Object: We validated the adequacy of using Palliative Prognostic Index (PPI) as a prognostic method for medical oncology patients. Method: PPI was measured for patients with advanced cancer admitted to our department from May 2015 to June 2016.Result: There were 45 patients analyzed. When classified into three groups according to the score of PPI, there was a tendency for survival curves to separate according to risk. Especially, there was a statistical difference in survival time between the high-risk group (PPI: ≥6.5) and the low-risk group (PPI: ≤4.0) (median survival time: 11 days vs 39 days, p=0.0048, HR: 2.75, 95%CI: 1.32-5.84). Prognostic accuracy of the PPI≥6.5 is similar to other reports. There is no difference in the accuracy of the prognostic prediction depending on the period from drug therapy to PPI evaluation. It was suggested that the influence of drug therapy on PPI evaluation is small. Discussion: We showed that it is appropriate to use PPI for the prognostic prediction of medical oncology patients.

Purpose: To clarify the factors that affect the family caregiver’s quality of life (QOL) of cancer patients. Methods: We conducted an internet survey including 21 items of the Japanese version CQOLC for 400 families of cancer patients in March 2012. Results: Factors that increased psychological burden were that caregivers were women, other family needed long-term care, and the patient had higher need for care. Factors that increased the family caregiver’s difficulty in their daily activities due to long-term care were caregivers are women, other family needed long-term care, caregivers did not think they had a good relationship with the patient, and the patient had higher need for care. Factors that increased financial burden were that the age of caregivers was less than 60 years, decreased of income after the patient’s diagnosis, and patients were men. Factors that increase the positive feeling for caregiving were that caregivers thought they had good relationship with the patient, and the patient’s need for care was higher. Conclusions: To reduce the burden in family caregiver of cancer patients without losing the positive feeling for caregiving would be important for both improving the family caregiver’s QOL, and to continue the care for patient in long term.

Aim: To clarify the predictive risk factors for bedsores of terminal cancer patients receiving home-based care. Methods: A retrospective study was conducted involving 95 terminal cancer patients receiving home-based care, including people using services provided by home-visit care providers until death. Results: The numbers of patients with and without bedsores were 31 and 64, respectively. Bivariate analyses revealed that significant variables were the Ohura-Hotta scale (P=0.02), hyperactive delirium (P=0.005), contracture (P=0.008), and anemia (P=0.02). According to multivariable logistic analysis, significant variables were contracture (OR=16.55, P=0.0002) and hyperactive delirium (OR=4.22, P=0.008) as independent risk factors for bedsores. Discussion: For terminal cancer patients receiving home-based care, hyperactive delirium should also be considered as a predictive risk factor for bedsores.

This study aimed to investigate the changes in physical function, fatigue, and psychiatric symptoms in patients with hematological malignancy undergoing chemotherapy and low-intensity exercise training. Sixty-two hospitalized patients with hematological malignancy undergoing chemotherapy and low-intensity exercise were recruited. At the time of exercise initiation and hospital discharge, grip strength, knee extension muscle strength, maximum walking speed, Eastern Cooperative Oncology Group (ECOG) performance status, a measure of functional independence, cancer fatigue pain, and hospital anxiety and depression were evaluated. When longitudinal data were analyzed in each group, changes in grip strength and knee extension muscle strength were unevenly distributed: some patients showed a decrease in knee extension strength. On the other hand, maximum walking speed, the measure of functional independence, and ECOG performance status were maintained or improved in more than 90% of the patients. Results of fatigue, anxiety, and depression tended to show an improvement in female patients, but not in male patients. In conclusion, physical function was maintained in nearly all patients with hematological malignancy undergoing chemotherapy and low-intensity exercise training. Sex differences were found in changes of fatigue, anxiety, and depression.

Purpose: We investigated the benefits and problem of the palliative care provided by long-term care unit through a survey of staff in palliative care units (PCU) and long-term care units. Methods: Self-reported questionnaires were administered to staff who engaged in PCU and long-term care units. Questions included: awareness of WHO palliative care definition, and, the general idea on palliative care, possibility of cooperation with PCU, advantages / disadvantages, and idea for non-cancer palliative care in long-term care unit. Results: We got responses from 248 medical and nursing-care staff. The percentage of “knowing” the WHO definition was 76.5% in medical staff / 32.3% in care worker, 87.6% in PCU experience / 46.5% in non-experience. Categories of responses are good, advantageous, problematic, difficult requirement, difficulty, etc. The main answers were the difficulty of care, problems of knowledge and technique, and points of problems related to personnel shortage. Medical staff or PCU experienced staff pointed out needs of palliative care and improvement of knowledge and skills. Conclusion: Opinions acknowledging the benefits and necessities for palliative care of long-term care units and a number of problems were revealed.

Backgrounds and Aims: Advance Care Planning (ACP) is necessary for the decision making support of cancer patients. To that end, the truth telling about the diagnosis of cancer, respect for thought, intention, privacy is important. In this study, we investigated the recognition about ACP for cancer patients in general ward nurses to clarify what kind of promotion is necessary to enhance ACP. Methods: Eight hundred nurses who are engaged in nursing cancer patients in the general ward of nationally designated cancer medical collaborating hospital in Hiroshima prefecture were included in this study. Survey was carried out by self-written questionnaire survey by mailing method. Results: Valid responses were 364/800 (46%). The rate of achievement of patients’ advocacy and respect for protection was about 74% and 88%, respectively. That of respect of patients’ privacy was 89%. However, there were variations in recognition when the patient’s condition deteriorated. Only 20% of nurses recognized properly the meaning of ACP. Conclusion: The recognition of ACP in general ward nurses was insufficient. Accordingly, the enlightenment, education, environment maintenance for general ward nurses are urgent themes.

Purpose: This study aimed at identifying the nature of nursing for patients who have appearance changes due to cancer treatment. Methods: Nurses’ focus group interviews were conducted at two cancer hospitals. The data were analyzed qualitatively. This study was approved by the Research Ethics Committee at the study hospitals. Results: Six focus group interviews were conducted, including a total of 21 participants. The participants’ mean age was 39.2 (SD=6.0) years. Their mean years of professional experience was 16.3 (SD=5.8) years. The participants also included a total of 16 Certified Nurse Specialists and Certified Nurses. Interviews took an average of 42 minutes. Four core categories derived from interviews were: “providing information in advance that is necessary for those having the risk of appearance changes to predict and to prepare,” “providing support to enhance patients’ self-care according to the processes of appearance changes in their daily lives,” “advocating patients’ decision to improve their quality of life,” and “utilizing specialty of multi disciplines through care coordination and collaboration.” Conclusions: Further study will systematically analyze details of appearance changes and necessary care associated with different cancer treatment methods, organ sites, and treatment cycles.

Introduction: We experienced a case of pneumatosis cystoides intestinalis with intra-abdominal free air following steroid therapy for an end-stage brain tumor. Case: The patient was a 67-year-old man. He had received surgery and chemotherapy for the brain tumor, but the disease progressed and his consciousness deteriorated. Eventually, he developed aspiration pneumonia and was hospitalized. His consciousness level remained poor even after the pneumonia improved. His survival prognosis was considered to be approximately 1 month, and he was transferred to a palliative care ward. After the transfer, administration of betamethasone 8 mg/day was started for the purpose of improving his level of consciousness. Temporary improvement was observed, and administration of this drug was continued with dose adjustments, as appropriate. Six weeks after the start of betamethasone administration, when his consciousness level again deteriorated, aspiration began to recur. Chest X-rays, obtained to assess pneumonia, showed intra-abdominal free air. Pneumatosis cystoides intestinalis was confirmed by computed tomography. He had few abdominal symptoms, and was managed conservatively. He died of respiratory failure. Conclusion: Pneumatosis cystoides intestinalis is mostly secondary, and steroid therapy is considered to be one of the causes. But follow-up observation is often conservative, and judgment of discontinuation of steroid needs to be made in consideration of its effect and prognosis is there.

We report three cases of terminal-stage ovarian cancer where diatrizoate meglumine and diatrizoate sodium solution (Gastrografin) was effective for malignant bowel obstruction due to peritoneal dissemination. All cases had gastrointestinal symptoms such as nausea, vomiting, abdominal pain, and constipation, showed air-fluid levels and dilation of the small intestine on imaging tests. Therefore, all the cases were diagnosed as bowel obstruction. We initiated oral administration of Gastrografin because the patients failed to show a sufficient response to other drugs such as octreotide. Their gastrointestinal symptoms such as nausea and constipation improved after administration of the drug, and they could continue oral intake. In addition, they were diagnosed as having an incomplete bowel obstruction since radiographic examination 24 hours after administration of Gastrografin confirmed its presence in the large intestine. In all the cases, Gastrografin could be used repeatedly without noticeable side effects. This study suggests that Gastrografin might be useful for evaluating bowel obstruction and improving gastrointestinal symptoms in patients with malignant bowel obstruction caused by terminal-stage ovarian cancer.

Malignant psoas syndrome (MPS) is caused by malignant infiltration of the psoas muscle and adjacent nerves. Patients with MPS have a combination of pain, both neuropathic and nociceptive, which is often refractory to conventional analgesic therapy. We report the case of a 53-year-old female patient with left MPS caused by the growth of pelvic lymph node metastases from uterine carcinosarcoma. Palliative radiation therapy (RT) to the regional lymph nodes was planned; however, we could not start it because the patient was unable to extend her left hip and stay at rest in the supine position during the RT. We administered epidural analgesia with short-acting local anesthetics 30 min before RT. She could extend her hips despite remaining of pain. We then administered single-shot epidural analgesia just before every RT and were able to perform RT as scheduled. Multimodal approach is needed to manage MPS. In this case, combined oral treatment and epidural analgesia was an effective analgesic therapy for relief of pain due to MPS. Here we report the effective pain management of MPS with repeated single-shot epidural block for palliative RT.

From January 2015 to January 2017, we encountered five terminal cancer patients with implantable cardioverter defibrillators (ICDs) in the palliative care unit of our hospital. Due to delirium or dementia, four of these five patients did not have the decision-making capacity to stop their ICD. Although one patient was capable of making his own decisions, his family did not agree with the medical professional considering the patient’s decision. The families of all five patients made decisions on behalf of the patients. The procedure for stopping the ICD was first discussed with the families at 2–21 days prior to the patients’ deaths. The ICDs were stopped between 3 h and 11 days prior to the patients’ deaths, following the consent of the families, which was obtained after 1–5 consultations. Through these experiences, we became aware of the following problems with regard to stopping ICDs: (1) the lack of experience of medical professionals in decision-making, (2) the lack of recognition of medical professionals to the distress caused to patients by ICDs, (3) the psychological burden and time constraint of discussions, and (4) the lack of knowledge of ICDs among patients and their families. These problems need to be addresses as part of advance care planning for cancer patients. 

Introduction: We report a very rare case of paraneoplastic chorea due to lung cancer that was ameliorated by administering tetrabenazine, the only agent used for treating the chorea of Huntington disease. Case: A 92-year-old woman was diagnosed with lung cancer but only followed up, based on advanced age and her own wishes. Given the absence of treatments such as chemotherapy, the lung cancer was not histologically diagnosed. During follow-up, involuntary movements appeared and paraneoplastic chorea was diagnosed. Therefore, she could not live alone and was admitted to a nursing home. Triple combination therapy with valproic acid, tiapride hydrochloride and risperidone was started, and showed efficacy for her symptoms. The symptoms showed amelioration but persisted in the upper extremities, face and neck. A neurologist suggested to her family that tetrabenazine, the only medication used for Huntington’s chorea, might be effective. After admission to our hospital, her family requested tetrabenazine. As both she and her family were suffering mental distress because “she was trapped in a body that moved regardless of her will”, we initiated tetrabenazine at a dose of 12.5 mg/day. After starting tetrabenazine, chorea of the upper extremities, face and neck almost disappeared. Moreover, her speech became clear and she spoke normally with her family. Discussion: Tetrabenazine is a drug receiving insurance reimbursement only for Huntington’s chorea, but was effective in this case. In our view, this treatment palliated the patient’s physical distress and the mental distress that she and her family were experiencing due to her paraneoplastic chorea.