Purpose: The aim of this study was to clarify the factors contributing to the evaluation of perceived care in inpatient palliative care services from the aspect of informal caregiver after their loss of the patient to cancer. Method: A questionnaire was mailed to 9,684 bereaved subjects who had lost family members at one of 103 palliative care units in Japan to evaluate their sociodemographic characteristics and the evaluation of perceived care. An institution survey was performed to collect organization-related variables. The evaluation of perceived care was rated by the Care Evalutaion Scale (CES), the Good Death Inventory (GDI) and single item of overall satisfation. Result: A total of 5,810 responses were analyzed (response rate＝60％). Uni-variate and multivariate analysis was performed to clarify the determinants of each scale. Significant determinants of the score in the evaluation of care identified were: the rate of private room (100％), independent facility, palliative care physician being night-time duty, the number of nurses at night (＞0.1 per bed), sending a letter to every bereaved family, holding a memorial services for every bereaved family and having a religious background. Conclusion: In conclusion, the evaluation of palliative care from the aspect of informal caregiver was influenced by various organization-related variables.

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Background: The aim of this study was to develop the Japanese language version of the Liverpool Care Pathway － Home (LCP－H), and to examine the feasibility of the LCP－H in a pilot study. Methods: LCP－H was administered to cancer patients who were predicted to be in their last few days. We evaluated the achieved care goals of LCP－H. A cross－sectional anonymous questionnaire was administered to home nurses who used LCP－H to evaluate usefulness in using LCP－H. Results: LCP－H was used to 35 patients. The care goals of LCP－H were achieved in almost 80%. The nurses evaluated the usefulness of LCP－H: Providing to continuous end－of－life care each staff, Communication well between home nurses and co－medical home staff, and Education for home nurses with limited experience with end－of－life care. Conclusion: The feasibility of LCP－H was confirmed. Therefore, LCP－H should help home nurses to care for dying patients and their families as guide for end－of－life care in home, and improve the quality of end－of－life care in home. However, because the LCP is now being phased out in the UK, it may be necessary to develop an original education tool to assist in care for dying patients and their families in Japan.

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Ceftriaxone is one of the easily administrative antibiotics, but little is known about their role in palliative care settings. The aim of this study is to show the effect and the safety of ceftriaxone subcutaneous infusion to infection among advanced cancer patients. Consecutive patients who received ceftriaxone subcutaneous infusion at the Seirei Hospice from January 2013 to January 2014 were enrolled in this retrospective analyses. Primary outcome was the response rate of ceftriaxone, determined by improvement of symptoms within 3 days of ceftriaxone use. Secondary outcomes are inflammatory site reaction, and a comparison of the response rate between ceftriatone and other antibiotics. Among a total of 100 admitted patients, 10 patients used ceftriaxone subcutaneous infusion (4 for urinary tract infection, 4 for pneumonia, 2 for soft tissue infection). The response rate was 70% (95% confidence interval, 39－89). There was no inflammatory symptom at the insertion site observed. For comparisons, 16 patients used other antibiotics with the response rate of 74% (51－88).In conclusion, subcutaneous infusion of ceftriaxone can be useful in the treatment of infections of end－of－life cancer patients, and randomized controlled trial is promising.

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Purpose: The simple conversion ratio of 1：1：1/50 between oxycodone injection (OXJ), morphine injection and fentanyl injection is used at Saga－Ken Medical Centre Koseikan. However, there are no studies on the validity of the simple conversion ratio. Methods: A total of 18 patients with opioid switching to OXJ using the simple conversion ratio were reviewed in this investigation. We surveyed the change in the numeric rating scale (NRS) and adverse effects before and after opioid switching. Result: The average period needed to reach a stable dose of OXJ was 0.6 days. The reasons of opioid switching to OXJ were the uncontrolled cancer pain in 11 patients, the impossibility of oral administration in 6 patients, the drowsiness in 1 patient. The average NRS decreased from 3.3 to 1.1 in 11 patients with uncontrolled cancer pain (p＝0.007). No obvious change in the NRS was observed in 6 patients with the impossibility of oral administration. In 18 patients, there was no significant difference in adverse effects before and after opioid switching. Conclusion: These results indicate that the simple conversion ratio could be safety for opioid switching between OXJ and other opioid in cancer pain treatment.

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East Japan earthquake after cancer is not little survey about patients with palliative care and home health care. In this study, the cancer during an earthquake which aims to make recommendations for future large－scale disasters, and investigation of actual conditions of palliative care and home health care system or manual for basic data. Healthcare in the stricken coastal region 53 conducted semi－structured interviews. Results than cancer healthcare for patients with palliative care and home health care experience is 【cancer providing healthcare to patients with disabilities】【patient lost during the tsunami damage and evacuation oral medication continued failure】【failure of the medical provision of in－home patients by disruption of lifeline】【regional health providers and backward medical assistance and emergency medical group with disabilities】【mental care to medical staff】【disorder of the nuclear power plant accident community health providers】 of 6 organized by category. Be prepared for major disasters, disasters when cancer patients with palliative care and home care issues and how to respond it became evident.

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Purpose: To investigate the indications for use of the Japanese version of the Liverpool Care Pathway (LCP), we evaluated the conditions of patients using and those not using the LCP. Methods: We retrospectively investigated the medical records of 71 LCP patients and 60 non－LCP patients who died in our palliative care unit between March and December 2013. Results: There was no significant difference in patients’ background between the LCP and non－LCP groups. For patients in the non－LCP group, sudden changes in condition were significantly more frequent and deep continuous sedation was used significantly less than in the LCP group. In the LCP group, the average duration on the LCP was 4.0 days, and the beginning criterion was met by three－point or more of all the patients. The initial assessment was achieved except for one case. In the non－LCP group, reasons for not using the LCP were a sudden change in condition (35 patients), a rapid change in medical condition (14), and a risk of falling (4). Conclusions: The LCP met the beginning criterion and was started at suitable time in the LCP group. The LCP is not useful for all patients; it cannot be used for a patient with sudden or rapid changes in condition, or at a risk of falling.

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Purpose: Patients with end－stage cancer are prone to various problems in their oral mouth. Survey of nurses’ attitudes regarding oral care in our cancer base hospital was conducted and discussed. Method: 197 nurses working with terminally ill cancer patients in the hospital were involved in the questionnaire survey. Results: 159 nurses completed the questionnaire (81%). 153 nurses responded that oral care was necessary for end－of－life stage (96%) but only 29 nurses responded that adequate oral care was provided (18%). Conclusion: The results showed that the nurses acknowledged of importance of oral care at end－of－life stage but didn’t provide the adequate oral care. The survey found that requesting oral care and relief of symptoms as supportive care are lacking of cooperation with the Dentists. How to share information and work with out－of－hospital dentists will be a challenge in the future.

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Purpose: We report a case of delirium and convulsion after administration of olanzapine in a cancer patient with refractory vomiting. Case report: The patient was a male in his 70s who suffered from lung cancer. After chemotherapy, olanzapine was used for refractory nausea and vomiting. Since this treatment, the patient has experienced delirium and convulsions. While we modified some reversible causes of the delirium, the delirium did not improve. Discontinuation of olanzapine resulted in improvement of the delirium. Recurrent convulsions did not occur with sodium valproate. Olanzapine might increase the risk of delirium and convulsions.

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Purpose: A report of effective occupational therapy for delirium patients with cancer is uncommon. We report a patient of carcinomatous meningitis, in whom her daily activity is improved by occupational therapy. Case: Firstly, we supported her meals and then started occupational therapy accepting her interest. Although degree of confusion and her performance status was not varied from beginning to end, she could concentrate our programmed works and change her way of feelings. Also occupational therapy promotes reminiscence about her life review and friendship among other patients even in delirium condition. Conclusion: Occupational therapy can reduce cancer patients' impatience, anxiety and solitary feelings and improve quality of life.

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【Case】 We report a 59-year-old man with severe pruritus due to hepatocellular carcinoma who responded to oxycodon. 【Discussion】 Pruritus is sometimes significant clinical problem among advanced cancer patients. The cause of pruritus was still unknown；however, increased endogenous opioids and activation of opioid receptors play an important part in its pathogenesis. Systemic administration of mu opioid receptor agonists, such as oxycodon, for patients without pruritus sometimes produces itching. They bind to the mu opioid receptors but stimulate them less than do endogenous opioids. In this situation of increased endogenous opioidergic tone, they may work as competitive inhibitors in comparison with endogenous opioids. As a result, oxycodon behaved an antipruritic drug. Our observation may lead to a new understanding of pruritus in jaundice due to advanced cancer and to new treatment of pruritus.

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Extended－release Oxycodone tablet has been available for cancer pain treatment since 2003 in Japan. After pure oxycodone injection became available in 2012, we have tried to switch from oral to injection when oral intake becomes difficult because of bowel obstruction, nausea or drowsiness due to progression of the disease. There is no evidence regarding the ratio of switching from oral to injection at present in Japan. We always pay attention to avoid patients drowsiness because of an overdose of opioid, because there is not enough time left for cancer patients in the terminal stage, and drowsiness takes away from the patient’s good QOL. We switched Oxycodone from oral to injection in 8 cases from June to December in 2012. At first, we assess if the patient is well controlled by oral oxycodone or not. If the patient is not relieved from the pain enough, we switch oxycodone from oral to continuous subcutaneous injection with a dose of around 75％ at first. After that we titrate the dose little by little up to an appropriate level. We were able to evaluate 5 patients out of 8 because there were 3 patients with consciousness disorder. As a result, we were able to decrease dosage to 46.4％ on average.

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Methadone, which has unique mechanism of long-acting mu receptor agonism paired with N-Methyl-D-Aspartate（NMDA）antagonism, is thought to have potential to control pain no longer responsive to other opioids. Fatal adverse effects of methadone are respiratory suppression and QT interval prolongation, which leads to ventricular tachycardia. Here we report a case of a patient who benefited from starting on methadone in hospital and increasing methadone safely in a home-based care setting. A 79-year-old Japanese woman, who developed local recurrence after resection for primary retroperitoneal leiomyosarcoma, presented with frequent burning pain in right groin area. After receiving palliative radiation therapy, she took oxycodone and adjuvant analgesics but without relief, and began experiencing somnolence. She underwent opioid switching from oxycodone to methadone with her breakthrough pain remarkably improved. When her breakthrough pain recurred after discharge, escalating dosages of methadone was performed successfully with no serious adverse effects even in a home-based care setting, by forming multidisciplinary collaboration for the management of prescribing methadone among healthcare providers near her home.

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Background：Although octreotide is effective in the relief of symptoms of gastrointestinal obstruction, it is also effective for gastrointestinal bleeding. It has been reported that octreotide reduced the splanchnic blood flow, and reduced the bleeding from esophageal varices, peptic ulcer and the tumor of gastrointestinal tract. We experienced four cases of end―stage cancer patients admitted to a palliative care unit whose symptoms of gastrointestinal bleeding were alleviated by octreotide（300μg／day）. Case：Case 1；A 75―year―old woman with gastric cancer developed melena and received octreotide. After octreotide was discontinued, melena and hematemesis recurred. Octreotide was restarted subsequently, and hematemesis resolved. Case 2；An 87―year―old woman with gastric cancer received octreotide for increase of bloody drainage from a stomach tube. She had epigastric pain and emotional distress from the blood. These symptoms were alleviated following the administration of octreotide. Cases 3 and 4；A 76―year―old man with gastric cancer and a 62―year―old man with bile duct cancer received octreotide for massive vomiting of blood. After the administration of octreotide, there was no reoccurrence of hematemesis in both patients. Conclusion：Octreotide may alleviate symptoms of gastrointestinal bleeding in end―stage cancer patients.

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Introduction：Hyponatremia, which is frequently present in patients with end-stage cancer, causes delirium and disturbance of consciousness and is considered a poor prognostic factor. We report a case of hyponatremia with hypopituitarism in association with leptomeningeal metastasis, resulting in reversible disturbance of consciousness. Case report：A 77 year-old female received chemotherapy at our hospital for postoperative recurrence of lung cancer, and best supportive care due to a side effect. After transfer to another hospital, she experienced a sudden disturbance of consciousness and was returned to our hospital. A detailed examination resulted in a diagnosis of hyponatremia from hypopituitarism following leptomeningeal metastasis involving the cerebral ventricles. Hyponatremia was improved by NaCl supplement and hormone replacement, followed by recovery from disturbance of consciousness. Discussion：QOL of patients with end-stage cancer can be improved through the active treatment of reversible causes of disturbance of consciousness. Conclusion：When severe hyponatremia is detected in cancer patients, it is important to consider the possibility of hypopituitarism with brain metastasis or meninges dissemination in the differential diagnosis.

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The 38-years old woman was hospitalized due to peritonitis carcinomatosa after 8 months, since the operation for advanced gastric cancer. Although the dosage of domperidone suppository, metoclopramide injection and haloperidol injection was started to prevent her from vomiting, it was stopped because of the complication of extrapyramidal symptoms. Instead of previous prescription, the traditional Japanese medicine, ice candy of rikkunshito, was prepared and started to give her. After its dosage, the number of vomit was gradually decreased, and she was permitted to go back her home. Before a dosage of ice candy of rikkunshito, it was impossible for her to eat orally even if she felt hungry and had appetite, which caused a strong grief to her. Ice candy of rikkunshito is a smooth medicine and expected to prevent from vomiting while an intake of ice candy orally. Hence, it is considered that there is possibility to have effectiveness both physically and psychologically. After few days from going back home, she caused a consciousness impediment. Her last stay at home was only few hours. After one month since then, she died leaving her message,“I was tired out, but happy to stay at my home.”

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Introduction：Patients with AIDS are considered appropriate for the admission to the inpatient palliative care unit（PCU）, but in reality, many facilities do not accept them. Furthermore, it is rare to see a patient with AIDS with complication of small intestinal adenocarcinoma. We report a case of our experience treating such patient at the PCU／hospice unit of our facility. Case：A 64 years old male patient, receiving a treatment with antiviral drug for AIDS diagnosis, was referred to our hospital for the admission to PCU due to the complication of small intestinal cancer. We treated his increased pain with the combination use of fentanyl patch and morphine continuous subcutaneous infusion, which successfully controled the symptom. During his final days, we had him on sedation upon his request；initiated from the intermittent sedation followed by continuous deep sedation using Phenobal. Discussion：Considering the aging society, the number of people with HIV／AIDS in need of palliative care would also be on the rise. Through close communication among facilities and pre-admission preparation to accommodate special needs those patients may have, palliative care units may be able to accept more people with HIV／AIDS.

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We report a case of successful treatment for bladder hemorrhage with intravesical alum irrigation. A 60 s woman, who had renal pelvis carcinoma and moderate renal dysfunction（eGFR＝48 mL／min／1.73 m²）, was hospitalized to our palliative care unit, for pain control of her lumber metastasis. During hospitalization, the patient showed dysuria and a lot of intravesical blood coagulum, which was caused from bladder metastasis. After bladder flushing, continuous bladder irrigation with saline was started. However, when we reduced the irrigation speed, dysuria appeared again. Thus, we started intravesical alum irrigation. Six days after this irrigation has started, we stopped the irrigation because no gross hematuria was seen any more. On the blood test done ninth day after irrigation, serum alminium level was 0.4μg／dL（normal value＜0.8μg／dL）. Three months after discharge from the hospital, the patient died, however, no gross hematuria or anuria were seen up to that time. Serious adverse effects with intracesical alum irrigation were reported in patients with renal dysfunction. However, if the renal dysfunction was moderate, intravesical alum irrigation with reduced doses seem to be safe and effective.

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Methadone oral tablets initially became available on the Japanese market in MAR－2013. Methadone, which has different pharmacological properties from other opioids including morphine, can cause serious adverse drug reactions such as respiratory depression and QT prolongation. One of the causes of these reactions is its extremely complex pharmacokinetics. Methadone is mostly metabolized in the liver, with a variety of metabolic enzymes, including cytochrome P450 (CYP) 3A4, CYP2B6, and CYP2D6, being involved. The characteristics of methadone include self-induction of metabolism, delayed excretion due to alkaline urine, and an extremely long half-life requiring a long time to achieve a steady state. Without a full understanding of its complex pharmacokinetics, the blood concentration of methadone is not maintained at a constant level, and serious adverse events could happen due to an unexpected increase in its blood concentration. Herein, for safe clinical use by physicians and pharmacists, we summarize the pharmacokinetics of methadone.

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