In these days psychotherapeutic intervention is important in the view of the rising prevalence and mortality rates from cancer and other non-communicable diseases, largely due to the ageing of the world’ population  . These people feel various kind of suffering like anxiety or depression, and one of the most serious is psycho-existential suffering, which is also called spiritual pain. One of the origins of this pain is the perceived loss of a future  . Spiritual pain consists of loss of meaning of life or loss of peace in mind.
For this suffering, there are various mental or psychotherapeutic interventions such as cognitive behavior therapy  or meaning-center group psychotherapy  for advance cancer patients. Though there are useful, terminally ill cancer patients sometimes may be hard to participate in group or formal counseling session. A life review interview was effective for spiritual pain or psychological distress  of terminally ill patients; however some patients did not hope to review their memories and some had severe past memories. To integrate sweet memories and severe memories of patients require professional skills for counseling for nurses. To propose psychological care by nurses, we need to develop another one.
A narrative approach was another useful psychotherapy which includes narrative theory. White and Epson demonstrated a narrative therapy  . It comes from social constructivism, and the meaning emerged from narratives between an interviewer and an interviewee. Narrative is an important way of constructing meaning  , and people create meaning of illness, suffering, and death through narrative, by telling a story   . A narrative approach was seemed to be suitable intervention for terminally ill patients to construct meaning.
Regarding narrative research, many are case studies. In this condition, Bronna, et al.  discussed the process of meaning construction, and Stanley and Hurst  showed a method of building empathy. Qualitative analyses of narratives at the end of life are very few; Tait, et al.  conducted Dignity therapy in which patients narrated their lives for legacy. Qualitative analyses were conducted by physicians who found three types: Evaluation narrative, Transition narrative, and Legacy narratives.
The above studies were almost entirely conducted in hospitals or palliative care wards, not at home hospice. And most of the interviewers were conducted by psychologists, physicians, social workers, and so on, not nurses. In the near future, the number of patients who spend time at home at the end of life, and the number of visiting nurses who take care of them in home hospice will increase and psychotherapeutic intervention by nurses will be required. Then we conducted a narrative approach by nurses for terminally ill patients in home hospice, analyzed the contents of the narrative to understand patients’ subjective thinking and feeling, and created a program for nurses to conduct in home hospice.
Participants: We attempted to recruit 12 patients, two declined to participate, and 10 participated. They were patients in three kinds of clinics in Japan (Table 1). The mean age was 68.9 years old. The participants had various primary diseases, and a Performance Status (PS)  from 2 to 4. The stage of cancer was “4” or recurrence. The inclusion criteria were terminally ill patients who used home hospice, were aged ≥ 20 years old, and had physical strength to talk about 60 minutes. The exclusion criteria were patients with cognitive impairment or serious mental illness.
Procedure: The following is the recruit method. The primary physician introduced the study to a patient who met the inclusion criteria. Patients who showed interest were registered and the researchers sent a letter about the research. After sending a letter, the researcher explained the details of the study to the candidate by telephone. If he or she agreed to participate, they decided the place and time for an interview. The interviewer visited a patient’s home or a clinic, and explained about the research again, and received informed consent after agreement for participation.
In the Narrative approach, there were two sessions. We prepared some question referring to previous studies to promote patients’ narrative   .
In the first session, there were the following questions, 1) How did you live before your illness? 2) How did you live after becoming ill? 3) What are difficulties in your life in home hospice, and how do you cope with them? 4) What are good thing in your life in home hospice? In the second session, the following questions were asked, 5) What were the changes after getting your illness? 6) What are the most important things in your life? 7) How do you think of your life? and 8) What is your hope in the future? With participants’ permission, their narrative was recorded on IC recorders. Before the first session and after the second session, the participants completed questionnaires. Each session lasted about 60 minutes. They completed some psychological questionnaires; these quantitative results are reported in another occasion. This study was approved by the ethical boards of St. Mary’s College.
Table 1. Patient background.
M: Male, F: Female, R: recurrence.
Analysis: We conducted qualitative analysis. For narrative data, we employed “qualitative analysis” by Funashima  based on the work of Berelson  which involves creating codes, subcategories and categories. These narratives were edited into the shortest statement without losing meaning and coded into one subcategory along with similar statements. Similar subcategories were then integrated into one category. To maintain reliability, categorization and coding were validated independently by researchers. Inconsistencies were discussed and negotiated until agreement was reached.
We recruited 12 patients, two withdrew because of their physical condition, and 10 participated.
We indicate a category as “ ” and the subcategories as < > in this study. The life before illness was various and the life after illness including medical treatments or daily life was also various. Then we analyzed narratives without these questions. These two questions were useful to begin narrating their lives.
To the question of “What are good things in home hospice?”, we chose categories (Table 2) 1) “Being able to spend time freely” like
Table 2. Categories about good points and troubles in home hospice care.
To the question of “What are troubles for you during home treatment?”, we chose the category (Table 3) 7) “Worries about economic problems” including
To the question of “What are changes through illness inexperience?”, we chose categories (Table 4), 11) “Positive consciousness for home hospice” like
To the question of “What is important for you”, we chose categories (Table 5), 19) “Spending left time usefully”, like
Tables 3. Categories about trouble points.
Table 4. Categories about the changes through illness.
Table 5. Categories what is important for you.
To the question of “How do you feel about your life”, we chose categories (Table 6), 23) “Acceptance of own life including illness” like
To the question of “What is your hope for the future”, we chose categories (Table 7), 28) “Hope to leave my living proof” like
Table 6. Categories about what do you feel about your life?
Table 7. Categories about what are hopes for the future.
1) Acceptance process model of patients’ life in home hospice
From selected categories, we can propose a process model of patient’ life (Figure 1).
Figure 1. Acceptance process model of patient’ life.
Most patients know their disease and prognosis. Patients spend time freely and have much time with family. Greeting people can visit always. Patients have time to insight their minds or thought. They recognize important things for them. They can consult their troubles with medical staffs, although troubles are not always resolved. In receiving medical and mental care by them, they feel familiar relationships and safety. They look back their lives, recognized important things, and feel satisfaction with their lives. Then they can have hopes to future, although not so far future.
In the beginning they can’t accept their life, because their self-concept with cancer is not congruent with their ideal. However, they experience the above process like warm human relationships, caring with respect by physicians or nurses, their inconsistency between self-concept and their ideal is reduced. A home hospice proposes these conditions. Redundantly their self-concept and their ideal may congruent. This process is near the person centered approach by Rogers  . Congruency promote for patients to accept their lives with illness and have peace of mind. For Japanese, the word of acceptance is near to resignation. We need to obtain the evidence of this model.
2) Required treatments to troubles
There are some troubles in home hospice. “Worries about economic problems” is related to insurance plan in Japan. Multidisciplinary workers such as social workers can support them and will be needed much more in home hospice. About “Worries about the future of people who remain”, medical staffs need to assess the level or kinds of worries and try to resolve realistic problems. A factor of “Troubles caused by various physical symptoms” is the same trouble factor from previous studies   , although medical staffs proposed care as much as possible. Since physical symptoms affects mental or psychological problem  and medical staffs are not stay always in home hospice, explanation about them and coping methods will be needed for patients and families much more.
The factor of “Suffering from putting a burden on the people around me” is one of the factors of Good Death  . In particular, in home hospice patients feel burden about receiving care from family member. Patients, their families, and medical staffs think and talk about plan of future. A family and a patient need to talk whether they use home hospice or not. In these days, importance of Advance Care Planning (ACP) is pointed  .
3) Development of the narrative approach program
In near future, the number of visiting nurses will increase in home hospice. And they are required mental or psychological care. A narrative approach may be useful to nurses. We propose the Narrative Approach program (Table 8) at home hospice by nurses. About questions, it is easy to talk about good points and troubles in home hospice. Then they can found changes after experience illness comparing before illness and recognize important things. They rethink their lives including their illness experience and found new hopes in near future. We set the questions.
Comparing method of life review with this narrative approach, in the life review  , factors like “Good human relationships and transcendence” “achievement and satisfaction” or “Good memories” are primary concerns and related to high spiritual wellbeing. Also, “Human relationships” or “Pleasant memories” were primary concerns  . In these life review method, the question of asking past memories and good memories affected the utility of life review. However, some patients do not want to remember memories. Life review is suitable for people with good memories and with integration power of good and bad memories, however, it needs professional skills like a psychologist and it is hard for a visiting nurse to conduct life review. Comparing a life review, narrative approach is not limited by memories and patients narrated freely. Visiting nurses may conduct this approach and effective.
From recent previous studies, usefulness of narrative is shown. Efficacy of narrative intervention was demonstrated in some previous studies. Lloyd-Williams et al.  showed the efficacy on depression; however definite question items were not showed. Wise et al.  showed the efficacy of Telephone-based narrative interventions on wellbeing; however since this method need telephone
Table 8. Narrative approach program for patients at home hospice by nurses.
or social networking system, it may be difficult for some patients. In that situation, the Narrative approach in this study would be convenient.
This work was supported in part by JSPS KAKENHI Grant Number JP 17K12559.
 Murata, H. and Morita, T. (2006) Conceptualization of Psycho-Existential Suffering by the Japanese Task Force: The First Step of a Nationwide Project. Palliative and Supportive Care, 4, 279-285.
 Moory, S., Cort, E., Kapari, M., et al. (2009) A Cluster Randomized Controlled Trial of Cognitive Behavioral Therapy for Common Mental Disorders in Patients with Advanced Cancer. Psyhologucal Medicine, 39, 713-723.
 Breitbart, W., Rosenfeld, B., Pessin, H., et al. (2015) Meaning-Centered Group Psychotherapy: AN Effective Intervention for Reducing Despair in Patients with Advanced Cancer. Journal of Clinical Oncology, 33, 749-754.
 Ando, M., Morita, T., Akechi, T., Okamoto, T., et al. (2010) Japanese Task Force for Spiritual Care. Efficacy of Short-Term Life-Review Interviews on the Spiritual Well-Being of Terminally Ill Cancer Patients. Journal of Pain and Symptom Management, 39, 993-1002.
 Bronna, D. and Romanoff, B.E. (2006) Meaning Construction in Palliative Care: The Use of Narrative, Ritual, and the Expressive Arts. American Journal of Hospice and Palliative Medicine, 23, 309-301.
 Stanley, P. and Hurst, M. (2011) Narrative Palliative Care: A Method for Building Empathy. Journal of Social Work in End of Life and Palliative Care, 7, 39-55.
 Tait, G.R., Schryer, C., McDougall, A., et al. (2011) Lingard L. Exploring the Therapeutic Power of Narrative at the End of Life: A Qualitative Analysis of Narratives Emerging in Dignity Therapy. BMJ Supportive Palliative Care, 1, 296-300.
 Oken, M.M., Creech, R.H, Tormey, D.C., et al. (1982) Toxicity and Response Criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology, 5, 649-656.
 Lloyd-Williams, M., Shiels, C., Ellis, J., et al. (2018) Pilot Randomized Controlled Trial or Focused Narrative Intervention for Moderate to Severe Depression in Palliative Care Patients: DISCERN Trial. Palliative Medicine, 32, 206-215.
 Wise, M., Marchnad, L.R., Roberts, L.J., et al. (2018) Suffering in Advanced Cancer: A Randomized Control Trial of a Narrative Intervention. Journal of Palliative Medicine, 21, 200-207.
 Ando, M., Ninosaka, Y., Okamura, K., et al. (2015) Difficulties in Caring for Cancer Patients at the Endo of Life at Home and Complicated Grief. American Jounal of Hospice and Palliative Medicine, 32, 173-177.
 Ishi, Y., Miyashita, M., Sato, K., et al. (2012) Family’s Difficulty Scale in End-of Life Home Care: A New Measure for the Family’s Difficulties in Caring for Patients with Cancer at the End of Life at Home from Bereaved Family’s Perspective. Journal of Palliative Medicine, 15, 210-215.
 Ohrnbergci, J., Fichera, E. and Sutton, M. (2017) The Relationship between Physical and Mental Health: A Mediation Analysis. Social Science and Medicine, 195, 42-49.
 Ando, M., Morita, T., Ahn, S., et al. (2009) International Comparison Study on the Primary Concerns of Terminally Ill Cancer Patients in Short-Term Life Review Interviews among Japanese, Koreans, and Americans. Palliative and Supportive Care, 7, 349-355.
 Ando, M., Morita, T., Akechi, T., et al. (2012) Factors in Narratives to Questions in the Short-Term Life Review Interviews of Terminally Ill Cancer Patients and Utility of the Questions. Palliative and Supportive Care, 10, 83-90.