Objectives: Primary aim of this study was to clarify the family evaluation about caring the body of the deceased patient by nurses at Japanese inpatient hospices and palliative care unit. Method: A mail survey was performed on 958 bereaved family members of 103 palliative care units in July, 2010. Result: A total of 597 family members replied（62％）. As a whole, 441（74％）families reported that they were satisfied with the way caring the body of the deceased patient by nurses. A multivariate analysis revealed three factors were significantly associated with the levels of satisfaction:the patient face became peaceful and calm, and nurses treated the patient in the same way before died, and patient age was over 70 years old. Conclusion: Making patient face peaceful and calm, and treating the patient in the same way before died is important in caring the body of the deceased.

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This study clarified practices in end-of-life care for non-malignant chronic illness patients by expert nurses in general hospitals. Interviews with 7 chronic illness specialist nurses on practice cases were conducted, and final labels were elicited using a qualitative synthesis method（KJ method）. As patients’ conditions deteriorated, nurses defined the necessary interactions to support patients’ decision-making for living their own way of life and accompany patients and families based on their experience, and using patients’ restoration of self-esteem, sense of satisfaction, and acceptance as indices. In general hospitals, measures to cope with pain for patients not receiving life-prolonging treatment were insufficient;and while it was difficult to agree on care between medical professionals and to maintain care in other facilities, expert nurses grasped patients’ wishes on a daily basis and made arrangements for them to permeate through family and community care systems. In end-of-life care in treatment settings, it is necessary to be supportive so that the family and medical professionals can continue the patient’s care. Medical professionals who have been involved from the initial diagnosis stage need to improve their awareness and support skills as medical professionals to be involved purposefully from an early stage to the final stage.

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Objectives:To determine the factors influencing death or the cessation of palliative care in home-based setting among patients with cancer. Methods:We included 352 terminally ill patients with cancer who received home-based palliative care from six specialized palliative care clinics. We reviewed the medical charts when patients died at home or chose to stop home care. Results:A total of 82％ of participants died at home, and 18％ chose to stop home care. Multiple logistic regression analysis revealed five independent factors that affected cessation of home-based palliative care:patient and informal caregiver preferences for the place of death not to be at home［odds ratio, 10.1（95％ Confidential interval, 2.5-40.9）and 51.9（11.9-226.6）, respectively］or uncertain preferences［5.0（1.3-19.4）, 10.8（2.3-50.5）］;anxiety and depression among informal caregiver［4.1（1.2-13.9）］;lower frequency of informal care［6.8（2.0-23.4）］;and history of admittance to hospital during home care［11.6（4.0-33.9）］. Conclusion:We revealed independent factors influencing death or the cessation of palliative care in home-based settings among patients with cancer. Our findings suggest the importance of providing support for decision making about the place of death and hospital admission, and psychosocial support for informal caregiver to ensure home death consistent with patient preference.

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Complex decongestive therapy for lymphedema includes skin care, manual lymphatic drainage, compression therapy, exercise, and management of patients will include education about risk reduction and self-management. Specifically, compression therapy commonly employs elastic bandages with garments having more than 30 mmHg of compression. Some patients have difficulty wearing general compression garments due to complications, conflicts with activities of daily living（ADL）, and lack of compliance. Therefore, the effectiveness of light pressure compression using a tubular bandage together with foam padding was examined in 15 lymphedema patients of ISL（International Society of Lymphology）stageⅡ classification. In circumference comparisons among limb measurements between pre- and post-treatment, a significant decrease was found for all measurement points. In comparisons of shape change of limbs, we also noted significant improvements between pre- and post-treatment assessments. Furthermore, patient feeling and behavior tended to ameliorate along with increases in ADL and quality of life（QOL）. Based on these findings, light pressure compression using a tubular bandage along with foam padding may be an effective treatment option for ISL stageⅡ lymphedema patients who are unable to wear general compression garments and short stretch compression bandaging.

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Insomnia in advanced cancer patients has a highly negative impact on the patients, their families and caregivers. Insomnia is principally managed by pharmacological therapy； however, most advanced cancer patients are unable to receive oral medications. This prospective audit study investigated the efficacy of single—dose subcutaneous administration of flunitrazepam for treating insomnia in patients with advanced cancer. Sleep evaluation was conducted using the St. Mary’s Hospital Sleep Questionnaire. The primary endpoint was the quality of sleep； the secondary endpoints comprised other subscales of total sleep time, sleep latency and adverse effects. We enrolled 30 patients. The average dose of flunitrazepam dose was 0.9(0.1)mg. The good response rate for the quality of sleep was 90％. The total sleep time and sleep latency were 7.5(3.2)h and 31(9.1)min, respectively. Two patients were newly diagnosed with delirium during the study. The mean respiratory rate decreased(15/min before treatment to 14/min after treatment, P＝0.01) without any critical events. Single—dose subcutaneous administration of flunitrazepam may be potentially efficacious and simple in treating insomnia in advanced cancer patients.

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Background： While the number of older cancer patients increases as the society ages, the current status of the pain control is not well characterized among older patients. To improve the quality of care, it is necessary to understand the current status. Objectives： The aim of this study was to describe the pain control for older cancer patients in comparison to younger counterparts and characterize it. Methods： During four months in 2013, Aomori Prefectural Central Hospital started asking all hospitalized cancer patients about their pain every day using a standardized pain questionnaire. In addition, a questionnaire adopted to the outpatient setting was distributed to the patients who visited outpatient department of the hospital. The information about pain, quality of life (QOL) and the medical histories were included in the data analyses. Their responses were compared between outpatients versus inpatients and older ( ≥65 years) versus younger (＜65 years) patients. Results： The response rate was 57.0％. Pain management was less adequate among outpatients than among inpatients, with pain relief rate of 28.9％ for the former and 52.6％ for the latter (P＜0.001). Among outpatients, the pain relief rate for the older patients was particularly low (older：24.7％ vs younger：35.8％, P＜0.01). Conclusion： Pain management for older patients in the outpatient settings needs a particular attention for improvement. Resources should be allocated to enable better detection and relief of pain among outpatients.

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Purpose： In this study, we aimed to investigate the discrepancy between interview by medical personnel using 3‒point verbal rating scale (VRS) and patient complaints using numerical rating scale (NRS) in nausea diary for chemotherapy‒induced nausea. Patients and Method： In this study, we targeted patients who received chemotherapy at the gynecology department in our hospital and who recorded information in nausea diary. The discrepancy was estimated from NRS in nausea diary and the degree of nausea obtained by medical interview at approximately the same time period. We classified it into overvaluation, undervaluation or non‒discrepancy. Result： A total of 663 cases was analyzed, and 54 patientswere enrolled. The discrepancy was 25.2％ (undervaluation 5.4%; overvaluation 19.8％), and mostly overvaluation was observed. NRS in nausea diary had a significant correlation with the degree of nausea obtained by medical interview（P<0.001, r=0.66） , and the kappa statistic was 0.36. Conclusion： Ratio of non‒undervaluation is approximately 95%; hence, we conclude that interview by medical personnel using VRS accurately reflects the degree of nausea.

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Background: Previous surveys have demonstrated that a significant proportion of inpatients did not receive adequate pain management at an acute care hospital in Japan. Aim: The aim of this study was to evaluate the usefulness of a hospital-wide audit for assessing pain management with opioids according to the electronic medical records (EMRs) Methods: The subjects of this audit were inpatients receiving strong opioids who had not been consulted by the pallia. tive care team (PCT). The PCT held a weekly pharmacist-led conference to evaluate the adequacy and appropriateness of analgesics, including opioids, as well as drugs administered for adverse effects according to information collected by the PCT pharmacists. The PCT subsequently recorded the advisory comments in the EMRs. Each week, the PCT monitored whether the suggestions had been accepted by primary physicians and whether the pain and/or adverse effects had improved. Results: Among a total of 4,978 cases evaluated during the 3-year survey period, 888 (17.8％) had inadequate pain and/or adverse effect management. Symptoms improved in 82.3％ of cases for which PCT proposals were accepted. Conclusion: The results suggest that this hospital-wide audit may be useful for improving pain management with opioids at an acute care hospital.

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A decrease in swallowing function growth may lead to drooling and a diminished quality of life in patients with tongue cancer. Common ways to counteract drooling include a reduction of fluid intake, and the administration of anticholinergics. These actions, however, may not often suppress drooling sufficiently. Here we report how the application of the formulation of scopolamine ointment near the mastoid process behind the ear resulted in the alleviation of drooling in a tongue cancer patient, after continuous intravenous scopolamine butylbromide infusion was unsuccessful. Dry mouth was noted as an adverse event, which was not problematic. Also, the ointment could be used without local dermatitis. Scopolamine ointment is much more convenient to use than continuous injection, suggesting the improved treatment for drooling in patients with tongue cancer.

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Objective:To report a case of serotonin syndrome induced by an interaction between fentanyl and amoxapine in a patient treated for cancer pain. Case:A 37-year-old woman with recurrence of cervical cancer was treated with oxycodone and etodolac for her cancer pain in the gluteal region. She developed acute abdominal pain and received emergency surgery under the diagnosis of upper gastrointestinal tract perforation.Continuous fentanyl infusion was initiated during surgery and was continued postoperatively to control postsurgical and cancer pain. The route of fentanyl was changed to transdermal patch the next day, and dose was escalated during the following days in attempt to control her gluteal pain. Eight days after the operation, amoxapine was prescribed as an adjuvant analgesic. Five days later, the fentanyl dose was further escalated to 2100μg/day. The following day, the patient developed tremors of the extremities, confusion and hallucinations, followed by fever and involuntary movements of the lower extremities. Amoxapine was discontinued and the symptoms subsided within 4 days.Conclusion:Co-administration of a tricyclic antidepressant and high doses of fentanyl precipitated serotonin syndrome in this patient.

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Introduction: Goshuyuto was effective in a case with intractable hiccups caused by the medulla oblongata dissemination of the cerebellum melanoma. Case:A 54-yearold male patient was diagnosed cerebellum malignant melanoma. He suffered from intractable hiccups caused by the medulla oblongata dissemination lesion of this melanoma. He was treated with some Western medicines such as Baclofen, Metoclopramide, Chlorpromazine and Clonazepam, which are usually used for the treatment of hiccups, but they were not effective. Therefore we gave him Goshuyuto which is Kampo medicine and his hiccups subsided immediately. Since then, he continues taking Gosyuyuto about a year and there has been no recurrence of hiccups thus far. Conclusion: Taking of Kampo medicine is the useful choice for a patient whom Western medicine is ineffective.

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Headaches caused by metastatic brain tumors result from dural tension and traction of the sites of nociceptive nerves that originates from displacement of cerebral vessels and intracranial hypertension caused by the tumor. Causes of such headaches also include meningeal irritation resulting from intrathecal dissemination of tumor and carcinomatous meningitis.Treatment of headaches resulting from intracranial hypertension involves alleviation of cerebral edema and reduction of intracranial pressure using hyperosmolar therapy and steroid administration, but treatment is often complicated by a lack of pressure reduction. We encountered 2 cases of headaches with intracranial hypertension that did not improve following hyperosmolar therapy and steroid administration, but resolved with increased opioid dose.In cases where intracranial pressure does not decrease, or for headaches attributed to direct stimulus of intracranial nociceptive nerves rather than intracranial hypertension, attempts to treat the patient with initiation or increased dosage of opioids may prove effective from a clinical standpoint.

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We have several choices against bleeding and obstruction in advanced gastric cancer patients such as surgical or endoscopic therapy. But we have few reports about palliative radiation. We conduct this study that we perform palliative radiation for unresectable advanced gastric cancer patients between April 2006 and March 2014 in single center. In the aim of the therapy, to stop gastric bleeding were 8, and to improve obstruction depend on gastric cancer were 4. Response rate of stop bleeding was 63％, and improve obstruction was 50％. Median duration of stop bleeding was 103 day, and improve obstruction was 52 day. Overall survival time was 567 day, survival time after the start of radiotherapy was 105days. Radiotherapy was limited in cases because onset time of response needed in comparison with surgical or endoscopic therapy. However, given minimally invasive therapy and a certain response, we can choice it so much more.

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The assessment of suffering in cancer patients affected by dementia can be challenging. We report a patient with advanced skin cancer and dementia who was admitted to our hospital without appropriate diagnosis as having cerebral infarction at previous hospitals. Case:An 85-year-old woman presented with existing cognitive dysfunction from 2009 and progression of a left facial skin tumor existing from 2013. She was admitted to hospital A for facial skin tumor with dysphagia, and diagnosed as having advanced skin cancer with dementia in June 2014. After palliative therapy for the skin tumor, she was transferred to hospital B. The physicians at both hospitals explained the presenting symptoms as complications of her advanced skin cancer and dementia. She was admitted to our hospital at 36 days after symptom onset, and we diagnosed subacute cerebral infarction based on head CT and MRI examinations. In this case, the patient’s advanced cancer and dementia might have interfered with the recognition of her symptoms of cerebral infarction. A detailed interview on admission might have contributed to our decision for further examination. Although the diagnosis of cerebral infarction could not palliate her physical symptoms, it might assist the family to recognize her suffering or to provide care perceiving her poor prognosis. Additionally, the diagnosis might have an effect for emotional satisfaction of the family.

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Trousseau syndrome is a clinical condition in which a thrombosis and embolism are caused by hypercoagulation associated with a malignant tumor. Here we report on a patient who developed a cerebral infarction during hospitalization in a palliative care unit due to advanced recurrent rectal cancer and was treated with anticoagulation therapy. A 50—year—old woman who experienced lung metastasis and bone metastases after rectal cancer surgery was hospitalized in a palliative care unit because increasing pain made home care difficult. Although her pain was relieved by drug therapy and irradiation, she developed a partial visual field defect and aphasia in succession when she received medical treatment because of respiratory discomfort due to advanced pulmonary metastases. Multiple cerebral infarctions were observed on a magnetic resonance imaging and blood tests revealed disseminated intravascular coagulation； therefore she was diagnosed with Trousseau syndrome. After the initiation of anticoagulation therapy, the aphasia improved. No adverse events were caused by treatment. All patients in the terminal phase should not be equally judged as not being candidates for anticoagulation therapy. It is necessary to examine each patient’s suitability by considering their prognosis and general condition as well as the significance and safety of the treatment.

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Oral transmucosal fentanyl has been developed for the management of breakthrough pain in cancer patients. Buccal and sublingual fentanyl tablets have been licensed in Japan. However, the optimal use of oral transmucosal fentanyl has not been elucidated. We describe the treatment of cancer‒related pain using a 100μg fentanyl sublingual tablet and a 12.5μg/hr fentanyl patch in a 77 year‒old man with rectal cancer and thoracic vertebral metastasis. After the first use of the fentanyl sublingual tablet, the patient’s consciousness was impaired for 6 hours, however respiration was stable. This case shows that administration of fentanyl sublingual tablets may not be recommended for breakthrough pain incancer patients who are being treated with 30mg/day of oral morphine equivalent dose (20mg/day oxycodone, 12.5μg/hr fentanyl patch).

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We often meet the patient suffer from skin pruritus caused by jaundice. Those patients are treated with various methods and care, but there therapy are often ineffective. Japanese herbal medicine Gosha‒Jinki‒Gan has been successfully used to reduce skin pruritus in two patients caused by jaundice associated with advanced cancer. Case 1： A 68‒yearold man had suffered from pruritus caused by obstructive jaundice associated with cholangioma. He had treated with endoscopic nasobiliary drainage (ENBD) and other methods, but pruritus was not reduced. Gosha‒Jinki‒Gan (7.5g/day) imploved sleep disturbance. Case 2： A 81‒year‒old man had suffered from pruritus caused by jaundice associated with liver cirrhosis and hepatoma. He had treated with various methods, but pruritus was not reduced. Gosha‒Jinki‒Gan (5.0g/day) reduced his Numeric Rating Scale (NRS) of pruritus (10→3). Gosha‒Jinki‒Gan is recommended for skin pruritus due to jaundice.

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[in Japanese]

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In 2011, we reported the usefulness of a database（DB）that was established by the members of a palliative care team（PCT）. Since then, we updated DB depending on the requests of PCT. We revised DB mentioned below. We developed a form for keeping a record of PCT members’care for patients, their family members or others, and a record of recommendation for each problem list. We also updated another form so that the evaluation of Support Team Assessment Schedule of Japan（STAS-J）had been showed sequentially, added an entry form of Palliative Prognostic Index, and extracted data required by Japan Society for Palliative Medicine in order to evaluate the activity of PCT. The database could be used by many hospitals, because it was created by the commercially available software.

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This study analyzed the outcomes of palliative care team（PCT）activity in Tottori Municipal Hospital. The PCT, consisting of doctors, nurses, pharmacists, and cancer consultants, made an“opioid round”weekly to evaluate the effects of pain management for inpatients and make proposals in cooperation with ward nurses and pharmacists. Excluding those treated through PCT intervention, inpatients receiving opioid for the management of cancer-related pain were targeted. Proposals were made, following the WHO guidelines for the management of cancer-related pain, and the results of each round were reported to the primary doctor. The effects of continuous rounds were examined 4 years after their initiation, in September 2009, by evaluating improvements in pain management by the primary doctor. The annual rate of proposals made during rounds steadily decreased:Year 1:16.7％, Year 2:12.6％, Year 3:8.1％, and Year 4:7.5％. These results might support the educational effect of opioid rounds as part of PCT activity to optimize pain management by feeding back the results to the primary doctor.

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[in Japanese]

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