[Definition of care failure and an explanatory model of pathology of home care].

We defined and discussed care failure as a concept of failure in home care in this study.Care failure is defined as an explanatory model of the pathology of home care. In care failure, the patient and family confront on the subject of physical, psychological, socio-economic and spiritual problems simultaneously. Nursing care shortages caused by the care failure tend to get worsen if the vicious cycle is neglected. With minimal family-care capacity, home care easily results in care failure. We need, not only medical care but also an enhancement of nursing-care capacity for the treatment and prevention of care failure.

[A case of Creutzfeldt-Jakob disease diagnosed with a combination of ER visit by the patient and a home visit by the physician].

In case of home care patient's health gets deteriorated, an admission is often requested due to a nursing care need rather than a medical need. However, it is often inevitable to transfer a patient to other nursing home, or to observe the patient at home, is caused by a limitation of medicalre sources and the capacity of the patient to adapt environmental changes. It may be criticized that a medical care of the elderly at home is left unattended as a consequence of the oversight of critical pathophysiologic changes. We have experienced a case diagnosed as Creutzfeldt-Jakob disease, which was not suspected at the initial visit of our ER unit. A grave hidden disease was recognized by next day's emergency visit and a follow-up elaboration examination at our hospital. Such cooperation may have a potency maintaining a home medical treatment level by grasping the precise pathophysiology of home elderly patients.

[For the seamless care of home ALS patient on a mechanical ventilator--the importance of reducing the sputum].

Recently, many of the ALS patients on mechanical ventilator have been shifting to home based care from hospitals, and these ALS patients are increasing in trend. In doing a seamless transition from hospital to home based care, it is important that the burden of the family caregiver should be reduced while the patient is still in the hospital prior to discharge. We experienced one ALS patient on ventilator who could be cared at home smoothly by several measures for a reduction of sputum. The following procedural measures are thought to be efficient: 1 set the tidal volume of ventilator rather high, 2 treat the underlying lung disease for the cause of sputum increase, and 3 keep a good sleep to prevent a sputum increase in the night by the patient's body movements.

[One successful end-of-life home care handled by three physicians].

Aging population has been advancing in Ito city located in the northern part of Izu peninsula. Many elderly people are hoping to receive an end-of-life care at home, but there is no home care section in Ito municipal hospital, a flagship hospital in this region. One of the end-stage leukemia patients of our hospital hoped to die at home. We report a case that three physicians joined together to take care of this terminal patient with a cooperation from nurses, home-visit nursing care station and a care manager.

[The experiences of elderly patients' successful resumption of oral ingestion with home parenteral nutrition and multi-professional team approach].

There are many elderly patients with poor oral intake when they are hospitalized with pneumonia or urinary tract infection, and we often need to consider their proper feeding method, such as percutaneous endoscopic gastrostomy(PEG)or total parenteral nutrition(TPN). However, it is difficult to receive homecare services for patients who rely highly upon medical treatment. Meanwhile, a prolonged hospitalization is a serious social problem. Here, we report two cases of elderly patients who were able to eat because home parenteral nutrition care and seamless approach were provided by multi-professional team.

[Evaluation of the family-care capacity by a home care score and management of home care].

We report the home care score (HCS) system to evaluate the capacity of care-giving family for the purpose of smooth and stable introduction of home care. We defined the family of low caring capacity characterized by low HCS as a "marginal family (in home care)". The HCS of a "marginal family" is less than or equal to six and decline easily to less than three by the progression of the disease or the environmental change, which means "care failure", the pathological status of home care. In the cases of low HCS, we should bear in mind the existence of a "marginal family", and "care failure". The close follow-up as well as the support of the community is indispensable for home care.

[A case report of a HIV-infected patient, who was denied to return home because of his psychological complications along with hepatocellular carcinoma].

Although a social support system has been developed in recent times, some of the difficult cases which complicate serious diseases due mainly to lack of family care power, have been reported. We experienced one HIV-infected patient who suffered from hepatic carcinoma and had been taken care of at home, but he was denied to return home after hospitalization. It has been reported that the management of homecare station has become worsened and the number of stations has been decreasing in various locations. If the patients were selected by homecare stations in which the management was going from bad to worse, it would be difficult to maintain a nationwide quality of homecare system. By presenting such an extreme case in the homecare services, we propose a homecare scoring system, in consideration of homecare service limitations, which will be helpful assessing a difficult case of a patient taken care of at home.

[A case report of a patient whose sputum culture of multidrug-resistant Pseudomonas aeruginosa (MDRP) disappeared after administration of green tea by gastric tube].

It costs a lot of burden to take care of MDRP carriers at home as well as preventing MDRP transmission to caregivers. It is reported that epigallocatechin gallate (EGCG), the most abundant chemical contained in tea catechin, is chemically similar to trimethoprim (TMP) and inhibits S. maltophilia growth by antifolate acitivity. In this report, we present a case of a patient, whose sputum culture of MDRP disappeared after a green tea administration by gastric tube. We thought that catechin escaped from a drug efflux mechanism(s) of MDRP and could act on its growth.

[Three elderly patient cases maintained by home hypodermoclysis--a practical hydrating method performed by family members].

Hypodermoclysis, the subcutaneous infusion of fluids, has been reevaluated as a useful hydration technique for elderly patients. In the care of end-of-life elderly patients who are unable to take adequate fluids orally, hypodermoclysis is a less stressful means for patients and family than an intravenous hydration. Further more, it shortens the duration of hospitalization. We report three cases of patients who could remain at home stably for a relatively long period of time because of hypodermoclysis administered by family members.

Femoral tunneled central venous catheters for terminally ill patients with cancer.

BACKGROUND: Oral administration of medication is often difficult in terminally ill patients with cancer. These patients require intravenous routes for high-dose opioid administration and/or parenteral nutrition. When the superior vena cava (SVC) is unsuitable for central vein catheter insertion (i.e., in patients with mediastinal masses involving the SVC), alternative access routes are needed. Of these, the femoral vein is most utilized. In our experience, the femoral tunneled catheter (FTC) is easy and safe to use. We retrospectively studied FTC outcomes in terminally ill patients with cancer. MATERIALS AND METHODS: Charts of consecutive patients admitted to the palliative care unit between April 2008 and December 2011 were reviewed. FTC is inserted into the vein by the single-puncture method using a 16-gauge catheter with a 14-gauge peel-away introducer. RESULTS: Eleven patients underwent FTC insertion. In total, there were 207 days of FTC placement; the mean period in place was 19±15 days. Eight patients received parenteral opioid therapy, high doses in four cases, via FTCs. Complications were incidental arterial puncture and poor infusion rate due to hip joint bending in one case each. Neither catheter-related infection nor clinical venous thrombosis occurred. CONCLUSIONS: FTCs were successfully inserted, with a low complication rate. FTC, a simple technique, might be an acceptable alternative in selected terminally ill patients with cancer, when SVC insertion is difficult or contraindicated.