Here’s this week’s Media Mix, which is about changing attitudes toward hospital care for terminal patients. In the column I only used the statistics I needed, but the issue is quite interesting in what it says about the government’s approach to medical care. Of course the government wants to cut expenses as much as possible, and hospital care costs more than home care, but in order to shift terminal patients out of hospitals and into homes they will offer an incentive by increasing compensation for home care from ¥42,000 to ¥50,000 and emergency compensation from ¥6,500 to ¥8,500 per visit. The strategy is extremely important since the health ministry wants to reduce the number of hospital beds, which may prove to be very difficult. Right now, about 1.2 million people die in Japan every year, and that number is expected to rise to 1.6 million by 2032, an increase of one-third. Another problem is the availability of physicians. Though Japan is supposedly suffering from a shortage of doctors, the main problem is distribution in terms of region and discipline. Hyogo Prefecture, for instance, solved its pediatrician problem in part by asking residents to not use resources at night or on weekends unless there was an emergency. Consequently, pediatricians’ work load became easier to manage. In order to realize more effective home care, clinics and doctors will have to become more flexible in terms of treatment and nurses and caregivers will need to take on more medical responsibilities. And while bringing families into the equation is basically treated as a cost-saving measure, home care is impossible without family participation, though, as pointed out by Dr. Yamazaki on the NHK program, the main job of nurses and caregivers will be to take some of the pressure off families. On the NHK show, the woman who was dying of uterine cancer was being cared for by her elderly mother, who was occasionally relieved by a nurse.
My own mother died at home, in 2006. Though her illness was not defined until several weeks before she died (and even that definition was not entirely clear), she had been in poor health for years. More than a year before she died she moved into an assisted care facility in Florida. For the first nine months she lived in a regular apartment, doing her own chores and shopping and cooking. She still drove. After a fall, however, she was moved into the assisted care wing, and though she improved somewhat it was not enough for the doctors to approve of her going back to her apartment. Since she had no family living in Florida, her sisters and my older brother talked her into moving back to her hometown in upstate New York. She resisted at first, but was eventually convinced that being near loved ones would be better for her welfare. So she bought a small house in her hometown, but her condition deterioriated almost immediately and within five months of moving she was in and out of the hospital. Eventually it was determined she had cancer (after several tests for cancer had come back negative) and since she had signed a DNR form some years earlier it was decided that she would leave the hospital and remain at home. The hospital and her insurance company provided a hospice nurse who coordinated her care at home (some of these nurses had been visiting her on a regular basis even before her cancer was discovered), and during the last week of her life her house was almost constantly filled with friends and relatives, who would sit with her and talk. My brothers and I flew in several days before she died and were by her side when she passed. So was the nurse, who told us exactly what to expect beforehand. When it was finished she prepared the body and arranged for its removal to the funeral home, where, in accordance with my mother’s wishes, she was cremated. The whole experience was sobering and, in its own peculiar way, uplifting. After going through that process, I can understand directly why anyone would want to die at home, but my mother was lucky. She had a large family and enough money. Many people have neither.