Background: Recently, there has been a growing interest in the use of artificial hydration therapy (AHT) for patients with terminal cancer. The Japanese Society for Palliative Medicine published the guideline for AHT in 2007, and it was revised in 2013 based on the concept of cancer cachexia.
Objectives: The purpose of this study was to evaluate the effects of AHT for patients with terminal cancer having overhydration symptoms based on this revised guideline.
Methods: This is a before-and-after study. We retrospectively analyzed 121 patients, of the 523 patients with terminal cancer who were admitted during the last 4 years, who were receiving “inappropriate hydration therapy.” We performed guideline-based AHT and examined the effects on the alleviation of hydration-related symptoms, quality of life (QOL), patient satisfaction, and the feeling of benefit from AHT using a numeric rating scale, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30, satisfaction scale, and benefit scale on day 7 ± 1 compared to those at baseline.
Results: Hydration-related symptoms (nausea: 32, abdominal pain/distention: 35, peripheral edema: 42, and dyspnea: 28 cases) were significantly improved after performing guideline-based AHT (5.35 ± 1.26 4.00 ± 1.51, P = .002; 5.41 ± 1.44 4.12 ± 1.52; P = .005; 5.16 ± 1.38 3.29 ± 1.66; P < .0001; and 5.24 ± 1.22 4.21 ± 1.53, P = .002, respectively). The general QOL scores, overall satisfaction, and feeling of benefit were also significantly improved (2.67 ± 1.21 3.98 ± 1.55, P < .0001; 2.25 ± 1.35 3.48 ± 1.44, P < .0001; and 3.12 ± 1.24 4.31 ± 1.38, P = .0001, respectively).
Conclusions: An appropriate AHT could alleviate overhydration-related symptoms and improve the QOL, patient satisfaction, and feeling of benefit.
OBJECTIVES: It is unclear whether patients with non-specific dyspnoea are suitable candidates for studies investigating the effectiveness of benzodiazepines against dyspnoea. The objective of this survey was to investigate suitable subjects for studies of benzodiazepines for cancer dyspnoea.
METHODS: A nationwide questionnaire survey was conducted among 536 Japanese-certified palliative care physicians. We randomly selected 268 physicians and inquired about their approach to dyspnoea management in patients with cancer, with and without anxiety, as follows: (1) Administration of a benzodiazepine. (2) Administration or titration of an opioid. We also asked them to consider their approach in the following situations: (1) Opioid-naïve. (2) Low-to-moderate baseline opioid dose. (3) High baseline opioid dose. We assessed the use of specific benzodiazepines separately.
RESULTS: Overall, 192 physicians responded to the questionnaire (71.6%). For patients without anxiety, the proportion of participants reporting that they frequently or very frequently 'administer a benzodiazepine' increased with baseline opioid dose (opioid-naïve: 5.2%, low-to-moderate: 11.5%, high: 26.0%). The proportion of participants reporting that they frequently or very frequently 'administer or titrate an opioid' decreased with baseline opioid dose (opioid-naïve: 83.3%, low-to-moderate: 73.4%, high: 41.1%). The pattern was similar for patients with anxiety, although more respondents said they prescribe benzodiazepine for these patients (naïve: 22.4%, low-to-moderate: 34.4%, high: 45.8%) and fewer prescribed an opioid. Alprazolam and lorazepam are frequently used.
CONCLUSION: Patients with anxiety or receiving a high baseline opioid dose could be potential candidates for future studies investigating the effectiveness of benzodiazepines against cancer dyspnoea.
Dementia is a major public health concern in ageing societies. Although the population of Japan is among the most aged worldwide, long-term trends in the place of death (PoD) among patients with dementia is unknown. In this Japanese nationwide observational study, we analysed trends in PoD using the data of patients with dementia who were aged =65 years and died during 1999–2016. Trends in the crude death rates and PoD frequencies were analysed using the Joinpoint regression model. Changes in these trends were assessed using the Joinpoint regression analysis in which significant change points, the annual percentage change (APC) and average APCs (AAPC) in hospitals, homes, or nursing homes were estimated. During 1999–2016, the number of deaths among patients with dementia increased from 3,235 to 23,757 (total: 182,000). A trend analysis revealed increased mortality rates, with an AAPC of 8.2% among men and 9.3% among women. Most patients with dementia died in the hospital, although the prevalence of hospital deaths decreased (AAPC: -1.0%). Moreover, the prevalence of nursing home deaths increased (AAPC: 5.6%), whereas the prevalence of home deaths decreased (AAPC: -5.8%). These findings support a reconsideration of the end-of-life care provided to patients with dementia.
OBJECTIVE: To describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents.
STUDY DESIGN: A self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding.
RESULTS: At 76% of facilities, withdrawing intensive care treatments was "never" done, while withholding intensive care had been done "sometimes" or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to "sometimes" (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing "everything possible" or providing the "maximum of intensive care". Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments.
CONCLUSION: Among NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been "sometimes" withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.
AIMS: To investigate the end-of-life nursing-care practice process in long-term care settings for older adults in Japan.
DESIGN: A qualitative study based on grounded theory developed by Corbin and Strauss.
METHODS: Sampling, interviewing and analysis were performed cyclically, with results for each stage used as the basis for data collection and next-stage analysis decisions. Semi-structured interviews were conducted from March 2015 - March 2019 with 22 nurses from eight long-term care settings. Analysis was performed using coding, constant comparison and emerging categories.
RESULTS: The core category, "guiding the rebuilt care community to assist the dying resident" comprised five categories: "assessing the resident's stage," "harmonizing care with the dying process," "rebuilding a care community," "helping community members care for the resident," and "encouraging community members to give meaning." The participants were the integral members of the care community, as well as guides who helped and encouraged the community.
CONCLUSION: Results revealed the holistic process of end-of-life nursing-care practice in Japan. Nurses aimed to allow long-term care residents to die as social human beings. Such practice requires nursing expertise, health-care skills and leadership qualities to build and serve care communities. Nurses must also consider residents' uncertainties and vulnerabilities as well as their cultural backgrounds.
BACKGROUND: No study has yet been performed on the importance of the rate of pure "attended deaths at home," excluding examined deaths subjected to a postmortem examination. Therefore, in the present study, we investigated actual state of pure "attended deaths at home," in order to provide reference data for the future development of end-of-life care at home.
METHODS: We performed a detailed survey in Yokohama City according to the type of death, age, and underlying cause of death in cases of home deaths, based on the detailed version of the Vital Statistics Survey Death Forms. Then, we divided deaths occurring in each municipality in Kanagawa Prefecture into two categories: "examined deaths" or "attended deaths," which were also stratified by the place of death, based on the Vital Statistics, and data on number of death cases subjected to postmortem examination from the Kanagawa Prefectural Police Headquarters.
RESULTS: In 2013, the survey in Yokohama City showed large differences in age distribution and cause of death between examined and attended deaths. In 2014, home deaths accounted for 15.7% of all deaths in the prefecture, whereas the overall proportion of attended deaths at home was 6.9%.
CONCLUSIONS: We should utilize the rate of pure "attended deaths at home" for objective outcome indicator.
OBJECTIVES: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out--of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome.
DESIGN: Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE).
SETTING: Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older.
PARTICIPANTS: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics.
RESULTS AND MEASUREMENTS: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the “appropriate” subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the “uncertain” subgroup, and 2 of 107 (1.9%) in the “inappropriate” subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms.
CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms.
verall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate.
CONCLUSION: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts.
AIM: The purpose of the present study was to clarify the current state of awareness-raising activities to educate residents about decision-making regarding end-of-life care using a nationwide survey of municipalities in Japan.
METHODS: A cross-sectional questionnaire-based survey of all municipalities in Japan (n = 1741) was carried out. We asked one representative from each municipality whether or not there were ongoing municipality-led activities to raise awareness and educate the community about end-of-life care decisions. A logistic regression analysis was carried out to examine the regional characteristics associated with running municipality-led awareness-raising activities. Additionally, we investigated the creation and contents of awareness-raising materials targeting residents.
RESULTS: The questionnaire was completed by 1145 municipalities (valid response rate 65.8%). We found that 39.4% of the municipalities surveyed were currently running or planning activities about end-of-life care. Municipalities with active public awareness campaigns had a significantly higher financial capability index than inactive municipalities. Awareness-raising materials targeting residents were created in 134 of the municipalities. The most frequently mentioned components of the materials were the importance of articulating one's intentions with regard to end-of-life care services in advance, sharing those feelings with the family and revisiting them repeatedly (73.9%), and the explanation of home healthcare and long-term care services (47.7%).
CONCLUSIONS: The present findings suggest that cities with tight budgets are unable to carry out activities to raise awareness and educate residents about end-of-life care. Thus, it is important to pursue the implementation of further national-level initiatives and funding support for municipalities.
The identification of death is critical for epidemiological research. Despite recent developments in health insurance claims databases, the quality of death information in claims is not guaranteed because health insurance claims are collected primarily for reimbursement. We aimed to examine the usefulness and limitations of death information in claims data and to examine methods for improving the quality of death information for aged persons.
We used health insurance claims data and enrollment data (as the gold standard) from September 2012 through August 2015 for nondependent persons aged 65–74 years enrolled in Japanese workplace health insurance. Overall, 3,710,538 insured persons were registered in the database during the study period. We analyzed 45,441 eligible persons. Inpatient and outpatient deaths were identified from the discharge/disease status in the claims, with sensitivities of 94.3% and 47.4%, specificities of 98.5% and 99.9%, and PPVs of 96.3% and 95.7%, respectively, using enrollment data as the gold standard. For outpatients, death defined as a combination of disease status and charge data for terminal care still indicated low sensitivity (54.7%).
The validity of death information in inpatient claims was high, suggesting its potential usefulness for identifying death. However, given the low sensitivity for outpatient deaths, the use of death information obtained solely from records in outpatient claims is not recommended.
Aim: To assess factors associated with home deaths in non-cancer elderly patients receiving home medical care by general practitioners.
Methods: A retrospective observational study was carried out in a primary care clinic in Tokyo. Patients who received home medical care and died between January 2010 and September 2017 were included in the analysis. Data from 119 non-cancer patients aged =65 years were collected between September and December 2017 using medical records. Patient characteristics, comorbidities, cognitive impairment, duration of home medical care, number of household members, patient's relationship with their primary caregiver, use of home care nursing services, and patient and family preference on place of death were obtained as independent variables. The main outcome was the place of death.
Results: Among the analyzed patients, 59.7% had impaired cognition and 47.1% expressed a preference for place of death. Patient–family congruence on the preferred place of death was 57.1% (kappa coefficient 0.39). Multivariate analysis showed that family preference for home death (adjusted odds ratio [aOR] 137.0, 95% CI 13.0–1443.8), cognitive impairment (aOR 4.26, 95% CI 1.12–16.2), death by non-infectious diseases (aOR 13.7, 95% CI 2.50–74.7) and living with more than two family members (aOR 4.79, 95%CI 1.38–16.7) were significantly associated with home deaths.
Conclusions: Family preference, rather than patient preference, was a facilitating factor for home death among non-cancer older patients receiving home medical care. As many patients receiving home medical care have impaired cognition, early end-of-life discussions with patients and decision-making support for caregivers should be promoted to realize their preferences on place of death.
Objectives: Pre-emptive conversations (PCs) about end-of-life (EOL) preferences are beneficial for both elderly people and their families to understand and share the preferences. However, the factors which promote/inhibit PCs have yet to be clarified. We therefore aimed to determine the factors related to having PCs with hypothesis that age, subjective economic status and subjective health status are associated with having PC experience.
Design: A cross-sectional study administering a questionnaire and using stratified random sampling by gender and region.
Setting: Residents aged 65 years or older who were not receiving nursing care as of 1 November 2016, were extracted from the Japanese long-term care insurance system registry in Koriyama City, Fukushima Prefecture, Japan.
Participants: 1575 participants (717 males and 858 females).
Outcome: Presence or absence of PC experience with family or friends (yes/no).
Results: The mean age of the participants was 74.0 years. A multivariable logistic-regression analysis revealed that having PC experience was significantly associated with gender (OR=1.907; 95% CI=1.556 to 2.337; p<0.001), subjective economic status (OR=0.832; 95% CI=0.716 to 0.966; p=0.016) and subjective happiness (OR=0.926; 95% CI=0.880 to 0.973; p=0.003).
Conclusions: Poor subjective economic status of elderly people may result in the absence of EOL conversation experience with their families and friends, hindering the elderly from sharing and understanding the EOL preferences. To promote PCs about EOL, gerontology and public health professionals should give special consideration to the subjective economic status of elderly people.
Background: The number of hospital-based palliative care consultation teams (PCCTs) has increased in Japan, and quality improvement (QI) of PCCTs is an issue. The Japanese Society for Palliative Medicine is building a framework for continuous QI of PCCT activities.
Objective: The objective of this study was to develop a program to support QI for PCCTs, and to describe the initial experience with the program.
Design: The report details the development of a self-check program, followed by a one-year follow-up observational survey.
Methods: We developed a self-check program using the concept of the Plan-Do-Check-Act (PDCA) cycle and a multidisciplinary expert panel. A total of 114 PCCTs entered the program in the first year.
Results: We developed three forms for the CHECK, ACT-PLAN, and DO phases aligned with the PDCA cycle. The forms consisted of 34 items across 8 domains. A total of 83 PCCTs (729 members) returned the CHECK, ACT-PLAN forms, and 41 PCCTs returned the DO forms after one year. Overall, 213 high priority issues were identified in the ACT phase. The issues of many PCCTs were "Sharing goals of care is inadequate within the PCCT (33%)" and "Sharing goals of care is inadequate between patient/family or primary team and the PCCT (28%)." Improvements in identified issues were: "achieved" 23% and "almost achieved" 48% after one year.
Conclusions: We developed a self-check program to support QI efforts for hospital-based PCCTs. The priority issues among PCCTs and improvement goals with examples were identified. These results will support ongoing efforts to develop a continuous improvement model for QI of PCCTs.
Objective: This study aimed to clarify visiting nurses' perspectives on critical practices to ensure they could advocate for patients who prefer to die at home.
Methods: Sixteen nurses, working at home-visit nursing agencies in Japan, participated in this study. Data were generated by interviews with the nurses and participant observations from nursing home-visits for six end-of-life cancer patients and were analyzed using content analysis.
Results: Five themes emerged: (1) nursing assessment, (2) support for comfortable daily life of the patient and their family, (3) advocating for the patient's views about continuing homecare until death, (4) supporting the patient's preparedness for death, and (5) coordination with other health professionals and related facilities for a comfortable environment for the patient. In addition, the nurses sometimes used humorous responses to death-related work to change the patient's melancholy thoughts.
Conclusion: The present study found that the participants advocated for the patient's views about continuing homecare until death while coordinating views between the patient and their family; they further supported the patient's daily life while helping them prepare for death to achieve their wish for death at home. In addition, our study uncovered the visiting nurses' unconscious practical wisdom of using humorous responses to death-related work to alleviate the patients' feelings of hopelessness. To develop practical wisdom for using humor effectively in end-of-life care, nurses need to verbalize unconscious practices, and accumulate empirical knowledge about nursing interventions using humor, including cultural attitudes, through case study analysis.
The current study examined Posttraumatic Growth (PTG) experienced by bereaved pet owners in the United States, French-Canada, Japan, and Hong Kong following the death of their pet. Using qualitative methodology, we analyzed responses of participants who answered “yes” to a question about experiencing PTG and explored to what extent the cross-cultural responses mapped onto the five factors of the Posttraumatic Growth Inventory (PTGI). For the U.S. sample, 58% of responses mapped onto the PTGI. For French-Canada, 72% of responses mapped onto the PTGI. For Japan, 50% of responses mapped onto the PTGI and for Hong Kong, 39% of responses mapped onto the PTGI. We also explored emergent categories related to PTG for individuals who have lost a pet and discerned the unique aspects for PTG across cultures.
Le Catalogue de la mort est une exploration décomplexée de la dernière grande étape de notre existence : la mort. Dans cet ouvrage à la fois drôle et érudit, Bunpei Yorifuji aborde tous les aspects imaginables du « passage vers l’au-delà » : où meurt-on le plus ? De quelles causes ? Qui vit le plus longtemps ? Quelles sont les cultures où l’on craint le plus la mort et comment la représentent-ils ? Quelles sont les meilleures (et pires) façons de mourir ? Bref : qu’est-ce que la mort ?
À cette interrogation naïve, l’auteur répond comme à son habitude en texte et en image, mêlant dessins humoristiques, anecdotes et recherches approfondies. Fort d’une culture japonaise où ce sujet est appréhendé sans tabou, Bunpei Yorifuji s’adresse dans cet ouvrage autant aux adultes qu’aux plus jeunes. Un livre à mettre entre les mains de toutes celles et ceux qui cherchent à aborder avec finesse et humour le thème de la mort.
Background: Use of patient-reported outcome measures in routine clinical practice has important benefits for patients with cancer. To examine the effect of a self-monitoring quality of life (QOL) intervention on global QOL and
physical and emotional function in patients with cancer receiving palliative care.
Methods: Prospective randomized study had been undertaken at Toshima Hospital, Japan. This study compared an intervention group that completed the shortened Care Notebook booklet versus a control group that received usual care. The primary outcome was global QOL and secondary outcomes were physical and emotional function. Participants completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative at baseline, and at 1 and 3 weeks. The effects of the intervention were evaluated with a linear mixed-effects model.
Results: Forty-three patients were randomized. One patient in each group could not receive the allocated intervention, leaving 41 patients for inclusion in the modified intention-to-treat (ITT) analysis for the primary outcome. Twenty-seven patients were analyzed for the secondary outcomes using per protocol set (PPS). The ITT analysis showed no significant overall effect on global QOL (P=0.285), but the PPS analysis showed a significant overall effect on global QOL (P=0.034) and physical function (P=0.047) for group difference over time in the linear mixed-effects model.
Conclusions: Use of the Care Notebook might have beneficial effects. The results could be interpreted as the effectiveness of the intervention of the Care Notebook for with cancer receiving palliative care.
Saving lives is the first priority in emergency departments. However, it is important to provide end-of-life care (EOLC) for patients and their families in these departments when the patient's life cannot be saved. Existing work reporting the obstacles and difficulties of nursing practice has found that the perceptions of nurses who provide EOLC include distress and conflict. The primary aims of this study were (i) to clarify the structure of the conflict experienced by nurses providing EOLC in emergency departments and (ii) to explore factors influencing this experience of conflict. A questionnaire survey was conducted among nurses working in emergency departments in Japan. The participants were sampled using a random sampling design. In total, 290 (55.3%) nurses responded to the survey and 288 (55.0%) responses were usable for the analysis. Seven components comprising 31 items were identified: (1) conflict about ability to practice EOLC; (2) conflict about relationships with the medical team; (3) conflict about the environment for EOLC; (4) conflict about decision making; (5) conflict about family nursing; (6) conflict about patients' pain; and (7) conflict about medical limitations. The nurses' individual backgrounds and support systems were found to influence their experience of conflict. To support nurses providing EOLC in emergency departments, we need to understand the conflict they experience, including how their backgrounds affect this experience, and construct a system that incorporates support from the specialized field of EOLC.
Objectives: To assess the association between receiving the certified care workers’ home care service, which is provided by non-medical professionals prior to a patients’ death and the probability of a home death.
Design: Observational research using the full-time translated number of certified care workers providing home care service per member of the population aged 65 or above, during the year prior to patient’s death per municipality as an instrumental variable.
Setting:: The certified care workers’ home care service covered by the public long-term care insurance (LTCI) system in Japan.
articipants In total, 1 613 391 LTCI beneficiaries aged 65 or above who passed away, except by an external cause of death, between January 2010 and December 2013 were included in the analysis.
Primary outcome measures: Death at home or death at other places, including hospitals, nursing homes and clinics with beds.
Results: Out of all participants, 173 498 (10.8%) died at home. The number of patients who used the certified care workers’ home care service more than once per each month during 1, 2 or 3 months prior to the month of death numbered 213 848, 176 686 and 155 716, respectively. This was associated with an increased probability of death at home by 9.1% points (95% CI 2.9 to 15.3), 10.5% points (3.3 to 17.6) and 11.4% points (3.6 to 19.2), respectively.
Conclusions: The use of the certified care workers’ home care service prior to death was associated with the increased probability of a home death.
La première partie présente les sources de cette étude... La deuxième expose le système d'analyse des données. La troisième dresse une typologie des caractères finaux des noms bouddhistes donnés aux foetus et aux enfants de façon posthume, tandis que la quatrième analyse le type de ces termes finaux bouddhistes employés pour nommer les foetus et les enfants mort-nés. La cinquième partie explique les relations qu'entretient l'âge au décès avec les choix des caractères finaux des noms bouddhistes posthumes et la dernière partie présente les lois et réglementations qui régissent les enterrements.
This study developed an end-of-life (EOL) care nursing knowledge scale for Japanese geriatric nurses (ELNKS-JG) to measure nurse knowledge of EOL care for older adults. It also was used to evaluate the quality of The End-of-Life Nursing Education Consortium–Japan Geriatric. Participants were 1168 nurses employed in 32 institutions across Japan. The items of our measure were developed to cover 8 important topics: principles of EOL care for older adults; pain management; symptom management; ethics of care; cultural and spiritual considerations; communication; loss, grief, and bereavement; and caring for final days. The measure included 51 items with an overall Cronbach a coefficient of 0.87 and an intraclass correlation coefficient of 0.81. Our measure, the ELNKS-JG, was confirmed to have good internal consistency, test-retest reliability, content validity, and known-groups validity. This scale’s items included knowledge about noncancerous diseases, physical changes due to aging, family care, and multidisciplinary collaboration. The ELNKS-JG comprehensively measures a nurse’s knowledge of EOL care for older adults in any EOL setting. Furthermore, this scale can evaluate educational programs aimed at improving care quality and encouraging related activities in facilities that provide EOL care.