Objectives: Spiritual pain is not formally defined. The aim of this study was to clarify the beliefs about spiritual pain among Japanese palliative care physicians and liaison psychiatrists and to compare their beliefs. Methods: A nationwide questionnaire survey was conducted by mail August, 2019 on certified palliative care physicians and liaison psychiatrists. We asked 9 questions about spiritual pain (i.e. current status, definition, and the delivery of care) using a 5-Likert scale. Result: 387 palliative care physicians (response rate, 53%) and 374 psychiatrists (45%) responded. 72% (76% of the palliative care physicians/69% of the psychiatrists) reported that spiritual pain was distinct from depression, but 69% (66/71) reported that it was not defined adequately; and 59% (59/60) perceived the risks of using the words ambiguously. Only 43% (40/47) recommended the universal definition of spiritual pain, and opinions about how spiritual pain should be defined (i.e, higher being, meaning/value, or specific terms) differed among physicians. Perception about spiritual pain of the physicians were significantly associated with their religion, while beliefs about spiritual pain were essentially similar between palliative care physicians and psychiatrists. Conclusion: Although physicians regarded the definition of spiritual pain as being inadequate, the opinions about preferable definition differed among physicians. Discussion about the value of developing a consensus of spiritual pain is needed.

Objective: This study aimed to investigate the effectiveness of an intervention that applied a behavioral change approach to the usual rehabilitation for patients with hematological malignancies undergoing chemotherapy. Methods: Patients with hematological malignancies undergoing chemotherapy were divided into two groups: patients who underwent conventional rehabilitation (control group, n=12) and a counterpart who received a behavioral change intervention with feedback on motor function and physical activity (feedback group, n=13). We analyzed the changes in motor function and physical activity between the two groups from the start of rehabilitation to discharge. Results: There were a significant difference in walking speed between baseline and discharge. Changes in weekly steps were significantly higher in the feedback group than those in the control group. Conclusion: A behavioral change intervention with feedback on motor function and physical activity may improve voluntary exercise in patients with hematological malignancies undergoing chemotherapy.

Objective: The purposes of this study were to explore the actual usage of a pamphlet for families of terminally ill patients both with and without cancer at home. Methods: We sent a questionnaire to 2,000 home-visit nursing administrators and obtained answers from 430. This study included 224 pamphlet users. Results: The pamphlet was used with 95.1% of families of cancer patients and with 76.8% of families of non-cancer patients. Most pamphlet users were concerned with the following: degree of worry and anxiety of the family, and the family’s and the patient’s hope for an at home death (families of both cancer patients and non-cancer patients more than 84%). The pamphlet was given to about 60% of families of both cancer patients and non-cancer patients between last last week and last month of life. Administrators found it difficult to decide the appropriate timing to hand out the pamphlet to 59.6% of families of cancer patients and 69.7% of families of non-cancer patients. Conclusion: Pamphlet use may be improved by clarifying the appropriate timing to give out the pamphlet.

The purpose of this study is to clarify the current state of nursing for the sexuality of patients with cancer at the end-of-life. In December 2018, we asked 313 nurses from 18 palliative care units in Kanagawa Prefecture about their awareness, feelings, and behavioral intentions and hands-on experience for the environment in which patients with cancer nurture love with their partners at the end-of-life. The collection rate of the questionnaire was 52.7% (165 cases). Eighty-two nurses (49.7%) had experience supporting the environment in which patients with cancer nurture love with their partners at the end-of-life. The contents of the support were “Recommend physical contact”, “Listening”, “Recommend hug”, and “Take sufficient time when entering the room, such as waiting for a reply after knocking or calling out”. Meanwhile, at ward conferences, only 11 (6.7%) had talked about the environment in which patients with cancer nurture love with their partners at the end-of-life. It has been suggested that, at present, support for the environment in which patients with cancer nurture love with their partners at the end-of-life is left to individuals and not systematically.

Objective: The influence of depression, anxiety, and family function in breast cancer patients on the quality of life of their children was investigated from the perspective of the participants’ demographic characteristics after controlling for their attributes. Methods: The demographic characteristics and confounding factors were divided into two subgroups, and two-factor analysis of variance was conducted with depression, anxiety, and family function as the independent variables, and the children’s quality of life scores as the dependent variable. Results: The quality of life of children in each characteristic demographic-subgroup was significantly lower when their mother had high depressed. Moreover, the quality of life in children of the subgroup with mothers receiving chemotherapy varied according to the quality of family function regardless of having siblings. Conclusion: It is necessary to focus on the conditions of children in addition to the psychological status of breast cancer patients. This investigation suggested that understanding mothers’ psychological status helps to identify children’s psychosocial problems. Moreover, it is suggested that the demographic characteristics of families with breast cancer patients should be considered when approaching mothers’ psychological status and family function.

The guide to proper use of methadone in Japan describes the SAG method (a method of stopping all leading opioids and starting methadone). Based on strict evaluation, our palliative care department introduces methadone by adding to the preceding opioid, and then tapering or discontinuation the preceding opioid. This time, we considered the clinical significance of 28 patients who received this method. In 20 of 28 cases (71.4%), methadone reached the maximum dose, and methadone titration could be safely performed without exacerbation of pain or serious adverse events. However, in order for this method to be performed safely, it is necessary to pay attention to the pharmacological properties of methadone, which has a long half-life, and to make a detailed evaluation and drug adjustment of the analgesic effect and adverse events after the introduction of methadone.

Palliative sedation (PS) is an effective way to alleviate the refractory symptom of terminally ill cancer patients, however it can be ethical. PS is now being implemented in general wards, and there is an urgent need to understand the actual conditions of sedation care for general ward nurses and improve the quality of care. In this study, a semi-structured interview was conducted with nurses working in a respiratory medicine ward of a core cancer treatment hospital. By Krippendorff’s content analysis, 16 categories of nurses’ actions/judgments, 8 categories of positive thoughts, and 5 categories of negative thoughts were extracted. Nurses have always sought the best way to alleviate the pain of patients and their families, and have endeavored to be close to their feelings. However, there was a difference in confidence and positivity regarding multidisciplinary collaboration and sedation discussions. It was suggested that the confident efforts of nurses may support the decision-making of patients and their families and consider methods for pain relief and QOL.

Purpose: We held workshops (WSs) that recommend the use of advance care planning (ACP) for medical and health care professionals, and clarified whether or not these WSs motivated them to engage in their own ACP using two indicators: the proportion of professionals who wanted to conduct ACP and changes in the Death Attitude Inventory (DAI). Method: After the WS, we divided participants into two groups, depending on whether or not they wanted to have end-of-life discussions with their family and loved ones. The changes in the DAI brought about by the WSs and their impressions of the WS were compared between the groups. Results: A total of 91 participants were analyzed, of which 42 (46.2%) wanted to have end-of-life discussions with their family and loved ones. In both groups, “afterlife view” and “death anxiety and fear” in the DAI were significantly reduced after the WS when compared to attitudes from before the WS. In the group which wanted to have end-of-life discussions, “death avoidance” (effect size −0.42) and “sense of purpose in life” (effect size 0.51) changed significantly and positively. Conclusion: About half of the participants wanted to perform ACP after having attended the WSs, apparently due to an increased sense of purpose in life and a reduced death avoidance.

Introduction: We report a case of intractable nausea of a terminal malignant lymphoma patient with diabetes, which improved by sublingual administration of asenapine. Case: A 78-year-old man suffering from diffuse large B-cell lymphoma with diabetes presented intractable nausea and vomiting. Those symptoms were thought to be due to masses and nodules in the right frontal lobe and the cerebellum, and/or due to edema in the peripheral brain parenchyma. Because it was difficult to take medicines orally, we selected injections to control those symptoms. However, the combination of metoclopramide, haloperidol, and hydroxyzine injections failed to relieve nausea. Olanzapine is effective against nausea but is contraindicated for diabetic patients, so asenapine, one of the multi-acting receptor-targeted antipsychotics the same as olanzapine, was expected alternatively. The patient was administrated asenapine sublingually 5mg once a day before bedtime. This administration of asenapine remarkably improved his nausea. Discussion: Sublingual asenapine dose may be an effective therapeutic option for intractable nausea.

Introduction: Although stop-and-go method is recommended for the introduction of methadone by the Japanese guidelines, it may temporarily result in inadequate pain control and/or serious side effects. We report our experience that alleviation of symptoms was achieved by introducing low-dose methadone at an early stage on top of preceding opioids for a patient with refractory cancer pain. Case: Tapentadol and an analgesic adjuvant were given to a 70-year-old man to treat the patient’s old anal pain due to recurrence of rectal cancer at the rectal anastomosis. However, since the pain was poorly controlled, methadone 5 mg was given adjunctively once daily. After methadone medication, remarkable alleviation of pain and improvement in QOL were observed. Discussion: To achieve a safe pain management, adding a small amount of methadone at an early stage, as in this case, may possibly considered.

Abstract: We report a case of intractable pain in a patient with amyotrophic lateral sclerosis (ALS) that was successfully managed by administering a fentanyl transdermal patch. Case: A 75-year-old man was diagnosed with ALS in 2013 after he became aware of difficulty in walking and systemic pain since 2010. In 2019, he underwent gastrostomy and tracheostomy, and intractable generalized pain necessitated the administration of morphine hydrochloride six times a day; however, it could not provide adequate pain relief. Later, morphine was replaced with a fentanyl patch under a very strict safe-monitored setting and the pain became bearable. Discussion: Although high-level evidence is lacking, pain experts have reported the effectiveness of morphine for intractable pain in patients with ALS. Frequent short-acting morphine dosing is often burdensome due to the complexity of its administration and it also causes end-of-dose pain. A fentanyl patch may possibly improve these drawbacks.

Introduction: We report two cases of infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients treated by the palliative care team during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. These patients were receiving interventions for pain control, but subsequently contracted COVID-19, leading to their deaths. Cases: Two patients with hematopoietic tumors had been taking hydromorphone tablets for pain control. Both patients contracted COVID-19 during their clinical course, and displayed happy hypoxia, a typical complication of SARS-CoV-2 infection. Although the rapid systemic deterioration of the patients' conditions were recognized, there were no complaints of breathing difficulties. We attempted to alleviate the symptoms by adjusting the medications, including changes to the administration route. Discussion: When a patient receiving palliative care is infected with SARS-CoV-2, the presence of an underlying condition may cause a rapid deterioration, and opioid titration may be required depending on the characteristics of the symptoms.

We encountered a case of HHV-6 encephalomyelitis following blood stem cell transplantation. A woman in her 30’s suffered from paroxysmal electric shock-like pain, itching, tremor of lower limbs and excessive sweating on the 15th day after cord blood transplantation. Urinary retention also occurred. Pregabalin and opioid administration was started, and foscarnet was administered after a finding of HHV-6DNA positive in cerebrospinal fluid. Combined use of levetiracetam 1000 mg per day decreased both frequency and intensity of the electric shock-like pain. In a week before the negative results of HHV-6 amplification, she became excessively drowsy. With withdrawal of levetiracetam, her consciousness returned to be clear. The main symptoms on discharge were pain and itching with numbness around the anus, and were well controlled with oxycodone 15 mg, pregabalin 225 mg, and lorazepam 0.5 mg per day. In our case of HHV-6 encephalomyelitis after cord blood transplantation, levetiracetam was effective in suppressing electric shock-like pain.

Food and eating are of great significance to humans, as we are the only creatures that establish relationships and sustain a social network through food and eating. Recent studies revealed that patients with advanced cancer and their family members often experience complicated eating-related distress due to tumors themselves, side effects of cancer treatments, and negative impacts of cancer cachexia. Therefore, we suggested the importance of the integration of palliative, supportive, and nutritional care to alleviate eating-related distress among patients and family members, and the significance of the development of tools to measure their distress in supportive and palliative care settings. No care strategies for eating-related distress experienced by patients and family members have been established, and the development of an interdisciplinary psychosocial approach and integrative care is required. As such, we are planning to start a nutritional support and cancer cachexia clinic in the National Cancer Center, and disseminate a newly developed care program across Japan.