This article describes the end of life of seven people with amyotrophic lateral sclerosis (ALS) under the care of a hospice. The reasons for admission to hospice were for the management of distressing symptoms and the support of families who were unable to continue care at home because of the increased burden of care and/or illness of families. The sufferings experienced by the patients with ALS included disability due to muscle weakness(100%), pain(100%), discomfort (100%), dyspnea (71%), difficulties in communication (71%), drooling (43%), insomnia (43%), loneliness (43%), swallowing difficulties (28%), clenching the mucosa inside the cheek (28%), anxiety (28%), the perception of being a burden to the family (28%), and concerns as to why they had developed ALS (28%). Opioid medication was effective in the management of dyspnea, pain and discomfort. The results showed that special attention should be paid to frequent changing of the patient's position during nursing care, including the passive movement of joints and massage. The use of communication aids was essential to allow people with ALS to communicate effectively and, together with support of joy of the patients and family, the quality of life could be improved. End of life care within a hospice is a useful alternative option for persons with ALS, extending hospice care in Japan from people with advanced cancer to other disease groups. Palliat Care Res 2010; 5(2): 137-143

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Purpose: Bone is one of the most common sites of metastases in patients with advanced lung cancer. Skeletal complications may cause significant morbidity and decrease performance status (PS). Such complications, referred to as skeletal related events (SREs), include severe bone pain, pathological fractures, spinal cord compression, and hypercalcemia of malignancy. We assessed the clinical impact of SREs in non-small lung cancer (NSCLC) patients with bone metastases. Methods: We retrospectively investigated the clinical records of all 120 patients who were diagnosed advanced NSCLC with bone metastases between June 1998 and March 2009. Results: A total of 23 patients (26.7%) were found to have SREs at the time of initial diagnosis. The median survival time (MST) was 123 days for patients with SREs, while it increased to 276 days for those without SREs. The MST of the patients with SREs were significantly shorter than that of the patients without SREs (p<0.001). We also studied the SREs during clinical courses of 89 patients whose records were available over 3 months. A total of 39 patients (43.8%) were found to have SREs during clinical courses. Conclusion: The patients in NSCLC with bone metastases were often found to have SREs. SREs cause significant morbidity and deterioration of PS. Systemic chemotherapy could not decrease SREs during their clinical courses. Further studies evaluating bisphosphonates in combination with chemotherapy are warranted. Palliat Care Res 2010; 5(2): 145-151

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In Kyoto, we held the first “Palliative care workshop for physicians engaged in clinical practice for cancer treatment” in Japan on June 7-8, 2008 under the directive of the Ministry of Health, Labor and Welfare. There were 163 participants in the workshop, including 56 physicians and 107 voluntarily participating healthcare professionals (77 nurses, 23 pharmacists and 7 other medical professionals). We analyzed the results of tests consisting of 25 questions classified into 7 categories based on their contents. Tests were administered before and after the workshop (pre-test and post-test), and the educational effects of our conference were evaluated by examining changes in test scores. Participants other than physicians, nurses and pharmacists were excluded from analysis of the test scores because comprehensive medical knowledge was required to solve the questions. The mean rates of correct answers on pre- and post-test were 87.9% for physicians (total 78.9%) and 94.6% for physicians (total 89.1%), respectively. The scores were markedly increased after the workshop, showing practical significance of our attempt. However, the percentage of correct answers regarding psychological symptoms was lowest for physicians as well as for other healthcare professionals on both pre- and post-test. These findings strongly suggest that the workshops produced a sufficient educational effect, but improvement in individual training systems is considered necessary, especially in fields related to psychological manifestations. Palliat Care Res 2010; 5(2): 152-161

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Purpose: The aim of this study was to clarify the experience of the bereaved families at the time of death of a patient. Methods: A cross-sectional nationwide survey of the bereaved families of cancer patients was performed at 95 palliative care units in Japan in 2007. Results: Of the 670 questionnaires sent to bereaved families, 492 were returned (73%). There were no significant differences between the level of the families' emotional distress and which doctor pronounced the death and whether the doctor was present at the moment of patients' death. Regarding the perceived need for improvement in the care of a dying patient, there were significant differences with respect to which doctor pronounced a patient's death and whether the doctor was present at the moment of a patient's death. There ware no significant differences between the attendance by doctor at the moment of patient's death and no attendance with frequent visit on that day. Conclusion: The bereaved families desire the patient's primary doctor to be present at the time of death and to then pronounce the death. However, the bereaved families consider an appropriate manner as the frequent visit by doctor on patient's last day even if the doctor do not attend at the moment of patient's death. Palliat Care Res 2010; 5(2): 162-170

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Purpose: Improving knowledge of palliative care among cancer patients and the general public may be useful for achieving a better quality of life for cancer patients. The aim of this study was to identify the actual situation after the dissemination of leaflets, booklets, and posters as a part of a regional palliative care program. Methods: We distributed leaflets, booklets, and posters on palliative care to 257 administrative and health institutions across the region. We also visited 216 institutions (84%) to observe the actual situation and performed interviews in 133 of the institutions (62%). Results: Overall, 58% of the institutions used the leaflets, booklets or posters. Public halls, libraries and hospitals used them at a rate of 65% or higher. Interviews identified 7 themes, including "explaining the aim of the project before dissemination is important", "few cancer patients or even the general public visit", "staff made various efforts to display the items after dissemination", and "staff learned from the leaflets and booklets, even if cancer patients seldom visited". Conclusion: The dissemination of leaflets, booklets or posters throughout the region might be useful for conveying accurate knowledge about palliative care not only for cancer patients and the general public, but also for health care professionals. Target institutions should include public halls, libraries, and hospitals, and pre-dissemination discussions about the aim of the project and what kinds of people visit the institutions in addition to post-dissemination follow-up may be useful. Palliat Care Res 2010;5(2): 171-174

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Purpose: The objective of this study was to investigate whether body fat rate (BFR) and triceps skinfold thickness (TSF) are associated with estimated fentanyl absorption in patients treated with the fentanyl transdermal matrix patch for moderate to severe cancer pain, by measuring the residual content of fentanyl in used matrix patches. Methods: Adult Japanese inpatients experiencing chronic cancer-related pain and receiving treatment for the first time with a transdermal fentanyl matrix patch (Durotep®MT patch) were included in the present study. During the initial application period, BFR was measured using a body fat scale, and TSF was measured by an experienced nurse with an adipometer. One patch was collected from each patient. The residual fentanyl content in used matrix patch was determined by high-performance liquid chromatography. The transdermal fentanyl delivery efficiency was estimated based on the fentanyl content of the used matrix patches. Results: Fifteen adult patients (5 males and 10 females) were included in this study. Nine patches with a release rate of 12.5μg/h and 6 patches with a release rate of 25μg/h were collected. The application site was the chest or upper arm. BFR and TSF both showed a significant positive correlation with delivery efficiency. Conclusion: In malnourished or low-body fat patients receiving DMP, pain intensity should be more carefully monitored, and fentanyl dose adjustment may be required. Additional parameters, such as nutritional status including body fat change, the degree of dry skin, and plasma fentanyl concentration, also require detailed evaluation. Palliat Care Res 2010; 5(2): 206-212

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The narcotics and psychotropic drug control laws were recently revised to enable the transfer of narcotics between narcotic retailers. However, there has been no study on the effect of this change to the law. For this reason, we studied whether there are any problems to this change in the law. We sent questionnaires to pharmacists at 3000 community pharmacies as a representative national sample, and 1036 responses were analyzed (response rate: 34.5%). Only 20.2% of pharmacists in community pharmacies answered that it is easy to obtain or transfer narcotics by applying for permission to transfer narcotics between narcotic retailers. The majority of pharmacists found the process to be difficult. The reasons for this included the complicated application procedure required by the regional bureau of health and welfare, and problems with the control of the prescribed narcotic's distribution as it is possible to apply only once for the supply of prescribed narcotics for the same patient. Furthermore, pharmacists cannot obtain the narcotics from a stock pharmacy. These results suggest that the current system of requiring permission for transfer of narcotics between narcotic retailers is inefficient and inadequate for maintaining a sufficient supply of narcotics for controlling the pain in cancer patients living in certain areas and overly complicates the procedure of obtaining narcotics by community pharmacies. It is important that the control of narcotics in Japan is changed to more closely resemble that of other commonly available prescription drugs, and allow narcotics to be obtained from stock pharmacies. Palliat Care Res 2010; 5(2): 213-218

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Purpose: The purpose of this investigation was to evaluate a suite of factors that may influence the use of gabapentin for the treatment of cancer pain in our hospital. Methods: We carried out a retrospective investigation of 52 patients hospitalized in our department with cancer-related neuropathic pain and under gabapentin treatment. Patients were divided into two groups: high dose (≥1,800mg gabapentin daily) and low dose (≤1,600mg gabapentin daily). The two groups were compared in terms of a suite of factors including patient background, type of neuropathic pain, dose of adjuvant analgesic drugs, period of administration, and the incidence of adverse effects. Results: Of the total number of patients involved in the study, 52% were in the high dose group. Patient age was significantly lower in the high dose group. There were no significant differences between the two groups in the dose of opioid analgesics, the number of adjuvant analgesic drugs, or the duration of administration. The incidence of adverse effects did not increase in the high dose group. Conclusion: In this retrospective investigation, we conclude that approximately half of our patient study population with cancer-related neuropathic pain may require daily gabapentin dose of 1,800mg or more. In addition, we observed that larger doses of opioid analgesics were used in the high dose group but without risk of increased adverse effects. This phenomenon may have been influenced by the lower patient age in the high dose group. Palliat Care Res 2010; 5(2): 219-226

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Purpose: We report a case whose anal pain accompanied by rectal cancer was remarkably eliminated by subarachnoid phenol block and sacral nerve root thermocoagulation. Case Report: The subject was a sixty-one-year old male. His anal pain failed to respond to opioid whereas his pain was alleviated by subarachnoid phenol block, but was exacerbated a few weeks later. This relapsing pain was completely eradicated by sacral nerve root thermocoagulation. Conclusion: Anal pain associated with rectal cancer recurrence of pelvic space is sometimes hard to be controlled only by subarachnoid phenol block, but there is a possibility of pain control by combination use with sacral nerve root thermocoagulation. Palliat Care Res 2010; 5(2): 314-316

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Objectives: Herein, we report a case in which intractable pain caused by prostate cancer bone metastasis was improved by long-term administration of ketamine at home. Subject: A male patient in his 50s developed prostate cancer and pelvic bone metastasis. Even after receiving combined modality therapy, including administration of morphine hydrochloride through an epidural catheter at a dose of 80mg/day and radiation therapy (twice), he continued to experience pain of bone metastasis, and in particular, significant pain was caused during body motion. The pain improved considerably after the administration of ketamine, enabling his long-term home care. Conclusion: We consider that ketamine still plays an important role in the improvement of opioid-resistant intractable pain of bone metastasis. Since ketamine can be used continuously at home, this medicine is able to be used for more appropriate cases as one of the choices. Palliat Care Res 2010; 5(2): 317-322

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Case: A 40-year-old woman. Clinical diagnosis: Autistic disorder with mild mental retardation. Case report: The patient underwent pancreaticoduodenectomy for the treatment of her pancreatic cancer. We held several conferences with individuals from different medical fields and examined the influence of the patient's autistic disorder on the perioperative conditions. The senior author, a clinical psychologist, conducted repeated individual, acceptive, and sympathetic interviews with the patient and her family and maintained supportive relationships with them as an honorary family member. Thus, the clinical psychologist helped reduce the patient's anxiety about the medical treatment. Conclusion: The participation of a clinical psychologist in the medical conferences enabled the medical staff to understand the complications involved and provide mental support to the patient and her family. Palliat Care Res 2010; 5(2): 323-326

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Opioids are potent analgesics mostly used for severe cancer and chronic noncancer pain. However, their efficacy and safety in acute noncancer pain are debatable. We describe the case of an 82-year-old male with severe back pain due to bacteremic Staphylococcus aureus spondylitis and paravertebral abscess. Pain in such cases is usually controlled by non-steroidal anti-inflammatory drugs (NSAIDs). However, this patient was administered morphine (oral, then intravenous; up to 23 mg/day) because acetaminophen and NSAIDs did not ameliorate pain. Considerable pain relief was achieved without toxicity, and the dose of morphine was tapered through 35 days. No symptoms of addiction or withdrawal were observed during or after this 35-day period. Thus, morphine appears to be safe and effective in the management of severe, acute noncancer pain in patients with bacterial spondylitis. Palliat Care Res 2010; 5(2): 327-331

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In palliative care setting, betamethasone is commonly used to relieve various symptoms such as general malaise, loss of appetite, fatigue and pain. In patients administered steroids, the psychic adverse effects should be cared as well as the physical adverse effects. Profile of Mood States (POMS) is a tool to evaluate a temporary mood and an affective state of a patient. The contracted version of POMS shortens intervention time by reducing question items. We administered betamethasone 3mg/day to the patient with digestive symptoms by bowel obstruction and the symptoms improved. Four months later, as the patient complained anxiety, irritation and insomnia, we prescribe predonisolone switching from equivalent dose of betamethasone. In this case we experienced that psychic symptoms improved without worsening digestive symptom since three days after the drug change. We evaluated a mood and an affective state before and after the drug change by using POMS contracted version. Palliat Care Res 2010; 5(2): 332-337

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Introduction: CPT-11 induced diarrhea reduces patient compliance, lowers quality of life, and can be potentially life threatening. Loperamide is effective in the majority of cases of CPT-11-induced diarrhea. However, the case of advanced gastrointestinal cancer where oral administration is difficult. We adapted octreotide for use in a case of CPT-11-induced diarrhea where oral administration was difficult due to digestive tract stenosis. Case Report: A 61-year old man was diagnosed with advanced gastric cancer. He was treated with CPT-11 100mg/m² weekly for three weeks followed by a 1-week rest. CPT-11-induced diarrhea developed after 10 days of treatment. At the same time, his digestive tract stenosis worsened, making Loperamide unusable. We administered octreotide 200μg continuous intravenous drip infusion. One day after octreotide administration, the number of diarrhea has decreased from 20 times to four times. Conclusions: Octreotide is one of the effective treatments for CPT-11-induced diarrhea. Palliat Care Res 2010; 5(2): 338-341

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