Aim: To develop a decision-making model for elderly end-of-life. Methods: A semi-structured interview study was conducted with 12 physicians in Tokyo and other prefectures. The process of data collection and analysis followed the Modified Grounded Theory Approach and the Steps for Coding and Theorization. We set up the theme of data analysis as “diagnosis regarding the elderly end-of-life” and then drew practical instances from the data coded to establish categories. Results: Fifteen categories emerged, of which five were main categories: Impossibility of end-of-life diagnosis, Decision-making at the end-of-life, Physician’s position in terminal care, Death with a feeling of achievement, and Culture of “Mitori” in the each community’s manner of staying together until death. Considering the connections between these categories, a practical model was developed. Conclusions: The practical model is that diagnosis at the elderly end-of-life is not possible. However, decision-making is to be done as the starting point of asking how the patient wants to live at the end-of-life and thinking what doctors and care providers could do to support the patient and his/her family.
Purpose: This study examined differences in circumstances during transition from a hospital to a home-care setting, depending on whether or not visiting nurses were directly involved in discharge coordination by visiting the hospital prior to patient discharge. Subject: The subjects were 12 family members providing care mainly for patients aged 65 years or older who were discharged from acute care hospitals in Tokyo. Methods: The subjects were divided into 2 groups based on the presence or absence of visiting nurses’ direct involvement in discharge coordination: an “involvement group”, if patients were discharged after visiting nurses took part in discharge planning in the hospital; or a “no involvement group”, if patients were discharged based on a regular discharge procedure without any involvement of visiting nurses during hospitalization. Data were collected through self-administered questionnaire surveys and semi-structured interviews. The interview results were examined and classified by the researchers. Feelings and experiences of the subjects during transition to a home environment from the hospital were analyzed employing a qualitative and descriptive approach. Results: An analysis of the level of involvement in discharge coordination showed that community cooperation was in place for the “involvement group”, with the greater involvement of hospital staff and collaborative relationships between visiting physicians/nurses and the hospital, compared with the “no involvement group”. Regarding the introduction of social resources to discharge planning, care plans for the “involvement group”, made prior to patient discharge, incorporated social resources needed for home treatment and recuperation. In contrast, care plans for the “no involvement group”, made prior to discharge, did not include social resources, and the lack of care and competence became evident after home-based care was started. Their initial care plans had to be revised to include nursing and social support services such as long-term care services. Regarding the feelings and experiences of the subjects during discharge coordination and the transition to home care, the “involvement group” was provided not only with home treatment/recuperation arrangements coordinated by various professionals, but also with support from visiting nurses who adopted a proactive stance in planning and delivering care services. They felt reassured by being able to consult at any time. In contrast, the “no involvement group” realized after discharge that preparation for home-based care was insufficient, and had their care plans rearranged by home-care service providers. They were aware of the lack of support personnel at the time of patient discharge. Conclusion: Social resources were effectively introduced to the “involvement group” through multidisciplinary collaboration, and the presence and responses of visiting nurses contributed to a sense of ease that there was someone to consult with. On the other hand, the “no involvement group” made additional care arrangements after patient discharge, such as the use of long-term care services, suggesting inadequate assessment for discharge coordination. Furthermore, they bore a greater burden of care after discharge, indicating the lack of support personnel on transition to home care.
Background: The chronic trauma produced by abuse of a child causes a series of symptoms very similar to a developmental disease as the sequela. Methods: We assessed 21 abused children who visited a hospital, and considered their characteristics based on clinical findings and psychological examination findings. Results: They showed mostly common psychological symptoms such as borderline intellectual functioning, hyperactive tendency, impulsiveness, retardation in linguistic sociality, disproportionate development of cognitive function and, especially, low levels of learning. In particular, younger children showed developmental retardation in language and facial expression, and excess impulsiveness. In addition, older children presented difficulties in auditory immediate memory and behavioral disorders including hyperactivity disorder and excess impulsiveness. Low self-esteem and low psychic energy were found in these subjects by the house-tree-person test. There was a significant difference in the relationship between levels of learning and simultaneous processing ability. Discussion: These findings suggest that child abuse influences childhood development in various ways according to age. Generally, it is said that the development of emotional attachments subsequently provides the foundation of social characteristics, such as personal relationships, emotional control and social behaviors. Attachment behaviors by caregivers to pacify alarmed infants help children internalize caregivers in their mind. Through this process, merely providing images of caregivers can soothe them. The characteristics of cognitive development in abused children observed in this study also suggested a strong influence of their previous life, in which they could not fully achieve developmental tasks via a sense of basic trust to develop sufficient attachments. There is a possibility that social developmental disability caused by underdeveloped attachments due to child abuse and childcare abandonment is formed through changes in the structure and function of the brain. Conclusion: Longstanding child abuse seriously impairs child development and causes severe brain damage, which leads to symptoms remarkably similar to developmental disorders. There is an urgent need to establish long-term psychosocial support systems including early detection and appropriate interventions.
The tsunami and fire resulting from the Great East Japan Earthquake that occurred on March 11, 2011, caused damage over a large area and destroyed the local healthcare system. Therefore, the disaster-hit areas required various types of medical support. Many doctors from the Department of General Medicine, Juntendo University School of Medicine, contributed to this effort. Some doctors who happened to be traveling on the Shinkansen on the day the disaster struck provided healthcare to other passengers and helped them until they reached home. Doctors also went to the coastal areas where the extent of the damage was unclear, in order to assess the medical requirements there. Other important aspects were providing medical examinations in evacuation shelters and controlling the spread of infection among the evacuees. To supplement the local healthcare system, which had been devastated, the doctors also set up and participated in a medical consultation system that utilized information technology. Furthermore, to prevent disaster-related deaths after the emergency period, pneumococcal vaccines were provided free of charge. The skills required to tackle the situation were very diverse and included those pertaining to areas such as acute disease care, chronic malady management, infection management, and disease prevention. However, all these aspects are handled by doctors as part of their daily duties and they are skilled at handling them. On the basis of the experience obtained during this period, we will reexamine physicians’ roles in General Medicine and prepare them for future disasters.
A 42-year-old woman was admitted to our hospital with severe hypoglycemia. She had undetectable plasma ACTH and cortisol before and after CRH stimulation. There was no evidence of other pituitary hormone deficiency. Thus, we diagnosed her with isolated ACTH deficiency (IAD). Replacement with hydrocortisone efficiently prevented hypoglycemia. Recent epidemiological studies in Japan showed that IAD should be considered as an important disease causing hypoglycemia well as insulinoma.