TITLE:
Advance Care Planning Practices of Japanese Visiting Nurses for Homebound Elderly Requiring Care
AUTHORS:
Midori Furuse, Miyuki Toukairin
KEYWORDS:
Home-Visit Nurse, ACP (Advance Care Planning), Elderly Individual Requiring Care
JOURNAL NAME:
Open Journal of Nursing,
Vol.15 No.12,
December
10,
2025
ABSTRACT: Objective: To clarify the ACP practices of Japanese visiting nurses for homebound elderly requiring care. Methods: Ten nurses with extensive end-of-life care experience working at Japanese visiting nursing agencies were sampled using snowball sampling. Data collection involved online semi-structured interviews. Results: The visiting nurses’ perspectives underpinning ACP included: [The presence of ACP in daily home-visit nursing care], [Understanding the patient’s wishes is also important for the family], [Seamless implementation of ACP], and [Supporting the realization of wishes through patient-centered ACP]. Furthermore, four sequential phases in decision-making support were identified in the home-visit nurses’ ACP support: decision formation, decision expression, decision-making, and decision implementation. Conclusion: Home-visit nurses repeatedly engaged in careful dialogue with elderly patients requiring care living at home, eliciting their wishes and facilitating their realization alongside families through coordination with other professionals. This suggests that, as a cornerstone of end-of-life care, home-visit nurses play a primary role in facilitating patient-centered ACP.