The practice of patient decision support in university hospitals

Abstract

In the past, medical treatment was left to specialists. In recent years, after informed consent was established, it has been recommended that advance care be considered as advance care planning (ACP). However, research shows that 75.5% of the general population does not know about ACP. It is recommended that medical care teams make policy decisions based on the choices of their patients. However, patients may still seek physician initiative at university hospitals. Therefore, doctors at university hospitals need to know the general public's awareness of ACP. In March 2018, A questionnaire was conducted to the general public assuming three cases of terminal cancer, severe heart disease, and dementia. Among them, there was a tendency for all three conditions typically did not want medical treatment that would prolong their lives. In the last stage of their life, they want to receive medical care at home for terminal cancer, at medical facility for severe heart disease, and at nursing home for dementia. The disease trajectory of intractable neurological diseases without the use of a respirator is very similar to the disease trajectory of severe heart disease. With the use of a respirator, such neurological diseases have a similar disease trajectory to dementia. When considering where to want to reach the end, it was important to consider, in order, that their families would not be burdened, that the patient would not suffer mental or physical pain, and that the financial burden would be small.

Of the 108 inpatients admitted to Department of Neurology at The Jikei University School of Medicine, Katsushika Medical Center in 2018, 75 were discharged, and more than half of them introduced new home–visiting care. This occurred because they were unable to enter the medical facility economically and had to return home. In addition to this, there are various other decisions to consider for neurological diseases, such as the need for a gastrostoma or ventilator. It is necessary to provide appropriate decision support at the right time, keeping in mind the trajectory of each disease. Because many home–visiting physicians and institutional physicians are not neurologists, it is difficult to visualize disease trajectories. Also, at the time of a patient's transfer from a medical facility to home–visiting care, a patient–physician relationship has yet not been established. For this reason, if it becomes difficult for a patient to go to or remain at a university hospital, there is an obligation to make a decision about ACP prior to leaving the university hospital, steer, and send it out.