[Primary factors for a transfer to home care]

The subjects for this study were patients in remission discharged from the Palliative Care Unit (PCU) between January 1 and December 31, 1999. There were 72 patients, which represents 22% of all discharged patients during the same period. The objective of this study was to clarify nursing intervention in the transition from admission to the PCU to the transfer to home care and primary factors in this process. The study of medical records and inquiries made of primary nurses served as methods for this. Unless patients or their families have the desire to shift to home care, the transfer is difficult. However, as a result of information provisioning and coordination through nursing intervention concerning the home care support system, the transfer to home care was possible for 22% of all discharged patients. Primary factors in the transfer to home care are that: 1. patients have the desire to shift to home care; 2. patients' families accept home care; 3. symptoms are controlled to the level sought by the patients; 4. patient's clinical process can be observed continuously by the PCU outpatient clinic; and 5. there are adequate preparations to receive patients in an emergency.