Realizing the Wishes of Terminal Patients: Caregiving Transport Efforts for End of Life in the Kuji Area of Japan

Abstract

Background: There are some restrictions in Japan regarding end-of-life care. For example, only physicians can legally issue death certificates. By law, ambulance staff members perform cardiopulmonary resuscitation (CPR) for all patients with cardiopulmonary arrest (CPA). Therefore, it is difficult to transport patients to hospitals without CPR, even in cases of terminal patients with do-not-attempt-resuscitation (DNAR) order. Furthermore, there is no 24-hour home care nursing system in our area. Therefore, terminal patients are unable to spend their last moments at their home in the Kuji area. Objective: To design a system in which terminal patients who wish to spend their final moments at their home can be transported to the hospital without CPR after at-home CPA and a system to avoid confusion between ambulance staff and family members using instructions provided by the physician. Setting/Subjects: The subjects were terminal patients with DNAR order who wanted to stay at home. The instruction to not perform CPR after CPA was created as a document by physicians. Patient information was shared with the fire department; patients were transported to our hospital without CPR after at-home CPA. Results: In total, 26 patients died during the study period; eight received emergency transport to the hospital without CPR after CPA. CPR was not performed for any patient. Conclusion: A system transporting terminal patients without CPR after CPA was necessary in our area. This instruction allows terminal patients to spend their last moments where they wish and avoids unwanted CPR and troubles after CPA.

Keywords: cardiopulmonary resuscitation; do not resuscitate orders; do-not-attempt-resuscitation; instruction of physician; terminal patients.

FIG. 1.

Physician's instructions for CPR. CPR, cardiopulmonary resuscitation.

FIG. 2.

Assessment of decision-making abilities. As shown in the upper part of the image, understanding, awareness, ethical considerations, and statement are comprehensively used for assessment. In the lower part, potentials to improve abilities are listed for use in cases wherein the patient lacks decision-making skills.

FIG. 3.

Flow from cardiac arrest to confirmation of death. If a patient goes into cardiac arrest at home or a facility, the family or other party called 119. They presented the physician's instructions for cardiopulmonary resuscitation to the arriving paramedics. Paramedics confirmed the physician's instruction and patient information with the emergency department of Kuji Hospital and transported the patient to the hospital in an ambulance. The patient's death was confirmed at the hospital.