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[Management of advanced cancer patients after discharge].

Our hospital carries the burden of providing high-level medical treatment, and at present patients who require constant attention tend to transfer to other hospitals rather than return directly home after being discharge from ours. We think, however, that the proportion of those who go directly to their homes will increase in the future. For this reason, one of our missions is to thoroughly understand the physical and social circumstances of each patient and coordinate with an area's medical community. For our patients to return home, we believe, that we are required to 1. gather sufficient information for them, 2. adjust treatment modes and gain firm control of their symptoms, 3. educate the patients' family members, 4. adjust family relationships, 5. coordinate area's medical professionals, and 6. re-adjust emergency medical services. Furthermore, because we are at the first step in the route of patients' return to their home, we need to grasp the hopes and desires of the patients once they are home. To meet these requirements, we need to know the activities in which patients can be involved at home, wishes of other members of their families and acquire information on available community resources and supporting organizations as well as thorough preparation to make such information widely known and ability to coordinate social resources and organizations.