Development of Educational Program for nurses-nurses Collaboration to Provide Community-based Palliative Care for Individuals with ALS

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The purpose of this research was to provide proposals for methods of collaboration among nurses (nurse-nurse collaboration) and for in-service education for intractable-disease nursing needed when providing palliative care for various pains and distresses experienced by ALS patients and their families from diagnosis to death in the whole community. As a result of this research, we found that the most important times at which the collaboration needs to be particularly strengthened for supporting ALS patients, characterized by progressive disease, are at the early stage of the disease, at the time of rapid progression of the disease, and in the terminal stage of the disease. For family members' education and care, strengthening of collaboration between hospital nurses and home-visit nurses is important. As an important content of the education for all types of nurses, education focusing on care of the mental status of the patients and family members is considered important. It has also become apparent that public health nurses should know how to get involved in the early stage of the disease and have knowledge about its respiratory complications, home-visit nurses should be aware of the methods of at-home terminal care, and hospital discharge planning nurses have a role in strengthening the collaboration between community nurses and doctors and to connect hospitals and communities.