The aim of the present study was to examine the current use of a palliative care manual, brochures for patients, and assessment tools designed for the regional intervention study. A questionnaire survey (706 physicians and 2,236 nurses) and interviews (80 health care professionals) were conducted. The tools health care professionals most frequently used were the manual and brochures for families of imminently dying patients. Health care professionals experienced [shared understanding as a region level despite the clinical experience and specialty] and [increased confidence in palliative care they had practiced without clear evidence]. The manual were positively evaluated because they “cover all necessary information”, “come in an easy-to-carry-around size”, and “provide specific and practical advice”. Health care professionals valued the brochures for families of imminently dying patients, because illustrations were very helpful as oral explanation was difficult. This study suggests that the manual and brochures for families of imminently dying patients could serve to improve region-based palliative care.

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We evaluated the association between respiratory symptoms and hydration volume during last 1 week of life in terminal cancer patients using retrospective study. The subjects were 138 terminally patients with malignancies. Patients were classified into two groups: the low hydration group (group L, n=85) who received 1,000 ml or less of artificial hydration per day in 1 week before death and high hydration group (group H, n=53) who received over 1,000 ml per day. We compared appearance of dyspnea and bronchial secretion on group L with group H. 64.1% of group H had dyspnea, and 52.8% had bronchial secretion. These fractions are significantly higher than group L (32.9%, 15.3%). In the results of multiple regression analysis, lung involvement (odds ratio: 3.55), hydration over 1,000 ml per day (3.54), and administration of opioid (0.40) were significantly related dyspnea. Lung involvement (7.29), hydration over 1,000 ml per day (4.43), and oral intake (0.31) were significantly related bronchial secretion. Our results provide preliminary evidence that excessive artificial hydration therapies influence the respiratory symptoms in terminal cancer patients. 1,000 ml of hydration may be used as a rough indication in terminal stage.

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Purpose: To clarify the family-perceived usefulness of a pamphlet for families of imminently dying patients. Methods: Physicians and/or nurses provided medical and practical information about the dying process using a pamphlet for families of imminently dying patients. We surveyed family members 6 months after the death of the patient about the perceived usefulness. Results: We sent out a questionnaire to 325 bereaved, and obtained an answer from 260 (response rate: 85%). Overall, 81% reported the pamphlet to be “very useful” or “useful”. The experience reported by the bereaved included: “Helped me to understand the dying process” (84%); “Helped me to understand how symptoms and changes occur” (76%), “Useful in preparation for patient's death“ (75%), “Helped me to understand the physical conditions of the patient” (75%), “Helped me to know what I can do for the patient” (74%). Conclusion: “A pamphlet for families of imminently dying patients” may be useful for members of an imminently dying patient's family.

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To investigate whether magnesium abnormalities are associated with the administration of magnesium-containing laxatives in a palliative care setting, we measured the serum magnesium levels in 48 patients with advanced cancer at our palliative care unit (PCU). The mean magnesium concentration in all patients was 2.09 mg/dl (confidence interval [CI], 1.38-3.62). Patients receiving magnesium-containing laxatives (n=38) showed significantly higher serum magnesium concentrations than patients without laxatives (n=10) (2.17 mg/dl vs 1.8 mg/dl, p=0.006). Although 10 patients had serum magnesium abnormalities (hypomagnesemia, 8 and hypermagnesemia, 2), we did not observe clinical manifestation associated with magnesium abnormalities. Interestingly, neither the duration nor the dose of laxatives correlated with serum magnesium concentration. Overall, patients at the PCU tend to have magnesium abnormalities and their symptoms may be analogous to those of advanced cancer patients; in particular, terminal patients with such symptoms might be considered to have magnesium abnormalities.

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The purpose of this study was to identify the greatest impact of the regional palliative care program on community health care professionals. Interviews were conducted involving 101 people who became involved in the intervention program implemented in 4 areas across Japan, and 96 valid responses were collected. The following were cited as the greatest impact: [I developed a network of people, and realized the importance of collaboration] (n＝61; “I was able to develop an interpersonal relationship” and “Now I understand the significance of collaboration”), [My knowledge and skills regarding palliative care were improved] (n＝18; “Knowledge and support helped me respond to patients with confidence” and “I have come to think that there is more to palliative care than terminal care”), [I rediscovered my role through a wide variety of experiences] (n＝10), [Both collaboration and palliative knowledge/skills meant a lot to me] (n＝4), [What I experienced in this program will help me play my role] (n＝2), and [Patients and their families became satisfied] (n＝1). The community palliative care program was most effective in facilitating collaboration, and helped participants develop knowledge and skills concerning palliative care.

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Objectives: At present, the dose conversion ratio for a continuous intravenous infusion of fentanyl (CIV) and fentanyl transdermal patches (TP), which are widely used in Japan, is not based on the results of clinical studies in Japanese patients. Studies comparing serum fentanyl concentrations in patients with cancer pain treated by TP showed large differences between Japanese patients and those in other countries. We therefore studied the dose conversion ratio in Japanese patients. Methods: From October 2003 through October 2008, we extracted information on all patients with gastrointestinal cancer who underwent rotation from CIV to TP in the gastrointestinal ward of Kitasato University East Hospital. We selected patients in whom the daily dose of CIV or TP (i.e., the basic dose) was unchanged for 10 days after rotation and the difference in the number of rescue doses (per day) as compared with immediately before rotation was 1 or less on at least 3 consecutive days. All TP preparations used in this study were reservoir-type. Regression lines were plotted on the basis of the relation of “the basic released dose of TP” to “the basic prescribed dose of CIV,” and the dose conversion ratio was calculated. Results: 47 patients underwent opioid rotation, and 11 of them satisfied the eligibility criteria. Eleven patients were studied. The following regression equation was obtained: Y=1.0227X+1.0103, r²=0.9188, indicating a strong correlation. The dose conversion ratio of CIV to TP (released dose) derived by regression analysis was 1:1. Conclusions: Our results obtained in Japanese patients will allow dose conversion at the time of opioid rotation from CIV to TP to be more appropriately performed.

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Purpose: The aim of this study was to examine the effects of community-based self-help groups for cancer survivors form supportive functions and benefit findings. Methods: A survey consisting of two scales was conducted with a sample of 109. The first scale measured the benefit finding in cancer experience, and the second scale measured supportive functions of self-help groups. Results: Exploratory factor analyses indicated that “benefit finding scale” included four factors, and the supportive functions of self-help group could be classified into four aspects. Benefit findings were related to the supportive functions. Conclusion: These results imply that the participation in self-help group is related to positive cognition of cancer survivors.

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The aim of this study was to explore the changes in the rates of discharge to home from the palliative care unit in the region where the regional palliative care intervention program, their home death rate, and their ratio to whole home death cancer patients in the region. During the study period, the palliative care unit changed an administrative policy actively end-of-life care to support patients at home. The rate of discharge to home from the palliative care unit increased 11% to 22% during the study period, and their home death rate increased 10% to 41%. The overall home death rate of cancer patients however remained 6.8% to 8.1%, and their ratio to whole home death cancer patients in the region was less than 10%. To establish health care system to support cancer patients at home, changing administrative policy of palliative care units is insufficient and increasing quality community palliative care resources seems to be essential.

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This study aimed to explore participant experiences and perspectives of a multidisciplinary conference held after a cancer patient's death in the home setting under planning by the regional palliative care team. The multidisciplinary conferences studied were held in the community following the deaths of three cancer patients who were cared for at home or in nursing homes and supported by a regional palliative care team. We surveyed a total of 56 participants across the three conferences using a questionnaire comprising demographical questions and free description. We asked for impressions of the conference and perspectives regarding palliative care. The survey drew 48 effective responses (response rate, 87.5%). Content analysis of the participants' descriptions extracted the following issues with the multidisciplinary conferences, categorized under either as availability or problems: “mutual understanding through dialogue between multidisciplinary members”, “awareness leading to future practice”, “learning about palliative care”, and “barrier to dialogue between multidisciplinary members”. Highlighted problems surrounding the practice of palliative care with multi-institutional and multidisciplinary members were “conditions for practice in palliative care and care for dying patients” and “multi-institutional and multidisciplinary coordination”. The results indicated that multidisciplinary conferences held with the regional palliative care specialists following a cancer patient's death might be useful to facilitate multidisciplinary coordination and lead to better practice in palliative care in the community.

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Oxycodone controlled-release (CR) tablets are used as a first-line opioid analgesic for cancer pain. However, use of oxycodone CR tablets is associated with toxicities such as drowsiness and constipation, leading to deterioration of the quality of life (QOL), especially in patients with gynecologic cancer. In contrast, fentanyl has a superior toxicity profile while still showing a strong analgesic effect. Although fentanyl has been approved for switching from opioid, there have been no Japanese studies of patients with gynecologic cancer who were switched to transdermal fentanyl after experiencing toxicity during therapy with oxycodone CR. More importantly early introduction of palliative therapy for pain has not been adopted routinely in the management of gynecologic cancer. Thus, it appears that treatment for patients with gynecologic cancer remains unsatisfactory at present. We conducted research into improvement of the toxicity profile and pain control with the aim of improving QOL for patients with gynecologic cancer. We showed that pain, drowsiness, and constipation could be significantly improved in gynecologic cancer patients as a result of switching to transdermal fentanyl therapy at an early stage.

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Purpose: We assessed the efficacy of a palliative care team (PCT) in improving quality of life (QOL) among Japanese cancer patients. Patients and methods: This prospective study involved adult patients treated in the Division of Respiratory Medicine and Medical Oncology/Hematology at Kobe University Hospital between November 1, 2009 and March 30, 2010. Every patient had requested intervention by the PCT. Patients were asked to complete the EORTC QLQ-C15-PAL questionnaire at baseline and 1 and 4 weeks after initiation of the PCT intervention. Result: Of the 35 patients enrolled, 26 patients and 15 patients completed the assessments at 1 and 4 weeks after starting the intervention, respectively. Pain subscale (PA) was improved at 1 week after starting the intervention (p<0.05). Dyspnea subscale (DY) and PA were improved at 4 weeks after starting the intervention (p<0.05). Conclusion: We prospectively showed that QOL of cancer patients was improved with the intervention of the PCT, using the Japanese version of the EORTC QLQ-C15-PAL. Even if the PCT can only provide short-term care for cancer patients, this intervention appears worthwhile to improve QOL of cancer patients.

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The primary aim of this study was to compare the ratios of specialized palliative care use to all cancer death using 2 methods: 1) total number of patients who received either of specialized palliative care services (unadjusted), and 2) number of patients after adjustment of potentially duplicated counts (adjusted). The research team obtained patient list from all specialized palliative care services, and counted the number of the patients who received any specialized palliative care services. The ratio of adjusted value to unadjusted value was 0.59, and had large region differences. Unadjusted values had, although overestimated, essentially similar trends in changes by year and differences in the regions. In conclusion, total number of patients who received either of specialized palliative care services could be simple and feasible indicator to roughly determine the activity of specialized palliative care services, but exact number of the patients who received specialized palliative care services should be determined on the basis of the patient lists without duplicated counts.

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The primary aim of this study was to describe how patient-held-records was used in the regional palliative care program (OPTIM-study). The number of patient-held-records disseminated was 1,131 per region per year. A total of 15% and 16% of 706 physicians and 2,236 nurses in the region reported that they used patient-held-records disseminated during the study periods, respectively. In-depth interview identified themes [difficulty in dissemination], potential benefits of patient-held-records ([improved sense-of-control of patients], [improved information sharing among health care professionals]), and barriers ([lack of patient-perceived benefits and patient burden], [necessity that all health care professionals involved should be aware the value of patient-held-records and understand how to use it]). Of 11 hospitals who introduced patient-held-records, only 2 hospitals continued to use it during 3-year study periods. In conclusion, region-wide dissemination of patient-held-records seems to be unfeasible in many regions in Japan.

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This study aimed to clarify whether a regional palliative care intervention program, the OPTIM project, increased home hospice utilization, and explore the potential association between the home hospice utilization and the hospital staff's perceptions on home care. A questionnaire survey was conducted involving 154 physicians and 469 nurses. The rate of patients who made the transition to home-based care increased 967% in A Hospital, 295% in B Hospital, and 221% in C Hospital in 2010 compared to 2007, which was assumed to be 100. Staff of a hospital where many patients made the transition to home-based care were more likely to agree with the following statements concerning home care perspectives: “I started to consider that even cancer patients can be treated at home until the last moment of their life”, “I usually ask patients whether they wish to receive home-based care”, “We decided on coping strategies for sudden changes in the course of disease and a place to contact in advance”, and “I started to simplify treatment procedures, such as prescriptions during hospitalization for patients and their families to prepare for home-based care“.

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Objective: This study aimed to investigate the effect of nutritional status on estimated fentanyl absorption in cancer patients being treated with a fentanyl transdermal patch (FP), by measuring the residual fentanyl content in used patches. Methods: 24 adult Japanese inpatients receiving FP treatment for chronic cancer-related pain were enrolled. During FP application, the nutritional risk of the patients was measured using the Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002), both of which are nutrition screening tools used widely in Japan. We then classified the patients into low-, medium-, and high-risk groups according to the nutritional risk measured by MUST, and compared the transdermal fentanyl delivery efficiency (FE) between that groups. Results: The FE, which is estimated by the residual fentanyl content in used FPs collected from the patients, was found to be decreased in the high-risk group. According to NRS 2002, the mean transdermal fentanyl delivery efficiency in the high-risk group was significantly lower than that in the low-risk group. Conclusion: These results showed that changes in nutritional status affect FE, and that poor nutritional status might decrease transdermal fentanyl absorption in cancer patients.

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The primary aim of this study was to estimate the number of cancer patients who wanted home death based on the bereaved family survey. A postal survey performed on 1,137 bereaved family members in 4 regions to clarify the degree what they believed that the patient actually died where s/he had wanted on the Good Death Inventory, and to explore the preferred place of death. We calculated estimated number of patients who had wanted home death as a total of (1) the actual number of home death × the percentages of the family members who agreed that the patient actually died where s/he had wanted, and × the actual number of hospital death × the percentages of the family members who disagreed that the patient actually died where s/he had wanted and home was the preferred place of death. Estimated number of cancer patients who wanted home death was 32.8%［95%C.I., 31.7, 33.9］ in the surveyed regions, and 31.2%［95%C.I., 31.1, 31.4］ for national data.

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Purpose: Head and neck cancer patients receiving chemoradiation therapy often suffer from severe mucositis. Chemoradiation therapy-induced mucositis is usually accompanied by severe and intractable pain that impairs quality of life. To establish an effective method for treatment of mucositis pain, we retrospectively investigated the relationships of radiation dose with severity of mucositis and opioid consumption. We also conducted a survey on satisfaction of pain treatment. Methods: Study 1: Fourteen patients who underwent chemoradiation therapy of 70 Gy for head and neck cancer from 2005 to 2009 participated in the study. The relationship of severity of mucositis with opioid use was studied. Study 2: Seven patients who had mucositis of over grade 3 and had completed radiation therapy participated in the study. We carried out a questionnaire survey about satisfaction of each pain treatment. Results: Study 1: Increase of radiation dose significantly worsened the severity of mucositis. Opioid consumption for treating pain was significantly greater in the pharynx cancer group than in the oral cancer group. Study 2: Oral care treatment was preferred to systemic administration of analgesics including opioids. Conclusions: In the oral cancer group, oral care treatment was thought to be useful for pain treatment. Oral cancer patients needed less opioids than did pharynx cancer patients.

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A forties year-old female visited our hospital on March 2011, complaining chest discomfort. Computed tomography (CT) revealed a huge mass in the anterior mediastinum combined with multiple masses in the lungs, the uterus and the bone. Since no abnormal shadow had been noticed on the chest radiograph on January 2011,they seemed to have grown very rapidly in a short period. The pathological diagnosis following needle biopsies of mediastinal and uterine cervix tumors was undifferentiated carcinoma of the thymus metastasizing to the uterus. She was also suffering from the pain on the right femur and intermittent hypogastralgia due to metastases to the bone and uterus. Although NSAIDs and oxicodone relieved the pain on the right femur, they could not significantly reduce the hypogastralgia. Judging from the nature of the frightful hypogastralgia, the cause was estimated to be not somatalgia but splanchnodynia. Ritodorine hydrochloride, which was then adnimistered for the purpose of inhibiting the contraction of the uterine, was remarkably effective in reducing the pain. According to the literatures reviewed concerning metastases of the extrapelvic malignant tumors to the uterus, the median survival period after occurrence of metastases was 14 months. This report suggests that the administration of Ritodorine hydrochloride can keep the quality-of-life of these patients without suffering from the pain due to metastatic tumor to the uterus.

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Purpose: Since malodor of a malignant fungating wound decreases quality of life of patients, its management is important. Metronidazol ointment, clindamycin ointment, and cadexomer iodine ointment have been used for treatment of malodor of a malignant fungating wound because they have antibacterial activity for anaerobic bacteria. Nevertheless, management of malodor of a malignant fungating wound has been unsatisfactory and it needs improvement. Methods: A mixture ointment of clindamycin and cadexomer iodine was employed in a case with malodor of a malignant fungating wound that had not been successfully controlled by cadexomer iodine ointment. Results: Malodor and exudate of a malignant fungating wound reduced. In addition, no adverse event such as skin troubles was observed and it was used safely. Conclusions: It was suggested that the clindamycin-cadexomer iodine ointment was more effective for treatment of refractory malodor of a malignant fungating wound than cadexomer iodine ointment.

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Purpose: Hiccups are a symptom that often appear in lung cancer patients during medical treatment. Although various drugs and non-pharmacologic therapies are used to treat them, they often are not effective. We report 2 cases of successful treatment for refractory hiccups due to chemotherapy for lung cancer using pregabalin. Case report: Both patients had advanced squamous lung cancer. That in case 1 was treated using chemotherapy with carboplatin and paclitaxel, while the case 2 received nedaplatin and irinotecan. Hiccups occurred and became exacerbated during chemotherapy in both, and were considered to be induced by the anticancer drugs. Separate treatments with metoclopramide, chlorpromazine, and gabapentin did not have any effect, whereas immediate improvement was seen after taking pregabalin in both cases. Conclusion: Pregabalin, often used as an adjuvant analgesic, controls excessive neuronal excitement. In the present cases, effective relief of refractory hiccups was seen.

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A man in his seventies sustained continuous bleeding from local recurrence at the residual rectal stump after Hartmann's surgery for rectal cancer. This patient declined chemotherapy and radiation therapy and conventional local anti-hemorrhagic treatments had not been effective. To assess the risk of Mohs' paste application to the rectal recurrence area, we checked the anatomical structures surrounding the application site by a CT study. In addition, two reasons we evaluated this Mohs' paste treatment to the rectal recurrence would be very safe were as follows: 1. A small amount of Mohs' paste was needed for the small rectal bleeding site. 2. Mohs' paste would not be applied to the rectum used for stoma. To avoid applying Mohs' paste to the neighbouring normal structures, a gauze coated with Mohs' paste was inserted into the rectum and placed only on the local recurrence site. Petroleum jelly was applied to the surface of normal rectal mucosa to prevent fixation. Bleeding and malodorous effusion decreased significantly without side effects such as pain, bleeding, or ulceration. Thereafter, additional fixation was not necessary. When all the other antihemorrhagic modalities are not available, Mohs' paste could be used for bleeding or an effusion from non-superficial tumors after a thorough risk assessment on this treatment.

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In general, intrathecal opioid administration is considered for intractable cancer pain management. We would like to report a case of carcinomatous meningitis that was successfully treated by using an intrathecal catheter with subcutaneous port. A female in her fifties with carcinomatous meningitis secondary to invasive ductal breast cancer was suffering multiple neurological symptoms including headache. Intrathecal catheterization with subcutaneous port was considered as an alternative to Ommaya reservoir placement to continue intrathecal antineoplastic treatment. The port was used for collection of CSF, antineoplastic drug administration and opioid delivery. Neoplastic cells in the CSF disappeared within one month and the headache and other neurological symptoms improved. The patient died five months post diagnosis (four months after initiation treatment via intrathecal catheter) without recurrence of significant headache, before developing coma seven days prior to death. This case suggests an intrathecal catheter with subcutaneous port may be used effectively for both symptom management and the administration of antineoplastic drugs. However, further study is necessary.

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Introduction: It is difficult to manage that pruritus complicated with jaundice, for invalidity of almost all antihistamines. Recently, effects of paroxetine for pruritus are reported, but the report to invalid cases of paroxetine is rare. We report a case treated effectively with mirtazapine for pruritus of the paroxetine invalid. Case report: A 56-years old woman was diagnosed cancer of head of pancreas and peritoneal dissemination. After stenting by a plastic stent for obstructive jaundice in previous hospital, she came to our hospital. But, her total bilirubin (T-bil) were very high (9.9 mg/dl), and she was suffering from systemic pruritus. The NRS (numerical rating scale) score for pruritus was 9-10. Though she was prescribed an antihistamine in previous hospital, it was invalid. We had changed it to paroxetine, but pruritus were protraction two weeks later. After changing it to mirtazapine, the pruritus became NRS 1 on the next day, and recurrence was not seen subsequently. Conclusion: For pruritus of the paroxetine invalid, mirtazapine is important as one of the choices.

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A 75-year-old man with end-stage colon cancer began to experience increased pain and distress and significantly deteriorated quality of life (QOL) due to internal hemorrhoids. In order to maintain the patient's QOL, the hemorrhoids were successfully treated with aluminum potassium sulfate and tannic acid (ALTA) injection, which involves minimal patient burden and pain. The outcome of this case suggests that ALTA might be useful and effective for the treatment of internal hemorrhoids in terminally ill cancer patients.

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When patients hospitalized in a palliative care unit die, particularly when their deaths were not peaceful ones, we, as health professionals, feel distressed, senses of helplessness and defeat, and even regret. However, busy daily clinical practice usually does not allow us to express these feelings. After going through such an experience repeatedly, your self-efficacy may be reduced and you could feel burned out. In this study, through the experience of coping with the death of a liver cancer patient who died of necrotizing fasciitis resulted from bedsore, a death conference was organized for us, health professionals who had been directly concerned with the patient, to discuss questions, conflicts, and dilemmas that arose when we provided care and express feelings that had been repressed. And other participants in the conference, who had not been directly concerned with the patient, gave their affirmative views. The conferences served to: (1) promote mutual understanding, trustful relationships, and teamwork among us, (2) increase our awareness of palliative care, and (3) allow us to cope with stress and prevent us from feeling burned out. These effects are considered to help implement improved health care. In the former part of the conference remarks were divided into three categories, (1) regret, (2) questions, conflicts, and dilemmas, and (3) senses of helplessness and defeat, and in the latter part affirmative views were mainly stated.

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Purpose: Refractory ascites is one of common symptoms in patients with breast cancer. Case report: A woman in her fifties was admitted with massive ascites and was diagnosed with advanced breast cancer with multiple liver metastases. Diuretics, hormonal therapy, and chemotherapy could not control the ascites. Therefore, we implanted a peritoneovenous shunt to continue the cancer treatment with good quality of life. Despite the liver metastases had progressed during subsequent chemotherapies, no ascites had been detected for 8 months. Conclusion: We believe that peritoneovenous shunt can be an effective treatment that support anticancer therapy and palliative care in patients with cancer accompanied by intractable ascites.

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Introduction: Amyloidosis is a variety of symptoms, such as organ failure and peripheral neuropathy amyroid protein is deposited in the systemic organs. We report a case of ketamine was effective for vulba referred pain in end stage. Case report: A 72-year-old male patient in end-stage primary generalized amyloid light-chain amyloidosis experienced excruciating pain in his genitalia about four times daily, lasting from tens of seconds to three minutes. No abnormal findings were noted in the genitalia. Bowel movement and large amounts of peritoneal dialysis fluid triggered excessive traction of the glans penis, which caused the excruciating pain. Referred pain originating from the pelvic plexus was suspected. Continuous infusion of ketamine was started at 50 mg/day for pain relief, which eliminated his pain, and the patient passed away 17 days later. Conclusion: The reason a small dosage of ketamine was effective, we consider there is a possibility of recovery from central sensitization effect of NMDA receptor antagonist worked effectively.

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Introduction: We described a patient with lung cancer who suffered from severe pain due to pelvic bone metastasis and opioid-induced delirium. Induction of subarachnoid analgesia using implanted intrathecal catheter almost abolished his pain and enable home palliative care. Case description: Seventy-year old man was admitted for intractable leg and hip pain due to pelvic bone metastasis and delirium induced by opioid. Although he was initially administered continuous subcutaneous morphine injection for opioid titration, delirium was deteriorated. Opioid rotation to oxycodone and increase in antipsychotic drugs could not improve his delirium. Epidural analgesia with local anesthetic and small dose of morphine improve his delirium with adequate analgesic effect. Finally, he was received intrathecal catheter implantation and discharged to home palliative care. Conclusion: Neuraxial analgesia may provide not only sufficient analgesia but also lower risk of delirium in patient who was administered high dose of opioids because of intractable cancer pain.

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