Advance care planning processes and specific assistance:

Through analysis of the timing of the confirmation of the intentions of care recipients by visiting nurses

Abstract

    The purpose of this report is to consider appropriate Advance Care Planning (ACP) processes and specific assistance by analyzing the timing of the confirmation by visiting end-of-life home care nurses of the intentions of care recipients and the specific assistance provided by said nurses. I conducted semi-structured interviews of visiting nurses with 3 or more years of experience using an interview guide. Twenty-three visiting nurses were interviewed with regard to 34 non-cancer patients aged 65 or older living with family members. The visiting nurses confirmed the intentions of care recipients in six different circumstances: upon commencing home care; while providing daily care; upon changes in the health condition of care recipients; when care recipients reach the terminal phase; where the nursing care burden on family members becomes overwhelming; and when the nursing requirements of the patient have exceeded levels that can be managed by family members. 18 distinct times at which visiting nurses confirmed the intentions of care recipients were extracted. Nurses determined confirmation timing not only by visually checking mental and physical changes but also through daily conversation while providing nursing care. Visiting nurses attempt to provide optimal, individualized end-of-life care by assisting care recipients and their family members in forming closer relationships and by helping care recipients prioritize their own intentions and wishes in making independent decisions. The timing of the confirmation of the intentions of care recipients and subsequent dialogue between care recipients, their family members, and medical teams are part of the ACP process. The research results imply that one of the most important duties of nurses assisting ACP is to provide insight based on the prioritization of daily care and assessments underpinned by sufficient medical knowledge and communication skills to build trust and allow care recipients and their family members to express their true wishes.