Objective: The aim of this study was to investigate the current status of the palliative care provided by long-term care unit that was established together with palliative care unit (PCU). Methods: Self-reported questionnaires were administered to long-term care unit administrators at 24 facilities that was established together with PCU. Questions included: managing the use of narcotic drugs, situation about receiving cancer patients, situation about cooperation with PCU, and difficulty with palliative care. Results: Eighteen (75%) facilities responded to the questionnaire. Fourteen facilities of respondents reported that narcotic drugs were available and usable in long-term care unit, and ten facilities reported that the narcotic drugs could be used in the same way as PCU could. Ten facilities reported that they had doctor(s) knowledgeable about palliative care or prescribing narcotic drugs, and 11 facilities reported that they had nurse(s) experienced about palliative care. Cancer patients were accepted in all 18 long-term care units. Transferring from long-term care unit to PCU due to medical condition changes after hospitalization had been carried out in 17 facilities. Unit administrator’s perceived difficulty lack of staffing, lack of staff expertise and education, and issues surrounding narcotic drug management. Conclusion: These long-term care units were providing palliative care for cancer patients in cooperation with PCU. The survey results indicated the need for solving human resource, educational, and administrative problems.

The aim of this study was to examine the usefulness of opioid initiation therapy with oral tramadol (TD) by comparing its efficacy and safety with that of sustained-release oxycodone (OXC). Although the complexity of clinical setting seemed to make difficult to carry out strict evaluation of TD initiation therapy, a higher number of patients experienced unmanageable pain with TD initiation therapy than with OXC. Almost half the TD-initiated patients switched from TD to another analgesic in earlier phase than those on OXC did. However, the number of patients who changed the initiation opioid because of side effects was larger with OXC than it was with TD. The incidence of nausea and sleepiness was significantly lower with the TD initiation therapy than it was with OXC. Additionally, cases of nausea observed after OXC administration were also significantly fewer in patients who switched opioids from TD to OXC than in the OXC-initiated patients. In the case of OXC-initiation, the number of onset of side effects was the highest immediately following opioid initiation, and then it gradually decreased. However, in switched case from TD to OXC, they mostly did not develop side effects after OXC administration. These results suggest that opioid initiation with TD could be a useful alternative for pain management with fewer side effects; however, careful monitoring of pain relief is essential, especially in the early phase of TD initiation.

The aim of this study was to investigate the dementia provision for elderly cancer patients in designated regional cancer centers. A survey was mailed to 389 designated regional cancer centers from February to June, 2015. A total of 188 facilities responded (response rate: 48.3%). 5.3% of the respondents used two manuals (on basic dementia care and the behavioral and psychological symptoms of dementia) to check whether these centers were following appropriate measures. About 50% of the respondents performed dementia assessments by the primary care team. 29.3% of the respondents maintained the system of the education and training of dementia care. Therefore, dementia provision for elderly cancer patients in designated regional cancer centers needs to improve the education of dementia care.

Purpose and method: The aim of this study was to explore the child-care and housework difficulties experienced by fathers during their wife’s cancer treatment. 7 men who had 0 to 15-year-old children when their wife was diagnosed with cancer were interviewed using a semi-structured interview format. Main results: Subjects’ report of their difficulties was assessed using the following 3 categories: 1) burden of housework 2) stress from life together with the in-laws 3) contact with schools and nurseries. The influence of background factors was considered: a) experience of housework in the family prior to his wife’s illness; b) experience of living with in-laws; c) degree of cooperation with their parents; d) degree of trust in their relationship with their in-laws; e) child’s/children’s age; f) availability of childcare resources; and g) assistance prepared by their wife. Providing information on child care and housework support or opportunities for exchanging information with other husbands in similar situations can be considered valid forms of assistance for fathers whose background factors may predispose them to a greater degree of hardship in child care and housework during their wife’s illness.

Aims: The aim of this study was to clarify practical use of feedback report in each institution participated the nationwide bereavement survey (J-HOPE3). Methods: After a nationwide bereavement survey (J-HOPE3) conducted in 2014, we sent a feedback report to each participated institution (20 general wards, 133 inpatient palliative care units, and 22 home hospice services). The feedback report included the results from quality of care, bereaved family’s mental status, and free comments from the participant of their own institution. We sent a questionnaire 4 month following to the feedback report for all institutions regarding the practical use of results from the feedback report. Results: The analysis included 129 (response rate 74%) returned questionnaires. The institutions that they passed around the report was 90%, discussed about their results at a staff meeting was 54%, and reported the results to manager/chief of the institution was 65%. Around 80% of the institutions responded positively to receive the feedback report of their own institution such as “It was good that they could understand the strengths and weakness of their own institutions” which reported that they worked on to improve care were 48%. Conclusions: Current study had shown data about practical use of the feedback report of bereavement study. It is important to feedback the results and encourage the institution to make use of the results in their daily practice, especially to discuss the results in staff meetings.

Objectives: We developed versions 2 and 3 of the Biological Prognostic Score (BPS) for advanced cancer patients and confirmed the prediction accuracy. Methods: We conducted a parametric survival analysis using blood test data, performance status (PS), clinical symptoms, age, sex, and cancer type as variables for advanced cancer patients who completed or suspended cancer treatment, in the development of BPS2 and BPS3. We then prospectively compared the accuracy between BPS2/BPS3 and the Palliative Prognostic Index (PPI). Results: We developed the BPS2 and BPS3 based on the data from 589 patients in a development cohort. While the former version was calculated based on the cholinesterase, blood urea nitrogen, and white blood cell counts, the latter was calculated based on the BPS2, ECOG PS and edema. For 206 patients in a validation cohort, the overall accuracy in prediction of survival for 3 and 6 weeks using the BPS2 and BPS3 were significantly higher than those for the PPI. Conclusion: The usefulness of BPS2 and BPS3 was suggested.

Objectives: This study aimed to evaluate good death (end-of-life quality of life) from the perspective of bereaved family members. Methods: We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members by web survey. Outcomes were achievement of a good death (Good Death Inventory, GDI). We compared the outcomes between with and without dementia. Results: 163 and 224 dying elderly patients with and without comorbid dementia were analyzed from bereaved family members’ responses. The achievement of good death were significantly different (GDI scores, 4.2±1.0, 4.4±0.9, Adj P=0.053) as regards “maintaining hope and pleasure,” “good relationship with family,” and “independence.” Conclusion: The achievement of good death was not significantly different between the dying elderly patients with and without comorbid dementia. Psychosocial care for informal caregivers would be important for better quality of dying in the terminally ill elderly patients with dementia.

Objectives: This study aimed to evaluate the consequences of caring for end-of-life elderly patients from the bereaved family’s perspective. Methods: We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members by web survey. Outcomes were caregiving consequences (Caregiving Consequences Inventory). We compared the outcomes between with and without dementia. Results: 163 and 224 dying elderly patients with and without comorbid dementia were analyzed from bereaved family members’ responses. The outcomes were not significantly different (burden, 5.24±1.12, 5.32±1.24, p=0.487; fulfillment, 4.53±1.06, 4.59±1.29, p=0.627; growth, 4.94±0.93, 5.00±1.04, p=0.523). Fulfillment was significantly associated with spouse, family visitation, and mental health. Growth was significantly associated with age, spouse, end-of-life discussion, and family preference of treatments. Conclusion: The evaluation of the consequences of caring for end-of-life elderly patients from the bereaved family’s perspective were not significantly between the informal caregivers of those with and without comorbid dementia.

Objectives: Peripherally inserted central venous catheter (PICC) is widely used, because the incidence of complications and bloodstream infection in patients receiving PICC was lower than that in patients receiving central venous catheter. We compared PICC between cancer patients and non-cancer patients. Methods: This retrospective single-center study included 157 patients receiving PICC from May 2012 to September 2015. Patients were separated into cancer and non-cancer groups. Results: Cancer patients were 88 and non-cancer patients were 69. The most common causes of PICC were intravenous hyperalimentation (Cancer vs. non-cancer: 45 vs. 51) and difficult peripheral venous access (40 vs. 12) (p=0.0022). The duration of catheterization was 15 (6-39) vs. 21 (12-40) days (p<0.0001). The causes of catheter removal were death (50 vs. 14), remission (9 vs. 26), redness on insertion site or infection suspicion (10 vs. 11), and Some kind of catheter trouble (8 vs. 4) (p=0.0002). Complications occurred in 8 vs. 9 patients (p=0.429), and infection occurred in 0.9 vs. 2.0/1000 catheter days (p=0.041). Discussion: End-stage cancer patients have a weakened immune system. In this study, the incidences of PICC-related infection and other complications were not different between cancer and non-cancer patients, suggesting PICC was a safer method.

Opioid-switching (OS) is usually performed with conversion methods based on the equianalgesic dose table. However, the conversion ratios might lead to significant differences in clinical practice. No clear guideline exists for safe, effective switching from transdermal fentanyl (TF) to oxycodone injection (OXJ). We retrospectively investigated the adequate analgesia dose of OXJ in OS from TF by comparing with the equianalgesic calculated dose based on the conversion ratio of 1.0 : 41.7 between TF and OXJ. Patients with a pain scale score of 0 were assigned to the “NRS/VRS=0” group (n=4), and the remaining patients were assigned to the “NRS/VRS>0” group (n=27). During a 4-year period, 31 of 49 patients with cancer-related pain who underwent OS from TF to OXJ were investigated. All patients in the NRS/VRS=0 group (4/4, 100%) and most in the NRS/VRS>0 group (23/27, 85%) achieved adequate analgesia. Among the 27 patients with adequate analgesia, the median effective OXJ dose was 28% (interquartile range, 21-47) of the equianalgesic calculated dose in the well-controlled group and 103% (interquartile range, 71-164) in the poor analgesia group. Strong drowsiness developed in two patients the day after OS, and the OXJ dose was decreased. Our findings suggest that in patients without pain, it might be necessary to reduce the OXJ dose to approximately 30% of the equianalgesic calculated dose for safe OS from TF. Pain intensity and drowsiness due to an opioid overdose should be carefully monitored and may require dose adjustment.

Introduction: We herein report a case whose terminal refractory delirium improved after discontinuation of continuous deep sedation for several days. Case: A 57-year-old head and neck cancer woman with brain parenchymal invasion was consulted to our palliative care team for delirium accompanied by sudden abnormal behavior. Her abnormal behavior did not improve with opioid switching or drug treatment. She was diagnosed as refractory end of life delirium, and her family wanted her to be sedated. We started intermittent sedation with midazolam and then shifted to continuous deep sedation. Several days later, her family expressed the conflict of continuing sedation. Ten days later we stopped sedating her according to her family’s will. She awoke from deep sedation and her abnormal behavior disappeared, although there was mild consciousness disturbance. The patient died 2 months later while maintaining communication with her family. Discussion: Cessation of various drugs which may provoke delirium is considered to be one of the causes of delirium improvement in this case. The guidelines of the Japanese Society of Palliative Medicine do not clearly state the criteria for suspension of deep sedation other than confirming the feelings of family members. A criterion for withdrawal of sedation should be discussed based on higher evidence level.

Introduction: We encountered a patient in whom pruritus was induced by obstructive jaundice associated with metastatic liver cancer. Nalfurafine hydrochloride, a selective κ receptor agonist, improved the patient’s pruritus. Case Presentation: The patient was a 70-year-old woman who developed metastatic liver tumor-associated jaundice after surgery for colorectal cancer. She developed pruritus, which was not improved by an antihistamine or a selective serotonin reuptake inhibitor treatment. Nalfurafine was administered for suspected central pruritus. The numerical rating scale for pruritus improved from 9 to 3. Discussion: Compared to other skin diseases such as urticaria and atopic dermatitis, pruritus that accompanies a systemic disease such as chronic renal failure and liver disease does not respond to existing therapeutic drugs in many patients. Chronic liver disease-associated pruritus is intractable and central. Pruritus through central and peripheral mechanisms was mixed in this patient; however, central pruritus may have been dominant. The antipruritic effect of nalfurafine has been confirmed. It may be an effective therapeutic drug for obstructive jaundice-associated pruritus.

We established the Early Palliative Care (EPC) outpatient department for patients who had received chemotherapy at other hospitals in August 2015. We retrospectively investigated medical records of patients who consulted the EPC outpatient department and patients who consulted the Medical Oncology outpatient department of our hospital between August 2015 and January 2016. The length of the first medical examination, the contents of the medical examination, period to hospitalization and period to death were investigated. Nineteen EPC outpatients and 11 Medical Oncology outpatients consulted a total of 80 times and 117 times at the respective outpatient department. The median length of the first medical examination in the EPC and Medical Oncology outpatient departments was 45 minutes (range, 10-106 minutes) and 38 minutes (range, 23-60 minutes), respectively (p=0.17). The contents of the examination in the EPC outpatient group included discussion about symptom management, coping, etc. Five patients (26%) in the EPC outpatient group passed away less than 60 days from the first medical examination. It would be possible for palliative physicians to establish and manage an EPC outpatient department in Japanese hospitals. However, some patients had late referral to the EPC outpatient department. Public awareness about EPC and the practice of EPC are important.

The experience at the time of a patient’s death can affect the mental health of bereaved families. Performing death pronouncements is an important skill for end-of-life care. However, almost no educational content regarding death pronouncements is presently included in medical educational programs. We have created a guidebook for “Physician behavior at the time of death pronouncement” based on the results of a questionnaire given to the families of deceased patients that included several items related to this topic. The purpose of this research was to investigate the educational effect of using this guidebook. The guidebook was given to 4th-year medical students attending the Yokohama City University School of Medicine. A survey was then conducted to assess evaluations of self-practice and feelings of difficulty at the time of making death pronouncements both before and after the class. Among the 39 students who provided valid responses, the majority (89.5%) indicated that they had difficulty with the item regarding “the specific method of death pronouncement.” A significant improvement was observed between the responses obtained before and those obtained after the class. We concluded that our guidebook for physician behavior at the time of death pronouncement might be useful for the education of medical students.