Thinking about the patient's wishes: practical wisdom of discharge planning nurses in assisting surrogate decision‐making

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Excerpt

National medical care expenditures in Japan are mounting year by year 1. In 2025, the baby‐boom generation will be at least 75 years old, and the generation that has always supported government expenditures will by then be the recipients. There is a growing concern that this could lead to a collapse in the financial balance of the social security system. As one measure to resolve the crisis of the increasing elderly population, the national government is developing an integrated, community care system targeted for completion by 2025 2. The system is designed to spur differentiation of medical care functions in close collaboration with regional communities.
Rational, effective patient transition is essential to the operation of this system. For patients lacking self‐decision capacity, it will be necessary to provide a new post‐transition environment that will be conducive to their safe recuperation following discharge from an acute care hospital. Since 2008 in Japan, the establishment of discharge planning departments (DPDs) has been directly linked to the medical fee system and has proceeded quickly, with assignment of discharge planning nurses (DPNs) as key staff members 5. Since fiscal year 2012, the standard for recognition as a DPD facility under the medical fee system has required that DPNs be assigned to the facility, and also includes an outcome assessment with stepwise scoring of medical fee points depending on the length of hospitalisation 6.
At present, decision‐making for patients lacking self‐decision capacity is generally performed by their families; however, this is not without complexities. According to the 2013 Comprehensive Survey of Living Conditions, the average number of household members in Japan at that time had declined to 2.51 7. Approximately 30% of households with persons aged 65 years and over were households comprising couples only, which was the highest among other types of households, and these along with one‐person households already accounted for more than half of all households 7, with a corresponding rise in the number of households having no available surrogate family members living nearby. Complexities also arise for nurses in such cases.
According to Popejoy et al.'s 8 review on discharge planning for elderly patients from 1990 to 2008, the effectiveness of discharge planning by hospitals had been noted in several studies but almost none focused on the establishment of partnerships between the patient, family and medical care professionals. In a subsequent study, Popejoy 9 interviewed elderly patients, their families, and DPNs or social workers involved in their discharge planning, and elucidated the complexities of discharge planning. None of these studies included instances of family conflicts with the patient or with a DPN or social worker 9.
Various studies have focused on surrogate decision‐making families involved in withdrawing or withholding life‐sustaining treatment 10. Meeker and Jezewski 13 performed a metasynthesis of studies on family experiences in withdrawal of life‐sustaining treatment. Bauer et al. 14 conducted a study on the experience of families in the discharge planning process for hospitalised elderly dementia patients, and reported on the perceptions of the family caregivers concerning discharge planning and preparation. The studies focused on families as surrogate decision makers, but gave no detailed description of the practices of the nurses engaging the families, their perceptions of the families or the judgements they form. In their review on the perceptions of nurses relating to ethical problems in elderly patient care, Rees et al. 15 showed ageism as one of the main reasons for the problem.
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