trust must exist be- ily conflicts is unknown octor and the family, including the patient Acceptance of Death as an Ultimate Goal 4. physical and spiritual care as well as patient pport must be provided after telling th The ultimate goal of death educ hospice care was the acceptance of death by the patient and family. Acceptance somewhat re- We concluded that these conditions could be sembled resignation but involved active discus directly applied to home hospice care. Truth- sion and thought. Deeken(3)criticized the state telling"consists of three steps for patients with of mind and psychological process of death pro- terminal cancer: naming their disease, stating posed by Kubler-Ross, and added a chapter that it is incurable, and giving the time remain- called " Stage of expecording to Deeken, a hu- tation and Hope"to her ng. Most of our patients were told the name of last(5th)stage(12).Acce the disease, that it was incurable, and the time man achieves tremendous growth of character remaining. For terminal cancer patients to de- in his or her last moment of life cide to spend their remaining days at home, the Hospice does not refer to a place, but a philoso patient had to understand her/his condition. phy. However, a patients own home was re- Discussing the time remaining was more ported to be the most suitable place, provided delicate and difficult than naming the disease. care was well arranged, for the patient to spend Selecting a suitable time to tell the patient was the remaining days with"expectation and hope difficult, but the most important factors were Patients can be masters of their own homes, and the relationship of mutual trust between the are able to live with dignity. It is the easiest place patient and doctor, and the mental condition of for them to accept death. The authors believe the the patient. We used expressions such as goal of home hospice care was to give a last touch Please organize a life plan on provisional sup- of life to the patient and family, and to allow them position that your remaining days are 30 days to live out their time together with hope. The to begin with. "The following expression was patient and family learned to live their remaining important: " I am sure that you will be fine one days with expectation and hope month from now. After that time, you will have The authors were of opinion that, at this arned extra life. You must make your life plan stage, a doctor and educator should not inter- for another one month all over again "This fere in their lives. Instead, it was important for helps the patient to be comfortable and hopeful them to play the roles exclusive to them, roles in the remaining days that could not be played by anyone other than The family, however, must be accurately in- a doctor and a nurse, so that the patient and formed regarding the time remaining. This family could learn by themselves. The doctor's Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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role as an educator was to show the inevitable at Home: the Introducton of Home Hospice Care. Tokyo: Medi- death, estimated time of it if necessary, and how cal Friend Co., 199 it would occur. The simple act of counting the in the home by his beloved family took a fight to heaven. The number of hour ining and of facing the imminence of death cannot but bring about a 3. Deeken A The significance of death education. In: Deeken A pid growth of character. Acceptance of death is nothing but a literary expression. The spir- 4. Ogura M, Soma M. The aims and contents of death education. 555g38a8 itual state of the patient and family was always unstable to the very last moment. In all the asmar school (in Japanese) had accepted death, but for each, the process of 6 Degner LK, Gow CM, Thompson LA Chie &s; 62(6): 37-2ath 5. Tamlyn DL Caty S. cases studied, the authors judged the patient effects of educatio acceptance was by no means eas y, hospice set- urs1991;14:246-253. 7. Welk TA. An educational model for explaining hospice services. The subject of autopsy in home Am J Hosp Palliat Care 1991: 8: 14-17. ting, which is closely related to the acceptance 8. Mathew LM, Scully JH. Hospice care. Clin Geratr Med 1986: 2. of death, has been reported previously(13) Swinehart P. How to get patients home and help them stay ee. Semin Ond1995:12:461-465. 10. Annas GJ. Rights of the terminally ill patient. J Nurs Adm 1974 Date received, October 16, 1998; date accepted, Sep 44044 ember 3. 1999 11. Yanagida K. A gente truth-telling. In: Truth-telling and Hospice Care(in Japanese). 17 Intemational Seminar on Medicine and Education. Tokyo: Life Planning Centre, 1992: pp. 5-14 REFERENCES 12. Kubler-Ross E On Death and Dying. Toronto: Macmillan, 1967. 13. Kawagoe K, Sato A. The autopsy findings of cancer patents who 1. Kawagoe K. General view of home hospice care in Japan. In clinical significance. J Jap soc Cancer Kawagoe K(ed). Cancer Patients in Teminal Stage Cared for her1993;28:619625. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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