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Advance Care Planning Process of Home Health Care Nurses for Home Care Patients

M. Yamamoto 1

1 Global Nursing, Otemae University, Japan

Background: In Japan, with the aging of the population, the promotion of home medical care,
decision-making support for medical treatment, and care of home care patients will become
increasingly important in the future. This study aimed to clarify the Advance Care Planning (ACP)
process among home care nurses with experience treating home care patients and provide evidence
for effective ACP practice.

Objective: This study aimed to clarify the ACP process by home health care nurses for home care patients.

Methods: We conducted semi-structured interviews with nine nurses from seven home health care
nursing stations that cooperated in the study. We made verbatim transcripts from the interviews and
analyzed them using qualitative descriptive methods. The data collection period was from November
2022 to April 2023.

Results: ACP practice for home care patients was divided into three categories.

Interventions for the patient were classified into six categories: (1) Creating an environment that enables the
home care patients to express their wishes, (2) Understanding the home care patients’ wishes, (3) Providing
care that the home care patients choose, (4) Providing care aimed to reduce pain, (5) Improving the
quality of life, and (6) Keeping an appropriate sense of distance.

Interventions for the family were classified into four categories: (1) Acting as a bridge between home care
patients and the family, (2) Recognizing the family’s anxieties and providing feelings of security, (3) Realizing
and accepting changes in the home care patients’ conditions, and (4) Coordinating opinions among
Poster Presentation Abstracts
family members.

Interventions for the surrounding environment were classified into two categories: (1) Support for the living
environment, and (2) Decision-making support through a team approach.

Conclusion: In the process of practicing ACP for home care patients, interventions were not limited
to the patients themselves, but also included support for family members and support through the
effective use of social resources.

Keywords: advance care planning, home care patients, home health care nurse

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Correspondence: Mariko Yamamoto, Global Nursing, Otemae University, Japan
E-mail: mariko-y@otemae.ac.jp

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