Background: The need for palliative care is increasing, and psychological care for cancer patients has been recognized to have an important role in palliative care. Purpose: To determine the medical knowledge and skills (especially in psychiatry) required in palliative care and to propose psychiatric training for palliative care education. Subjects/Methods: Using a questionnaire, palliative care doctors (working less than 3years) and nurses were asked their opinions on the necessity of palliative care and requested to self-evaluate their knowledge and skills in palliative care. Results: The survey revealed that many doctors and nurses felt the need for an "Interdisciplinary team approach" "Good communication with patient and family", an "Understanding of total pain" and "Listening". Palliative care doctors had low self-evaluations of their psychiatric knowledge and skills with regard to palliative care, but they recognized the necessity for greater knowledge and skills in this area. Conclusions: In a palliative care setting, it is important to establish training programs for consultation-liaison psychiatry that provide opportunities for learning about psychiatric practices, including diagnostic evaluation, psychotherapeutic and pharmacologic treatment, as well as skills for communicating with cancer patients, families and staff. Palliat Care Res 2009: 4(1): 101-111

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Purpose: The aim of this study was to develop a nursing intervention program for use in enhancing the self-care abilities of cancer patients receiving treatment on an outpatient basis. Method: Four-week-long combined group therapies were conducted on 15 subjects. The effects of these therapies were then examined. Results: Subjects' mean age was 56.86±11.52 years; mean duration of disease was 28.6±18.14 months. Between before and after the intervention, two scales showed significant improvements: EORTC QLQ-C30 Global health status (p<0.023) and STAI state anxiety scale (p<0.022). As a result of field note data analysis, "change of attitude toward cancer treatment at home" and "response to the program" were identified. Conclusion: Because the subjects were highly motivated individuals, with substantial self-care ability from the beginning, their ESCA scores did not show any change between before and after intervention. Nevertheless, the inner changes that occurred to the subjects indicated that their self-care ability had improved. Palliat Care Res 2009; 4(1): 201-206

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Purpose: The present study aims to evaluate the effect of analgesics in cancer patients based on their pain descriptions. Methods: The relationship between the words that patients used to describe their pain due to cancer and the efficacy of treatment with analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or opioids was evaluated. Results: We recorded 529words that were used by 164patients to describe their pain and pain quality and classified them into 108types of pain. For patients who used the actual word 'dull' or one with a similar meaning, treatment with opioids was effective. However, treatment with opioids was less effective in patients who used words such as "numb" and "tingling". Conclusion: We were able to gain a good understanding of cancer pain by listening to the actual words that patients used when complaining of pain. These findings suggested that we could choose a suitable medication through evaluation of the actual words cancer patients used to describe their pain and successfully relieve their pain. Palliat Care Res 2009: 4(1): 207-213

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The first step of cancer medical treatment is to eliminate anxiety about opioids. It is recommended to use printed matter in the "Guideline for Cancer Pain Management" edited by Japanese Society of Palliative Medicine, but few medical professionals actually use it. We developed the Opioids' pamphlet designed by Aichi Prefectural Society of Hospital Pharmacists; abbreviated OPA. This pamphlet is little burdened for readers; focusing on eliminating anxiety about opioids. Evaluation of the utility of the OPA and the actual conditions of patient education about the use of opioids by medical professionals were investigated, since there have been no reports on these issues. A questionnaire survey was conducted in hospitals with more than 150 beds in Aichi Prefecture. It targeted doctors, pharmacists and nurses who were practicing palliative care using opioids. There were many pharmacists and nurses who had been consulted about opioids, and most of the consultations were about addiction. 60% of pharmacists and 30% of nurses voluntarily performed patient education. Awareness of the guideline for of cancer pain management was low. OPA, which was reviewed based on the guideline, was applicable to 99% of the cases where the nurses were consulted. Its size and contents were highly acclaimed. Therefore, OPA is extremely valuable in clinical practice. Palliat Care Res 2009; 4(1): 214-227

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Purpose: Some patients with cancer pain are relatively less responsible to opioids, and require other strategies to improve the balance between analgesia and adverse effects. In those patients, the usage of some adjuvant analgesic drugs is recommended with opioid analgesics according to the first step of the WHO ladder for cancer pain relief. Recently, the efficacy of gabapentin for several cancer-related neuropathic pain has been reported. Case report: We present the case of a 64-years old female patient who had extensive vertebral bone destruction of C1-C2 due to metastasis of multiple myeloma, complicated with acute tetraplegia. Invasion to the retropharyngeal space by tumor enlargement seemed to increase the risk of upper airway obstruction. When our palliative care team first met her, she was suffering from the severe nape pain with allodynia at her right shoulder and incurable headache, refractory to intravenous morphine hydrochloride administration of 100mg/day (numerical rating scale; NRS 7/10). Her chief physician was negative against the dose escalation of the opioid analgesics, because of the risk of respiratory depression. Significant analgesic effect (NRS 3/10) was immediately achieved with oral gabapentin 900mg/day on day1. On day5, after gabapentin was increased up to 1,800mg/day, her nape pain was remarkably reduced to NRS 1/10, and no adverse effect was reported. Conclusion: For patients who are relatively naïve to increase of opioid analgesics, the supplementary use of adjuvant analgesic drugs would be favorable to both objectives; fewer adverse effects and reduction of the pain. Palliat Care Res 2009; 4(1): 301-306

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Introduction: Although fentanyl patch (FP) are often used to treat cancer pain because of the low incidence of adverse effects of this formulation, there are cases in which it is impossible to eliminate the pain despite increasing the doses. We report a patient of advanced gastric cancer with abdominal pain, in whom successful pain control was achieved by opioid rotation from FP to continuous intravenous infusion of morphine hydrochloride. Case Report: The patient was a male in his 60's who had been diagnosed as having primary gastric cancer and complained of abdominal pain, thought to be visceral pain caused by obstruction of the digestive tract. Oral intake became more difficult as the disease progressed. Despite a switch to FP from oxycodone used to treat the abdominal pain and an increase in the dose, pain relief was not achieved. Then, we undertook a partial opioid rotation to continuous intravenous infusion of morphine hydrochloride, which provided adequate pain control. Discussion: One possible reason for the pain relief in this patient is suppression of the gastrointestinal motility by morphine. When adequate pain relief cannot be achieved with one opioid, opioid rotation should be considered. We concluded that the opioid rotation should, however, be performed in a stepwise manner. Palliat Care Res 2009; 4(1): 307-311

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It is well known that haloperidol is effective in the management of nausea and vomiting in cancer patients and that midazolam is used for inducing sedation in patients with delirium. Both the drugs are frequently used in a clinical setting, but there have been only few reports thus far on the concomitant administration of these 2 drugs. We report the case of a patient with massive ascites due to peritoneal carcinomatosis who had severe nausea and vomiting and went into a delirious state. This patient received a concomitant continuous infusion of haloperidol and midazolam for the management of these symptoms. Both haloperidol (up to 1.87mg/h) and midazolam (up to 1.87mg/h) were infused intravenously. For about 20 days, the nausea, vomiting and delirium were well under control without the development of any life threatening toxicities. Concomitant haloperidol and midazolam infusion was found to be a safe and effective therapy for the management of nausea and vomiting in the patient. Palliat Care Res 2009; 4(1): 312-316

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Purpose: We report two patients receiving high doses of systemic opioids in whom gradual switching of the opioid administration route from systemic to intrathecal provided satisfactory pain relief without excessive sedation or withdrawal symptoms. Case reports: In one of the patients, who was already receiving 500mg morphine intravenously but still suffered from right upper quadrant pain, it was difficult to increase the opioid dosage according to the WHO guidelines because of intolerable side effects. The other patient, in spite of taking a combination of systemic opioids equivalent to 760mg oral morphine, had inadequate pain relief and could not continue receiving home medical care. In both cases we could successfully change from systemic to intrathecal opioid administration in a step-wise manner without deterioration of pain control, adverse effects due to over dosage, or withdrawal symptoms. Intrathecal opioid administration also reduced drowsiness and improved daily activity. Conclusion: Currently, there are no guidelines for change of route of opioid administration from systemic to intrathecal administration and few published reports have concretely documented opioid route switching in Japan. A carefully planned, step-wise switching of opioid administration route from systemic to intrathecal should be considered in patients who are already taking high doses of systemic opioids. Palliat Care Res 2009; 4(1): 317-320

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