By Mizuta Tetsuaki, the director of Yoshikawa Chuo Hospital,member of Matsudo Church, Chiba Subdistrict, Tokyo District
During the first half of the 1960s, 80 percent of Japanese people died at home, but since then the number of people dying in hospitals has increased so that deaths occurring at home decreased to a mere 14.4 percent in 2005. However, following the establishment of the medical clinical support system in 2006, the ratio of deaths occurring at home have increased and in 2009 became 16 percent of all deaths. In particular, it is reported that 60 percent of cancer patients opt to die at home. In relation to that, we would like to introduce one example of home hospice care by a Christian doctor, Mizuta Tetsuaki.
In October 2007 Mariko (a pseudonym), age 47, had surgery following the diagnosis of advanced rectal cancer. Therapy to prevent the recurrence of cancer was begun, but the following year it did recur. Outpatient treatment continued, but in July 2009 her condition worsened, and she was hospitalized. Her condition was thoroughly explained to her and to her mother, and as a result of their discussion together, Mariko chose to begin hospice care at her home from July 23. Mariko did not profess any particular faith, but when she was discharged from the hospital I prayed for her, with her consent, and gave a written copy of the prayer. She responded with words of gratitude. After that, with each house call a prayer was written, and after the prayer was offered, it was given to her and accepted.
In addition, during the first house visit, we exchanged mobile phone email addresses. When a report of Mariko’s medication condition was received from the visiting nurse, Mariko was quickly contacted by email, with words such as “May God protect your body and your heart. I do not need a reply. When you are experiencing difficulties, even in the middle of the night, please call me at any time or send me an email”; “We are always with you! Trust in God’s love, living each day with care, and let’s live together”; ”Always praying for you!” In the case of patients with terminal cancer, the visiting nurse is on call 24 hours a day, and the program is structured so that she can call whenever there is an emergency. During one visit, I gave Mariko an "angel" music box to celebrate her birthday. She responded with gratitude.
One of the principles of home hospice care is that, to the extent possible, no restrictions are placed on the patient’s normal life. With the passing of time, Mariko’s physical condition worsened, and a report was received disclosing Mariko’s feeling: “I want to die quickly!” Along with giving palliative care, I asked the visiting nurse to tell her that I had prayed, asking God to take away Mariko’s pain.The other aspects of hospice care are for the family: meeting with them, and when the cancer advances and the patient reaches his or her limit, the family is told that death will soon occur. It is important to help the family understand and be able to accept that the death of the patient is a natural occurrence. This is one area of care for the family and is called "death education." Mariko entered into eternal sleep on the morning of Aug. 13, with all her family at her beside. Three months later, I visited her mother in her home to console her. Bringing consolation to relatives is also part of the work of hospice care and is called "grief care."
Looking back at the experience of this home hospice care, Dr. Mizuta shared the following remarks.
This hospice care is bringing faith to the fore in mental health care. The patient is contacted directly by email. The hospice care given this time was a bit different from a typical one, though basically the same, with religious faith being included in mental care and frequent and direct communication with the patient through email. I think the exchange of email, as a sure means of communication, gave Mariko a sense of security. Depending on the situation, that can be thought of as a very helpful means of care. Prayers were prayed for Mariko in front of her, and the emails also spoke of faith with colorful words. She remembered that with joy, and I think it surely gave her courage and comfort. However, I have doubts about my own words; perhaps I blocked her from really being able to express her true self and by so doing to have a peaceful heart. Mariko shared with the visiting nurse the 'fear of death' that she was not able to tell me about, and received a hearing. By lending an ear to what the patient says, the visiting nurse gives valuable care, I think.
In approximately her last month of home care, Mariko felt stress related to her consciousness of death. I think that even in the midst of that pain, she was able to enjoy the periods when she was physically comfortable and even while experiencing fear was able to transcend it, being able to live out her own strong individual life, which had joy and pain.
Valuing the patient is an important aspect of hospice care. Good care cannot be given without emotional input. However, if the emotional input is too strong it cannot help but cause one’s judgment as a doctor to become lacking in objectivity. Maintaining emotional distance between the patient and doctor is a difficult thing.
Mariko's ability to surrender herself obediently to the support of the persons around her enabled her to live out her last moments in her own way, and beautifully. As persons face death, they frequently return to their true selves and become very beautiful people. Strengthened by that kind of posture, I want to continue from here on to do hospice work. (Tr. RT)
— Summarized by Nishio Misao, member
Suginami Church, West Tokyo District and
KNL Editorial Committee member
Based on an article in Shinto no Tomo (The Believer’s Friend)
Note: What is home hospice?
Hospice care is care that is given to patients who, at the time when there is no hope of recovery, decide to stop painful medical treatment in the desire to make the most out the remainder of their lives.
A team representing various specialty professions, in response to societal needs, brings psychological relief in relation to an illness in which a key element is pain, with the basic concept being that care encompasses not only the patient but also the family. When the place sought for medical treatment is the home, and the care providers visit there and carry out hospice care, it is called home hospice.
信仰の言葉で支えた在宅ホスピスの経験
――クリスチャン医師による臨床レポート
水田哲明（みずた てつあき）
吉川中央病院院長
松戸教会員、東京教区千葉分区
1960年代前半、日本人の自宅での死亡率は8割を占めていたが、その後病院での死亡者が増加し、2005年には在宅死亡はわずか14.4%になった。しかし、2006年に在宅療法支援診療所制度が出来てから在宅死亡率は増加し、2009年には全死亡率の16%になった。特に、がん患者の6割は在宅を希望するとの報告がある。ここに、クリスチャン医師水田哲朗さんによる在宅ホスピスの一例を紹 介する。
2007年10月に進行直腸ガンと診断されたまり子さん（仮名・43才）は手術を受け、抗がん剤治療を始めたが、翌年４月に再発。通院治療を続けたが、2009年7月に病状が悪化して入院。本人と母親に病状を詳しく説明し、いろいろ話し合った結果、本人の選択で7月23日から自宅でのホスピスケアが始まる。
まり子さんは特別な信仰は持っていない とのことだったが、退院の時、本人の承諾を得て彼女のために祈りを捧げ、祈りを書いた紙を渡した。彼女からは感謝の言葉が返ってき た。それ以後、往診の折りは祈りを書いて持っていき、祈った後それを渡すことにした。
さらに初回の往診の際、メールアドレス を交換した。訪問看護師より病状報告を受けるとすぐまり子さんにメールで対応。「あなたの身体と心を神さまが守って下さるように。返 事は要りませんよ。つらいときは、夜中でも、いつでも、電話でもメールでもしてください。」「私たちはいつもあなたと一緒にいますか らね。神様の愛を信頼し、一日一日を大切に、ご一緒に生きていきましょう」、「いつも祈っています」とも伝える。末期がん患者の場 合、訪問看護は二十四時間対応で、緊急時はいつも訪問する体制にしている。また、往診の時、まり子さんの誕生日祝いをして、天使のオ ルゴールをプレゼントした。彼女から感謝の応答があった。
在宅ホスピスの基本の一つは患者の日常 生活を出来るだけ制限しないということだ。時が進むにつれて、まり子さんの身体症状は悪化し、看護師には「早く死にたい」との気持ち を漏らしたとの報告を受ける。緩和ケアをすると共に常に神さまが彼女の苦痛を取り除いて下さることを祈っていると伝えた。
残される家族へのホスピスケアとして、 家族に会い、がんが進行して体力が限界になり、まもなく亡くなられることをお話しする。患者の死が自然の出来事であることを理解さ せ、それを受け入れられるように説明することが大切である。これは家族へのケアの一つで、死の教育と呼ばれている。まり子さんは、8月13日の朝家族に看取られて永眠された。三ヶ月後にご自宅に母親を訪問し、見舞った。遺族への慰めのためのケ アもホスピスケアの仕事の一つで、悲嘆のケアという。
この在宅ホスピスケアの体験を振り返っ て、水田医師は次のように述べている。
「今回のホスピスケアは、メンタルなケアに信仰を持ち込んだこと、患者さんとメールを通して直接、頻繁に コミュニケーションしたところが通常とやや異なってはいるが、基本的には変わっていない。
メール交換による通信手段が確保されて いたことはまり子さんに安心感を与えたと思う。場合によってはケアの手段として、役に立つと思われる。
まり子さんの前で彼女のために祈りを捧 げ、メールでも信仰に彩られた言葉を語った。彼女はこのことに喜びを覚え、心に勇気と慰めを与えられたのは間違いないと思う。しかし 彼女が本当の自分を表現すること、そしてそのことで心安らかになることを私の言葉はさえぎった疑いがある。まり子さんは私には言えな かった‘死の恐怖’を訪問看護師に訴え、聞いてもらっていた。訪問看護師が患者の言葉に耳を傾けるのは大事なケアだと思う。
在宅ケアに入ってからの最期の一ヶ月 弱、まり子さんには死を意識した緊張感があった。その苦痛の中でも身体が楽になった一時を喜んだり、怖れながらもそれを乗り切り、喜 びも悲しみもある中身の濃い命を自分らしく生きることができたと思う。
患者を大切に思うことはホスピスケアの 大切な要件である。感情移入がなければ、いいケアは提供できない。しかし、感情移入が強すぎると医師としての判断に客観性を欠くこと になりかねない。患者と医師の感情的距離感をどう保つかが難しいところだ。
まり子さんは、素直に周りの人びとの支 えに自分を委ね、終わりの時を自分らしく、美しく生きられた。人は死を前に真実のその人に戻り、とても美しくなることが多い。そうい う姿に力を与えられながら。私はこれからもホスピスを続けていきたいと思う。」
＊「在宅ホスピスとは」
ホスピスケアは、がんの治る見込みがなくなったとき、苦しい治療は止めると決断し、残る人生を自分の生 活を大切にして過ごしたいと望まれる患者さんに提供されるケアです。
痛みを主とする症状の緩和、心理的、社会的ニーズへの対応、異なる専門職種のチー ムによる対応、ケアの対象が患者のみでなく家族も含まれることなどが基本的な考え方になります。療養の場が自宅で、そこへケア提供者が訪問してホスピスケアを行う場合を在宅ホスピスといいます。（「信徒の友」要約：西尾操 杉並教会 員、KNL編集委員）
