A pilot study of narrative approach for terminally ill cancer patient at home hospice

In these days in Japan, the number of elders is increasing rapidly and many will be die in near future. Home hospice is one of the facilities where they spend their final stage. In Japan the Ministry of Health, Labour and Welfare has recommended the expansion of equality for accessibility of care [1]. However, since home hospice has just begun rapidly in Japan, there are few a formal psychological or spiritual care.


Introduction
In these days in Japan, the number of elders is increasing rapidly and many will be die in near future. Home hospice is one of the facilities where they spend their final stage. In Japan the Ministry of Health, Labour and Welfare has recommended the expansion of equality for accessibility of care [1]. However, since home hospice has just begun rapidly in Japan, there are few a formal psychological or spiritual care.
Generally, cancer patients feel psychological problems like depression and anxiety [2], or religious and spiritual distress. Religion and spirituality are important dimensions of most patients' experiences of advanced illness [3]. One of the psychological or spiritual care is the Short-Term Life Review, in which a patient reviews his life with an interviewer. It was effective on depression, anxiety, and spiritual wellbeing [4].
However, the Short-Term Life Review is for terminally ill cancer patients of palliative care wards and conditions of home hospice is different, also it had a problem such that patients with severe past memories were hard to participate it. On the other hand, narrative approach was seemed to be much more suitable, because they could tell their life freely, not only past but also present and future. In order to start narrative approach for many participants, we needed to examine the possibility and utility of narrative approach at home hospice as a pilot study. Narrative approach is patients' subjective storytelling and try to find meaning in events, which was appeared from social constructivism. White & Epson [5] are seemed to be leading researchers. Based on the narrative approach, we prepared questions for terminally ill cancer patients at home hospice.

Methods Participant
A 60s terminally ill cancer patient who used home hospice participated in this study. The medical social worker introduced the study to him and he agreed to it voluntary. The other day, a nurse who was trained of counseling and interview visited the patient's home and started it. And the nurse recorded his narratives with an IC recorder.

Narrative approach
The Narrative approach had two sessions, about 60 minutes per one session, and the nurse with interview training interviewed with the patient individually. There were questions about: 1) "Process of the illness," 2) "Reasons of decision for home hospice and resources," 3) "Impression of home hospice," 4) "Changes or growth through this illness," 5) "Strength of you to get along with illness" 6) "Hopes for future

Abstract
In these days in Japan, the number of terminally ill cancer patients who wanted to spend time at home is increasing and development of intervention of psychological or spiritual care for them may be important. Then this study examined the possibility of narrative approach for terminally ill cancer patients at home hospice as a pilot study. A 60s male participated to this study. A nurse who received interview training visited the patient's home and she conducted narrative approach. In the narrative approach, there are some questions about 1) the process of illness, 2) the reasons of decision for home hospice, 3) impression of home hospice, 4) changes or growth through the illness, 5) strength of you to get along with illness, and 6) hope or future. His narrative was recorded and summed up qualitatively. Results showed that the patient felt like being thrown out when he was told that there was no effective treatments. Then he found a reliable physician and a medical team, he was relaxed. After the narrative approach, he recognized his social role to leave memories of him, and found meanings to live for future. These process are explained by the Maslaw's motivation theory. The narrative approach may promote recognition of safety and relax, importance of human relationships, social roles, and improve self-esteem and found meaning to live.
In the first session, a patient narrated about his life through questions asked by a nurse. In the second session, the patient and the nurse confirmed the contents of narratives, more in detail.

Ethical consideration
The ethical review board at International University of Health and Welfare, School of Nursing at Fukuoka, Fukuoka, Japan approved the study. The medical social worker explained and introduced the research to a patient. If the patient agreed to participate, the interviewer explained again about research. If the patient agree to the participation, he signed the form.

Analysis
The patient's narrative was summarized. Their words were relatively short, and therefore we did not conduct a qualitative analysis. Instead, we summarized their words. To maintain reliability and validity, researchers discussed categories to obtain agreement and asked professional researcher about palliative care to confirm this categorization.

Results
The patient completed two sessions without any problems. His narrative to the question was summed up the followings.

1)
To the question about the process of illness: The process of the illness had been continued about 2 years. He was a teacher of physiotherapist. He told his memories enjoyably.
2) To the question about the reason to decide home hospice: When he was told that there were not any medical treatments, he felt like being thrown out the world. Since he hoped to spend left time at home, he looked for home hospice. Then he found a reliable home hospice physician and a medical team. He felt relaxed.

3)
To the question about impression of home hospice: He was a teacher, and previous students who were societies come to see him. He could remember old memories with them. And he recognized his social role as a teacher. Also, he had good relationships with medical staffs. His wife took care of him tenderly. He had positive comments to home hospice.

4)
To the question about his changes: He resign to live longer and accepted his death. Then he was relaxed. He wanted to do as much as possible.

5)
To the question about his strength: He felt himself life a God. Now he had peaceful mind, not be distressed.

6)
To the question about hope for the future: He wanted to attain his social role as for future hopes.
In the second session, he talked about his thinking and changed during one week. He began to make an album by himself with photos and messages to students. Also he began to plan to do for other people. He was not so afraid of death.

Discussion
About the process of the illness, when he was informed that there were not any medical treatments, he felt like being throw out the word (Figure 1). However, he found the reliable physician and a team including nurses, medical social worker, and vising nurses. And he decided home hospice and he was relieved. Maybe he found peoples who assisted him at heart. Peplau [6] said the importance of human relationship between patients and staffs. In interaction between them, he resigned cured illness and recognized his near future death.
After the first session, the patient found his role at last stage. The patient was a teacher and wanted to leave his thinking. Students came to his home, the patient talked or consulted with him. These attainment of social role might improve his self-esteem. Maslow's [7] need theory found a reliable physician and the team, it is "safety." And next stage, he can give and get love through medical staffs, family, and students. It is "love and belonging." Moreover, he found his role to leave some kind of memories. These attainments improved self-esteem.
From his case, the narrative approach may be effective on psychology or spirituality from the followings: 1) A patient has a chance to talk and reflect his life in home hospice, 2) A patient has a chance to recognize his important human relationships around him much better than palliative care wards, 3) Narration of a patient life promote reflection, found his important things, 4) A patient have a chance to find roles in narratives, leading to improve self-esteem or meaning to live of left time.