2012 Volume 5 Issue 1 Pages 28-34
Purpose: This study examined discharge planning in an acute hospital to ensure a smooth transition from the hospital to home-based care for a terminal cancer patient, and the complementary roles of formal and informal home-based care services. Methods: We analyzed the process regarding meetings between staff of the acute hospital and health care workers involved in home-based care, and the roles and influence of health care professionals and family members. This was a case study. Results: Primary physician’s active involvement and medical advice during the staff meeting greatly contributed to the realization of home-based care for the terminal cancer patient. Despite the short duration of cooperation, seamless care was successfully performed with formal and informal services provided by multiple health care professionals and family members. The patient expressed various emotional conflicts as well as her appreciation for the care provided by family members or friends. She received home-based care for approximately 1 month until her death, and showed various changes in mental status during this period. Conclusion: It is important to link home-based care services among community, medical, and welfare facilities by comprehensive support or cooperation, and consider informal services equal to formal services.
