Support through treating the discomfort that accompanies aging is the home medical care of the aging society

In the 20th century, the basic viewpoint was to cure disease by medical care. However, physical problems caused by phenomena of aging are not always curable. Aside from the obvious chronical diseases such as diabetes and high blood pressure, there are many physical disorders accompanying aging, such as cartilage of the neck, lower back, or knees becoming worn out and causing pain, or limbs becoming numb. Medical care in the aging society tries to maintain the quality of daily life by alleviating the discomfort while acknowledging these problems. In other words, not only medical care for curing disease, but also medical care for supporting as well as curing is the home medical care of the 21st century.

Home medical care in Japan started from a project that was carried out for patients with intractable diseases in the middle of 1980s by the Tokyo metropolitan government. In the 1990s, the movement to prepare for the home medical care system advanced, and in the 2000s, the long-term care insurance system started. In the 2010s, the legal system regarding home care in local medical care matured in an attempt to prepare for the 2025 problem.

It is considered that there are two aspects to the reason why the government started to promote home medical care. One aspect of the reason is half diplomatic, half honest. They say that, unlike receiving treatment in hospitals, home medical care has benefits that are irreplaceable. Another aspect of the reason is entirely honest. It is the reduction of medical care expenses.

The origin of the medical care expense issue is the free medical care system for the elderly, which was set out in 1973 by then Prime Minister Kakuei Tanaka. By making patients’ share of medical costs free for those of 70 years of age or older, elderly people started to visit hospitals every day for their incurable pain of lower back and shoulders, or a little discomfort in the stomach, etc. Unscrupulous hospitals started to take advantage of the system and hospitalize more patients than their maximum capacity. This system was abolished within about 10 years. However, as a result, this led to today’s deficit of social security expenses.

Aiming to reduce medical costs, the Japanese government established the medical fee schedule system, so that the profit of medical institutions would decrease by extending the hospitalization period. However, there may be quite a few households that are not able to take care of elderly people with dementia, etc. at home. Home medical care includes care at facilities for elderly people such as geriatric health services facilities and fee-based nursing homes. However, if they cannot find the next facility to move to, although it is desirable that the elderly people continue to be hospitalized there, they will end up being discharged. Being passed around hospitals is not necessarily done in accordance with the wishes of patients or their family members, and this is becoming a major challenge.

Ultimate goal of home medical care is to support a person’s life true to his/herself as much as possible

As I mentioned before that there are irreplaceable benefits, home medical care has many unique advantages. Wouldn’t you be relieved to get back home? Hospitals are something out of the ordinary, while in home medical care, medical care will come to you in the ordinary life. This is the most different point. In hospitals, you cannot read books and watch DVDs whenever you like, while at home you are not constrained. Moreover, you are able to play a role as a family member at home. For example, you can freely talk about delicate topics that are hard to discuss when surrounded by other people, such as career guidance for children and family issues.

On the other hand, one of the disadvantages is that it is burdensome for the family members. Additionally, if conditions of patients suddenly change, while in a hospital nurses can immediately rush to them, at home, it takes some time before they arrive after calling 119. Furthermore, care equipment such as beds and space to take care need to be prepared. In some cases, refurbishment such as attaching handrails and removing level differences may be necessary.

Ultimate goal of home medical care is to continue to support a person’s life true to his/herself as much as possible. To do that, there are two things that we need to keep in mind.

One is to be empathetic towards the feelings of care recipients. What they think is important, what they value, and what they focus on should be respected. In any case, home care is a lot of work. When issues like dementia are further added to that, it becomes tough for those involved, and they might take it out on care recipients at home. As this might lead to abuse, caution is needed.

Another is to cherish family members who give care. While the burden is considerable, there are quite a few cases in which one person takes on all the burden. The collapse of home medical care starts from putting all the burden on one person. It is important to cherish the caregivers as well as the care recipients.

Furthermore, home medical care eventually leads to the issue of end-of-life care. As a precaution, when someone dies, people should not throw their arms around them or move the body.

Legally, only a medical doctor can judge whether the person is dead. It is allowed after checking the cause of death. However, under the law, if people touch the body, the body will be treated as an unnatural corpse, or in other words, a corpse of unknown cause of death. The police will start investigating the situation under the assumption that touching or moving may have caused the death. In some cases, an autopsy will be conducted to prove that there was no foul play, and only after that, the body will be returned to the family, and a notification of death can be submitted.

From a different perspective, the family members are suspected of committing a crime. The major problem here is that the psychological state immediately after the death of the loved one is not taken into account. I think that the law itself should change.

Legislation regarding issues revolving around emergency transport of elderly people who do not want cardiopulmonary resuscitation is also necessary

Another issue related to home medical care is emergency transport of elderly people who do not want cardiopulmonary resuscitation.

When the condition of an elderly person with a disease suddenly changes, there may be a situation where the doctor and nurse in charge and the care manager, along with the family members, know that the person would not live much longer even if resuscitation measures were taken. Based on this, suppose that they had already signed an agreement not to undergo excessive resuscitation measures and to be allowed to pass away. However, in reality, when the person is about to stop breathing, the family members may call 119 frantically.

Even if they were prepared for the moment in advance, it is human nature to make such a call, thinking “not yet.” Can people remain so strong and not call an ambulance even if they know that the person will die? I myself could not, and even if someone is confident to do so, you never know in the actual situation. So, we need to consider what the emergency medical team should do when they are called.

The emergency medical team’s job is to rush to sites and bring people who asked for help to hospital. However, upon their arrival, if opinions among the family members were divided and they were kept waiting, an ambulance cannot be used. Still, if the team takes the patient away without permission, the family will ask why the team took the patient away. This could lead to a court case. If the emergency medical team had to wait for a conclusion at the site, they may feel conflicted, thinking “if we leave now, we could go and help another person.” Such cases are actually happening.

Tokyo Fire Department set up a committee and they are working on establishment of guidelines for actions such as contacting the home doctor, etc. I also participated in the committee as a member and was asked to share my views from a legal perspective. To emergency medical team members who faced the situation, I conveyed that their roles were fulfilled as they made an opportunity and time for the family to be prepared to say good bye. If they do not understand and come to terms with it, they will also become worn out. This is a problem that will further increase from now on. “An emergency medical team does not need to bear responsibility if it handles the situation like this.” Such a guidance system should be established nationwide.

Home medical care and related issues should be seriously considered by the caregiver and the care recipient, rather than being seen as someone else’s problem. Before it starts collapsing, some measures should be taken. First of all, it is important to notice that there is a problem. Whatever you do, end-of-life homecare often comes with some regrets in the end. We should not think that we can be perfect, even if we try our best. That is why all of us should think about how we should do it, even if there is no perfect answer.

* The information contained herein is current as of December 2024.
* The contents of articles on Meiji.net are based on the personal ideas and opinions of the author and do not indicate the official opinion of Meiji University.
* I work to achieve SDGs related to the educational and research themes that I am currently engaged in.

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