The improvement of "Clinical Thanatology" requires comprehension of its existing problems and consideration about them.From the above standpoints, the condition of patients with terminal stage lung cancer was investigated.<Method> Ninety patients with lung cancer, who were admitted to our hospital since 1975 and died were examined, especially concerning the data within three months of their death.<Results> (1) Period of hospitalization The average period of terminal hospitalization was 70.3 days. The shortest was three days (of re-entrance) and the longest 433 days.(2) Informing the name of disease In almost all cases, the patient was given a name of diseases other than cancer. The most common name was pulmonary tuberculosis, followed by pulmonary suppuratino and tuberculous pleurisy. There were cases where these names caused some troubles in the doctor-patient relationship. On the other hand, there existed some difficulties when the real diagnosis of disease was told to the patients.(3)Symptoms At the terminal perild, loss of appetite was apparent in alomost all the cases. Other complants such as dyspnea 76%, cough and sputum 75%, back pain of chest 63%, and fever 51% were noticed. There was almost no response for the treatment of the above complaints.(4) Treatment During the last three months, 73 cases, 81.1%, received mainly chemotherapy, some of which are conservative. The cases which received anticancer therapy of any kind during the last week were about 50% of the total. Among these cases, the unexpected sudden death, contrary to the attending doctor's expectation, seemed to occur.<Conclusion> It is necessary to investigate the actual condition of patients hospitalized with terminal lung cancer and to consider the existing problems.

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In the Western world hospices and nursing teams are already available for the care of dying patients and in fact are functioning effectively. Such facilities and organizations are also gradually coming into being in Japan.Successful management of terminal patients requires a humane holistic bio-psycho-socio-ethical approach from a standpoint of psychosomatic medicine.Kubler-Ross classified the psychological process of moribund persons into 5 stages, including one of depression. According to her, there re two types of depression, i. e. reactive depression and preparative depression. The former type of depression is a problem that must be solved early and one of the important factors productive of depressive reaction is the pain of cencer.Seventy to 90% of terminal stage cancer patients are suffering from pain and it is well known that chronic pains give rise to a depressive state.We assessed 15 terminal cancer patients with pain for depression using the Toho University Depression Scale (Self Rating Questionnaire for Depression, SRQ-D). According to the results, the mean depression score was 11.1±6.9; 4 of the patients had a high score on the scale, 3 others had a moderately high score and 46.7% were found to exhibit a more or less distinct tendency to depression.On the other hand, antidepressant drugs are known to have an action to elevate the pain threshold. When 5 cases with cancer pain and depression were treated with clomipramine given by intravenous drip infusion, pain relief of a dosage reduction of analgesics with disappearance of depression was achieved in 3 of the 4 cases. In the remaining one case, the use of clomipramine was attended by lassitude and nausea, hence the medication was discontinued.In caring for terminal patients, relieving them of somatic distress is the minimum necessity. The fact that antidepressant medication proved to be effective not only in the relief of cancer pain (which perhaps in the greatest of all physical pains) but also in lifting or combatting depression encourages us to use positively such a drug therapy in the management of terminal cancer patients.

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On my visit to St. Christopher's Hospice in the suburban London, England in April, 1977,I met and exchanged views with the director, Dr. C. Saunders, who is the leader in the hospice care. I inspected the total care given to patients in the wards deeply impressed. I reflected upon the conditions of the terminal care prevailing in Japan even though the spiritual environment is different in two countries.I think it is a universal desire of a man to accept death at home surrounded by his family if there are no medical problems. Based on this theory, I have tried to give the terminal care with the main emphasis on home care as a medical practitioner responsible for primary care. In case of severe pains, etc. and in case where nursing at home is not quite satisfactory, patients were received in a mini-hospice under my supervision.Among those who visited my hospital during the five years between 1977 and 1981,120 expired; 59 at home (49%), 15 in my hospital (13%), 45 in other hospitals (38%) and 1 outside his house (1%). The ratio between those who died at home and those hospitalized was 1 : 1. In case of patiets with apoplex, more died at home, 21 at home (64%), 4 in my hospital (12%) and 8 in other hospitals (24%). Among those with malignant neoplasm, 16 died at home (30%), 10 in my hospital (19%), and 45 in other hospitals (38%). The main complaints of 25 cancer patients whom I cared till death were : 13 of fatigability and anorexia, 6 of intractable pains, 2 of ascites, 2 of gastrointestinal bleedng, 2 of dyspnea, and 5 of insufficient number of people to look after them. Based on psychosomatic medical care, these terminal patients were given (1) such physical cares as specially prepared diets suitable for ingestion and preventive administration of Brompton Cocktails, and (2) such mental cares as non-verbal communication with patients to relieve their anxiety and loneliness and support their hope as well as physical and mental assistance given to their families who were tired with nursing.The terminal care given by our staff is generally supported and appreciated by the bereaved families.I firmly believe that "care of dying patients" in the primary care should be given at homes, if possible. To achieve this purpose, socialized medicine is essential. The technique to support "clinical medicine for the dying" is one of applying psychosomatic medicine.

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Parental participation, especially maternal one, in clinical practice of pediatrics is quite important which is usually not seen in adult medicine. When the diagnosis of cancer in children is made, the diagnosis must always be told and the disease has to be explained to both parents together in a quiet room.Our attitude in talking with the parents is a most important consideration. Many discussions must be held with the parents even after the first talk and the parents should be told that they should feel free to ask any questions. Particular attention must be paid to the psychological impact that the diagnosis has upon the parents. They should be assured that their child will receive the best treatment currently available and the importance of their cooperation for the welfare and happiness of their child should be stressed. We also tell them that cancer is no longer invariably fatal due to recent medical development. The situation today has changed from expectation of certain death to anticipation of a normal life although this may be uncertain at the time of diagnosis.Another important problem is how to explain the disease to our patient. According to Japanese beliefs, children must not die while their parents remain alive. It appears to be most catastrophic when the order of death by seniority is disrupted. Since death of children evokes utmost fear as human beings, no scientific studies on this subject have been carried out in Japan until recently. For children with cancer, the pattern of open and honest communication is most important. If they ask you specifically about their diagnoses, prognosis or treatment programs, their questions shoud be answered forthrightly.In the terminal stage, a dying child generally regresses to a more primitive level asking the mother just to be there with him. He may be content if the mother holds, comforts and feeds him. When feasible, the best comfort for the child is the mother's active and close care, day and night. Therefore, all of us must support the mother who is living in with the child and carrying much of the care of the dying child. She should be looked after, encouraged and given occasional rest from her heavy duties.The hospital staff also experience the strong emotional reactions. Group meetings and conferences on "approaches to dying children" should be held at intervals and meneuvers and training of the treatment on this subject are mandatory in strengthening the staff's therapeutic and supportive role.

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O__-rganized C__-are of the D__-ying Patient (OCDP) is a team approach to the dying patient. Physicians, nurses, social workers, paramedical staff and pastors make one team to take care of the many needs of the dying patient (physical, psychological, social, and spiritual needs). The functions of OCDP are as folloews : 1. The organized evaluation of the patient's psychological state 2. The approach to the family 3. To help the attending physician 4. Mutual help among team members 5. Carrying out the agreed upon plan of action 6. To encourage each one to carry out his own job.7. The organized evaluation of the conditions of the patient and the family Hospice exists for the terminally ill and their families. It is a comprehensive health care program designed to meet their special needs. Its aim is to allow patients to live out their days as fully and comfortably as possible.The hospice program includes sophistivated medical and nursing care, employing new drug therapy and other methods to control pain, nausea, loss of appetite-debilities that deprive patients of strength, will and even human dignity.Hospice considers the basic care unit to be the patient and the patient's family. It serves both Hospice ministers to their emotional, social and spiritual needs. (quoted from annual report of The Connecticut Hospice).

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According to the recent investigation about terminal care, the educational curriculum of terminal care is set up only by 21.2% of Japanese large hospitals (Miyamoto, et al.). This demonstrates the lack of educational methodology for terminal care in Japan.We have been practicing terminal care education by the Baliant Method for more than two years. The Balint Method is developed by Michael Balint M.D. (1896-1970), who was born in Hungary and opened his clinic in London as a general practitioner. He developed his way of medical interview by "listening" to the patient. He tried to understand his patient biologically, psychologically and sociologically. He began his group-work in order to educate general practitioners so that they can understad their patients as whole persons. Ikemi, Y. has theorized essentially that the Balint Method makes it possible to understand the doctor-patient relationship (interpersonal communication) objectively, which hepls intrapersonal communication in the patient which covers his own bio-psycho-social levels. According to this mechanism, the patient will become aware of himself as a whole person, and then he will try to solve his problems for himself.Recently, especially in the U.S.A., behavioral medicine ahs developed its methodology, whose medical model is a bio-psycho-social one (Day, S.). Ikemi has added the psychoecological (or bioethical) point of view to this model.We began our "Fukuoka Balint Group" to study terminal care since July 1980,which includes medical doctors, nurses, psychologists and citizens concerned. We discuss freely, from a bio-psycho-socio-ecological (or ethical) standpoint about dying cases with difficult problems. A leader and a moderator helps participants expose their feelings to the case and the others accept them positively. The TPEG (Terminal Patient Evaluation Grid) has been made use of effectively as a learning strategy. According to the TPEG, we analyze the case bio-psycho-socio-ethically. In experience of 2 year-group-work, 93% of the participants have changed their view of patients' dying, and 44% of them have improved their own view of living and dying, and 31% of them have evaluated that their therapeutic selves have improved.Ikemi points out the merits of the Balint Method in terminal care as follows : 1) Through free discussion, the therapist can learn objectively how he himself treats his patients. 2) In the Balint Group, the participant can expose his feelings about the patient freely, and the others accept them positively. 3) In the process of dying, the patient shows various psychological reactions. The therapist can control his subjective impressions (subjectivity) and come to understand the patients' reactins objectively through the Balint Work. 4) Reactions of the dying patients are rich in variety. It is impossible for a therapist to understand all of them. In the Balint Group, many participants have various experiences. To hold them in common helps to solve this difficulty. 5) These experiences in the Balint Group will deepen the view point of living and dying and will be the base of the therapeutic self.

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In patients who are sentenced to have cancers in general, the period of 'shock' primarily appears and then comes the period of 'denial', in which patients dare to deny the presence of cancer. Subsequently, the period of 'agony' with anger and depression, the period of 'acceptance' in which patients accept the presence of cancer, and death in peace and dignity follow them. Medical doctors have to know and keep in mind such psychological transitions of the patients.We studied the psychological trends and adaptation towards social environment of the patients, who knew themselves to have cancer, with spontaneous regression of cancer (SRC) and those with the end-stage of cancer who showed long survival.We could collect 45 cases of SRC according to the definition by Everson and Cole, with the aid of several universities and their related hospitals. The SRC cases are mainly composed of digestive tract and respiratory tract cancers and metastasis was identified in 73% of them; histologically adenocarcinoma and squamous cell carcinoma were frequently observed. Cancer patients in general are emotionally repressed, overly adaptive, conservative and adherent to social customs. In other words, despite their sharp temperament, they make good social adjustment; though they look warm on the surface, they are unable to express what they actually are, thus completely unadaptive in their inner life. However, psychological evaluation in the patients who show SRC revealed that after they know they have cancer, their conditions take a favorite turn when an existential shift takes place and they overcome fear and anxiety of cancer and live a meaningful life afterwards. They also show active adaptation towards social environment. It appears that the way which stands superior to life or death and recovery of a life worthwhile to live may lead a profitable host reaction. These tendencies were observed not only in SRC cases but also in cancer patients with long survival. In management of such patients with the end-stage of cancer, doctors should keep in mind that it is necessary to cure and care the patients both from physical and psychological aspect.

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Unhappily, we enocunter some cases of suicide in the clinical practice.It is one of the most important tasks for the clinician to predict and prevent suicides during each clinical course.Psychological characteristics of the suicidal are like the following.a. He is psychologically very lonely.b. He has desires both to die and to be helped.c. One suicide infects others psychologically.d. The thought of suicide does not last long.e. Suicide is raised from the transient psychological crisis.For the prevention of suicide, one of the most important task is to manage and relieve the loneliness of the suicidal in the clinical practice.

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