Aim: The usefulness and safety of strontium chloride (⁸⁹Sr), a radiopharmaceutical agent for painful bone metastasis, varies from patient to patient, but the reasons for why the usefulness and safety vary have not been elucidated. The purpose of this study is to explore the background factors of patients who experienced pain relief or bone-marrow suppression after ⁸⁹Sr was administrated. Methods: In the cases of pain relief, we divided the results from a numeric rating scale (NRS) before and after ⁸⁹Sr administration into effective and ineffective groups as outcomes. In the cases of bone-marrow suppression, we analyzed neutrophil cells, blood platelets, and hemoglobin levels, respectively, before and after ⁸⁹Sr administration as outcomes. Then, we performed statistical analyses on both case groups. Results: The results showed that the background factors associated with pain relief were weight, the ⁸⁹Sr dosage amount, NRS, eGFR, SCr, and Ca levels before ⁸⁹Sr administration and the area of bone metastasis (number of sites reached). We found that background factors associated with bone-marrow suppression have a moderate significant correlation with hemoglobin, NRS, and SCr levels before ⁸⁹Sr administration after investigating factors which influence neutropenia. In the case of thrombocytopenia, there was a moderate significant correlation with platelet counts before ⁸⁹Sr administration. In the case of hypochromia, there was a moderate significant correlation with hemoglobin levels before ⁸⁹Sr administration. Discussion: Our study could elucidate patient background factors associated with pain relief and bone-marrow suppression after ⁸⁹Sr administration.

Purpose: The field survey was conducted to evince the current status of palliative care for non-cancer patients. Methods: The on-line questionnaire survey was conducted covering 196 representatives of the Japanese Society for Palliative Medicine. Multiple-choice questions were asked about their medical experiences with non-cancerous diseases, their attitudes towards palliative care, their feelings of bewilderment upon providing palliative care, and what they thought would be required for future education in this field. Results: One-hundred and eleven (111) representatives (57%) responded the survey. Ninety-nine (99)% of the respondents experienced providing non-cancer patients with palliative care, but 63% of them experienced less than 50 patients in the terminal phases even in cumulative total. Eighty (80)% of them said they were feeling insecure about providing non-cancer patients with palliative care, and 83% of them were feeling difficulty when they had to do so. The reasons listed included that prognostic prediction for such cases wouldn’t be easy and that it wouldn’t be covered by public health insurances. What they felt necessary about future education included communication and multi-disciplinary team medicine, in this order. Conclusions: The representatives of the Japanese Society for Palliative Medicine are well-aware of the demands for palliative care for non-cancer patients, but not many of them have experienced such cases and more than 80% of them are feeling insecure and difficulty about providing it.

Purpose: This study investigated the current state of medical care and palliative care provided at home and the factors influencing death at home for terminally ill cancer patients living in single-person households. Methods: We conducted a retrospective questionnaire study of 1032 cancer patients living in single-person households who received home palliative care from 17 specialized home care clinics and finished home care between June and November 2013. We compared patient background factors, outcomes, home care services, and medical care between these patients and others not living in single-person households to investigate factors influencing death at home. Results: Compared with patients not living in single-person households, the patients living in single-person households were older, had a better performance status at initiation of home palliative care, showed a lower preference for dying at home, and received more frequent social hospitalization. Among the subjects from single-person households, factors influencing death at home were a family preference for dying at home (odds ratio (OR)=14.0), poor performance status at initiation of home palliative care (OR=4.0), and no hospitalization during home palliative care (OR=16.6). Conclusion: We found that death at home for terminally ill cancer patients living in single-person households and receiving home medical care and palliative care was influenced by family preference, the performance status at initiation of home palliative care, and hospitalization during home palliative care.

Objective: This study aimed to reveal the relationship between anxiety and depression and personal attributes or difficulties in daily life in patients after total laryngectomy. Methods: An anonymous questionnaire was mailed to 135 members of a self-help patient group. The questionnaire included the following items: personal attributes, difficulties in daily life, and anxiety and depression (according to the Nottingham Adjustment Scale-Japanese Laryngectomy Version). Multiple regression analysis was conducted with anxiety-depression score as the dependent variable and personal attributes and difficulties in daily life as independent variables. Results: Among the 57 patient respondents, 43 provided valid answers and were selected for analysis (valid response rate: 36.8%, 41 men and 2 women, mean age: 67.5±10.6 years). Results revealed that presence of anxiety and depression were significantly associated with patient age (β=−0.369, p=0.004) and difficulties pertaining to speech/performance during outings and engaging in hobbies (β=0.419, p=0.002). Conclusions: Our findings indicate that there is an increased risk of anxiety and depression in patients are young or middle aged and have difficulties in outings and engaging hobbies. Therefore, in clinical practice, nurses should carefully assess the mental state and difficulties in daily life in these patients after total laryngectomy. Moreover, nurses should continuously provide psychosocial support to patients and their families in order to help patients prevent psychological problems even after they are discharged from hospital.

Background: Mental assessment for patients in a palliative care unit with no regular psychiatrist tends to depend on subjective judgments by other health professionals. We introduced the 9-item Patient Health Questionnaire (PHQ-9) to screen major depression from patients in a palliative care unit and assessed the usefulness of the questionnaire. Methods: The subjects were all patients who were admitted to a palliative care unit. Each patient was asked to answer the PHQ-9 on admission and then was interviewed by a psychiatrist. When PHQ-9 score was of 10 points and above, the case was judged to be positive for depressive disorder. A psychiatrist diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). Results: A total of 83 patients were hospitalized between January 2016 and October 2016. 50 patients completed PHQ-9 and psychiatrist’s interview. Nine cases were positive by PHQ-9 and diagnosed as depressive disorder by a psychiatrist. Seven cases were positive by the PHQ-9 but not diagnosed as depressive disorder. Although 34 cases were judged to be negative by the PHQ-9, 2 cases of them were diagnosed as depressive disorder. The sensitivity and specificity of the PHQ-9 were 81.8% and 82.1% respectively. Conclusion: We found that the PHQ-9 was useful screening test for depression even in palliative care settings.

Objective: The purpose of this study was to clarify the job types and related factors that physicians and nurses feel easy to consult about pediatric cancer patients’ and their families’ end of life care. Design and methods: We conducted a self-reported questionnaire survey for physicians and nurses who have experienced at least one case of end of life care of childhood cancer. In the survey, we asked participants about whether they feel easy to consult about 15 job types such as palliative care team, certified nurse specialist in child health nursing, physicians and nurses of the same team. Results: A total of 427 physicians and nurses participated in this study. More than 70% of the respondents felt that it felt easy to consult with three job types such as “Nurses of the same team” and “Physicians of the same team”. Job types of the respondents were the main related factors in the most job types. Physicians felt easier to consult with person in each job type than nurses. Consideration: It was suggested that it would be necessary to consider the systems that allow individual professionals to feel easy to consult with persons in each job type, such as specifying consultation methods and procedures for each job type, and introducing inter-professional education.

This study aimed to clarify the current status of and factors related to support by general ward nurses for transition to home care settings for end-stage cancer patients. A questionnaire was sent to 1,019 general ward nurses. Multiple regression analysis was performed to determine related factors. The 17-item scale to evaluate nurses’ decision-making support for transition to home care settings was used as a dependent variable. A total of 653 valid responses were obtained (valid response rate: 64.0%). The following factors were correlated with decision-making support for transition to home care settings: “experience supporting transition to home care settings” (β=0.26), “professional autonomy in nursing: concrete judgment” (β=0.23), “professional autonomy in nursing: performance” (β=0.18), “learning experience with home care nursing” (β=0.13), “belief in an afterlife” (β=0.12), and “learning experience with family nursing (β=0.07)” (adjusted R²=0.27). The results suggest the practical abilities of nurses, i.e., relevant experience, knowledge, and views on death and dying are related to nurses’ decision-making support for transition to home care settings for patients with end-stage cancer.

We conducted a questionnaire survey of nurses to develop a scale for the Japanese version of the Quality of Dying and Death in the Intensive Care Unit (ICU-QODD) instrument for use by nurses. The questionnaire was based on “patient’s experience at the end of life” in ICU-QODD for health professionals in the United States. We assessed whether it could be used as a comprehensive evaluation tool. Respondents included 1,372 nurses for factor validity and internal consistency, and 39 nurses for test-retest reliability. Two factors, “physical symptoms” and “dignity” that comprised 6 items were identified. Cronbach’s alpha values were 0.89 and 0.75, respectively. Intraclass correlation coefficients were 0.62 and 0.72, respectively. Sufficient reliability and validity were confirmed. It was suggested that 6 out of 15 items could be used as for comprehensive evaluation of the ICU-QODD.

Objective: We retrospectively studied the adaptation and limits of applying Biological Prognostic Score Version-2 composed only of blood test results to prognostic prediction in end-of-life non-cancer patients. Methods: The prognostic score was calculated from the cholinesterase, blood urea nitrogen, and white blood cell counts of hospitalized end-of-life non-cancer patients, divided into three groups with cutoff values, and prediction accuracy analysis, survival analysis, and simple regression analysis were performed. Results: Diagnostic accuracy of 204 non-cancer patients at the same cut-off value and predicted survival time as cancer was 79% accurate at 3 weeks survival and 63% at 9 weeks. Specificity and negative predictive value were highly accurate, sensitivity and positive predictive value were low. In the survival analysis, the discrimination between the 3 groups was significant (p<0.05), but the regression coefficient in the regression analysis was not significant (p=0.43). Conclusion: The prognostic prediction using this score for non-cancer patients has high prediction accuracy in the case of good prognosis. It is suggested that clinical use of this score is also possible if used cautiously.

Purpose: The aim of this study was to describe research trends and content of educational intervention for promoting self-management of patients with cancer pain. Methods: A literature search for papers published from January, 2000 to July, 2017 was conducted using the keywords “cancer pain” and “self-management” “self-care” on electronic databases MedLine, CINAHL, and Ichushi. Results: Three Japanese language papers and twenty-seven English language papers were used for analysis. Many papers had been made public since 2010, and several interventional studies using an educational intervention program have been published. An educational intervention program is a combination of a main session and a follow-up. Additionally, this method has several types of individual intervention. The main sessions included knowledge and skills required for medication, self-monitoring of pain, and the method of communicating with the doctor. The outcome of educational intervention was an increase knowledge of cancer pain and the reduction of the pain itself. Conclusion: Because there are few intervention studies about self-management of cancer pain, it is a task to develop the educational intervention program for patients with cancer pain according to the intervention method and educational contents which identified in this result in Japan.

In recent years, cancer treatment methods have diversified, and there are increasing numbers of occasions where patients or their families are required to make increasingly complex decisions. Currently, there are no guidelines for determining the process and the individual who decides the treatment strategy for cancer patients who are unable to decide for themselves. Particularly, no report has been published on decision-making for end-of-life care in patients with intellectual disabilities. This report documents our involvement in decision-making during end-of-life care for a cancer patient with intellectual disabilities. This patient’s decision-making ability or lack thereof was determined using reliable and validated assessment scales. The collective decision to not resuscitate in case of cardiac arrest and to care for the patient in the palliative care unit was made through a multidisciplinary collaboration between the social welfare team and the hospital based on reports and guidelines from abroad. Going forward, guidelines for decision-making support for terminal ill cancer patients with intellectual disabilities and decision-making by proxies for such patients need to be established in Japan.

Purpose: To describe a patient receiving maintenance hemodialysis complicated with calcific uremic arteriolopathy (calciphylaxis) in whom ulcer pain control was successfully achieved by buprenorphine. Case: A 75-year-old man was admitted due to intractable, extreme pain, which was accompanied by skin ulcers of the lower extremities. By a series of examinations including skin biopsy, the lesion was diagnosed to be calcific uremic arteriolopathy. The pain was not controllable with non-steroidal anti-inflammatory drugs and even by the nerve block. Buprenorphine, a partial agonist for the opioid receptor, markedly alleviated the mixed pain which was attenuated from Numerical Rating Scale (NRS) 10/10 to 0-2/10. Conclusion: Buprenorphine was very effective for the refractory pain control in a patient with skin ulcer due to calcific uremic arteriolopathy.

Introduction: We report on a patient with end-stage lung cancer who developed the relatively rare condition of emphysematous cystitis. Case: A 72-year-old man was diagnosed with carcinomatous meningitis while being treated for lung cancer and bone metastasis. Anticancer therapy was terminated, and he was transferred to our palliative care unit. During the transfer, he exhibited progressively impaired consciousness and bilateral leg paralysis. Imaging studies performed to assess his medical state revealed intrathecal nodes associated with carcinomatous meningitis and emphysema in the bladder wall. Emphysematous cystitis was diagnosed. The bladder was irrigated and drained, and antibiotic therapy was administered. Although the bladder wall emphysema resolved, the patient died of progression of carcinomatous meningitis on the 10th day after transfer. Discussion: The development of emphysematous cystitis is reported to be likely in patients with underlying diseases, such as malignant tumor, diabetes mellitus, and neurogenic bladder, as well as in those with a history of steroid use. Our patient also exhibited many risk factors, including a history of steroid use and bladder and rectal disturbance due to carcinomatous meningitis, in addition to cancer. In end-stage cancer patients, the risk of developing emphysematous cystitis is expected to be higher than in normal persons because they have often used steroids for malaise, anorexia, and other conditions, and exhibit metastasis to the central nervous system, drug-induced dysuria, and other complications. Caution should be exercised in end-stage cancer patients to recognize emphysematous cystitis, which can be life-threatening in some cases.

Introduction: G-CSF producing tumors often cause various symptoms at the end of life, such as fever, fatigue, and fluid retention as a result of high cytokine status. Case: The patient was an 80-year-old woman. She was referred to our hospital because of anorexia and urine volume reduction. After a detailed examination, she was diagnosed with duodenal cancer. Although she decided not to receive anticancer treatment because of her old age and poor general condition, she felt a great distress with abdominal distension by large ascites. Furthermore, peripheral blood smear examination showed remarkably increased levels of normal neutrophils. We suspected G-CSF producing tumor and, hence, dexamethasone administration was initiated to suppress cytokine release. As a result, renal dysfunction and urine volume were improved, and ascites accumulation was not observed again since initial paracentesis. The number of neutrophils also declined, and the patient was in a good condition, even though it lasted for a short time. Conclusion: In patients with high cytokine status caused by G-CSF producing tumor, steroids may be useful for pain relief.

A 68-year-old man with a diagnosis of transformation to undifferentiated carcinoma of the left thyroid who was being treated with Lenvatinib presented with swelling and pain around the left clavicle, and tramadol was started. Two days later, he developed diarrhea, sweating, disorientation, and myoclonus, leading to a diagnosis of serotonin syndrome. He also exhibited dyskinesia including involuntary movements of the arms and legs and squirming movements of the trunk. Tramadol was thus discontinued. His myoclonus and dyskinesia resolved within half a day and had disappeared the day after tramadol discontinuation. These symptoms were attributed to tramadol because there was a reasonable temporal relationship between drug administration and the adverse event. Tramadol inhibits serotonin reuptake, and thus has the potential to cause serotonin syndrome. However, there have been relatively few reports describing the occurrence of this syndrome, and there have been none showing concomitant dyskinesia. Clinicians should be aware that tramadol can cause serotonin syndrome accompanied by dyskinesia.

Objectives: To clarify the content of death conferences. Methods: 60 death conferences held in the palliative care unit of the National Cancer Center Hospital East between May 2012 and November 2014 were analyzed in a retrospective study. Medical records and notes from the time of the meeting were used. Results: 170 units of data were abstracted from the death conferences held during the studied period. These data were categorized into five groups: 1. supporting family members as subjects of care, 2. understanding and cherishing patient’s thoughts, 3. reducing symptoms and relieving pain, 4. realizing the importance of communication between medical personnel, and 5. becoming anxious due to interaction with patients. Conclusion: The results suggest that the death conference is a useful opportunity to look back on support from various perspectives and directions.