Medical care-related decision-making among patients with malignant brain tumors has not been sufficiently discussed. This study aimed to develop a framework for understanding patients’ experiences in the decision-making process. Semi-structured interviews with 14 patients were analyzed using a grounded theory approach, focusing on their 48 decision-making points. Additionally, interviews with two family members and seven healthcare providers, and participant observations were used to gain contextual insight into patients’ experiences. Patients faced decisions while they struggled in vulnerability under shock, fear, and anxiety while hoping. Under this context, they showed four decision-making patterns: (1) led by the situation, (2) controlled by others, (3) entrusted someone with the decision, and (4) myself as a decision-making agent. Across these patterns, the patients were generally satisfied with their decisions even when they did not actively participate in the process. Healthcare providers need to understand patients’ contexts and their attitudes toward yielding decision-making to others.

Objective: To clarify the education and training-related factors associated with provision of endof-life care by home-visit nursing agencies that did not calculate the medical expenses for functionenhanced home nursing management.Methods: An anonymous questionnaire was administered to 2,000 randomly selected home-visit nursing agencies throughout Japan. It asked about the facility structure, training/education factors among nurses and managers, regional and cultural difficulties in implementing end-of-life care at home, and provision of end-of-life care at home.Results: A total of 242 responses were analyzed. Logistic regression analysis was carried out, adjusting for the number of full-time equivalent nurses, the presence of an additional 24-hour response system and regional and cultural difficulties in implementing end-of-life care at home. It showed that the provision of end-of-life care at home was associated with end-of-life care training for managers (odds ratio: 4.17, 95% confidence intervals: 1.76-9.90), and support to increase the frequency of accompanied visits for nurses practicing end-of-life care at home for the first time (3.12, 1.33-7.29).Conclusion: End-of-life care at home may be promoted by providing specific training for managers and ensuring that nurses who are practicing end-of-life care at home for the first time are accompanied.受付日：2022 年 4 月 22 日 受理日：2022 年 9 月 5 日 1) 公益財団法人日本訪問看護財団 Japan Visiting Nursing Foundation 2) 東京大学大学院医学系研究科健康科学・看護学専攻高齢者在宅長期ケ

BACKGROUND: Patients with leptomeningeal metastasis (LM) have symptoms related to disease within the neuroaxis, cancer sites outside the neuroaxis and treatment toxicities. The meaning ascribed to advanced cancer has been shown to impact the perceived severity of symptoms as well as quality of life (QoL) and depression. Our aim was to explore and describe relationships among meaning of illness (MoI), depression, QoL and symptom burden in LM patients and to explore whether adding spine-related items from the MD Anderson Symptom Inventory-Spine (MDASI-SP) to the MDASI-Brain Tumor (BT) enhanced understanding of symptom burden in LM patients. METHODS: Thirty participants with LM were consented and enrolled into one of two groups: Newly-diagnosed (n=15) and on active treatment (n=15). Five items unique to the MDASI-SP were added to the MDASI-BT and the difference between the mean scores of the MDASI-BT and modified MDASI-BT was analyzed. The relationships among variables were assessed with correlational analysis. RESULTS: The sample was primarily white (73%), female (63%) with a median age of 54 years. Breast cancer was the most common primary cancer (50%) with the brain being the most common site of metastasis (23%). There were no associations between MoI and symptom burden (p=.12). Higher MoI was associated with better QoL (p<.01) and less depression (p<.01). Though there was no significant difference between the original and modified MDASI-BT (p=.33), there was a wide range of responses to the spine related items with some considered to be severe. CONCLUSION: Depressive symptoms and QoL in LM patients were related to better MoI indicating a need for further exploration. The wide range of responses to spine-related items on the modified MDASI-BT indicate the need for an instrument to measure symptoms anywhere along the neuroaxis. Longitudinal studies exploring the relationship of MoI with symptom burden may clarify non-significant associations.

We conducted a one-year survey of homecare service users aged 75 years and older. Data from 769 clients were examined. Altogether 47 (6.1%) received physical restraint at least once among the five survey points conducted over a one-year period. Among them, 27 (57.4%) received restraint only at one point, and only 2 received restraint in all five points. In the bivariate analyses, the factors associated with the use of physical restraint were: diagnosis of neurological disease, unstable general condition or terminal stage, high level of care required, medical treatment, and family burden. When those who were released from the restraint at 12 months (n=30) were compared with those who were not (n=17), not having stroke, not receiving suctioning, and not having home-visit medical care were significant factors. Physical restraints at home were not common but we must be careful when we serve clients with significant factors of prolonged restraints.