Transmucosal Immediate-Release Fentanyl（TIRF）can be a key-drug for breakthrough cancer pain. Prescription audit is needed because there are concerns about tolerance or serious adverse events including respiratory suppression and addiction due to inappropriate use of these drugs. The aim of this audit study is to evaluate appropriateness of TIRF prescriptions, reasons of violation, and adverse events in the real-world setting. A retrospective chart review was conducted in 31 patients who had breakthrough cancer pain and were treated with TIRF. A 2-step algorithm was generated：baseline pain and administration situation of other opioid rescues. TIRF was prescribed appropriately in six patients（19.4％）. Reasons of violation were as follows：prescriptions only for using same drug with around-the-clock opioids（fentanyl transdermal patches, n＝19）, and patients could take oral medicines and use of morphine or oxycodone rescues would be preferable（n＝12）. TIRF was initiated with a minimum dose in all patients and no serious adverse events were observed. Although TIRF was used widely for breakthrough cancer pain, prescription was not necessarily done appropriately. Detailed assessment of breakthrough cancer pain and consideration of the use the other rescue medication would be required.

This paper aimed to summarize the current situation of prognostication for patients with an expected survival of weeks or months, and to clarify future research priorities. Prognostic information is essential for patients, their families, and medical professionals to make endof-life decisions. The clinician’s prediction of survival is often used, but this may be inaccurate and optimistic. Many prognostic tools, such as the Palliative Performance Scale, Palliative Prognostic Index, Palliative Prognostic Score, and Prognosis in Palliative Care Study, have been developed and validated to reduce the inaccuracy of the clinician’s prediction of survival. To date, there is no consensus on the most appropriate method of comparing tools that use different formats to predict survival. Therefore, the feasibility of using prognostic scales in clinical practice and the information wanted by the end users can determine the appropriate prognostic tool to use. We propose four major themes for further prognostication research: (1) functional prognosis, (2) outcomes of prognostic communication, (3) artificial intelligence, and (4) education for clinicians.

Purpose: The purpose of this study was to clarify the current status of Do-Not-Resuscitate discussions (DNRd) with terminally ill cancer patients in Japan and the psychological burden on bereaved families depending on whether or not a DNRd is performed. Method: A multicenter prospective observational study of advanced cancer patients admitted to 23 palliative care units (PCUs) in Japan was conducted, and a questionnaire survey of bereaved families was also conducted after patients died. Result: 1,605 patients were included in the analysis, and 71.4% of patients had a DNRd with doctors before PCU admission, 10.8% at admission, and 11.4% during admission. In contrast, 93.3% of family members had a DNRd with doctors before PCU admission, 48.4% at admission, and 52.1% during admission. Conclusion: Although DNRd was performed between patients and physicians in 72.3% of cases at any point throughout the course of time from before PCU admission to death, there was no evidence of psychological burden such as depression or complicated grief in the bereaved families due to patient participation in DNRd.

Objective: This study aimed to reveal the prevalence and characteristics of anguish among delirious patients with advanced cancer receiving specialized palliative care services. Methods: We conducted a subanalysis of a multicenter, prospective, observational study at 14 inpatient palliative care units and 10 general wards that offered psycho-oncology consultation service in Japan. We consecutively enrolled the patients with advanced cancer who were diagnosed with delirium and prescribed antipsychotics. Palliative care specialists decided whether patients suffered from anguish or not. We assessed patients’ background and severity of delirium with the Delirium Rating Scale-Revised (DRS-R-98). Results: Of 818 enrolled patients, 99 (12.1%) suffered from anguish. We observed a significant difference in the mean age (68.9±12.6 vs. 72.1±11.2, p=0.009), prevalence of dementia (2% vs. 10.4%, p=0.005) between patients with anguish and those without anguish. Patients with anguish had lower DRS-R-98 total scores before medication than those without anguish (15.3±8.1 vs. 17.3±7.8, p=0.018), but higher severity score in lability of affect (1.2±0.8 vs 1.0±0.9, p=0.023). Conclusions: The results of this study suggested that patients with anguish tend to be younger, mostly do not have dementia, and have lower delirium severity score but higher score in lability of affect. Nevertheless, further research, investigating appropriate evaluations and medical interventions for patients with anguish is warranted.