We performed cardiac resynchronization therapy (CRT) in addition to coronary artery bypass grafting (CABG), mitral valve replacement (MVR) and tricuspid valve annuloplasty (TAP) in a 72-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 38%), triple coronary vessel disease, and mitral and tricuspid valve insufficiency after three-area old myocardial infarction. Electrocardiography showed no change in the QRS interval after CRT. However, tissue Doppler echocardiography showed synchronicity of the septum and posterior segments in the left ventricle, and that contraction of the septum was in the systolic phase of the cardiac cycle after CRT. New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in which ischemia and volume overload were improved by CABG, MVR and TAP may improve regional cardiac function and synchronicity.

Purpose: To clarify factors associated with the Japanese perception of whether they can live at home until death with the inclusion of knowledge and beliefs about end-of-life. Methods: A questionnaire survey was conducted on the Japanese general population who participated in a lecture meeting about palliative home care (N=61, effective response rate, 100%). Results: Ten (16%) responded they could live at home until death. Barriers to end-of-life home care were "Home care would burden my family (80%)," " Family and I are anxious about emergency care when I get worse (59%)" and "Family and I are anxious about whether I can enter a hospital emergently when I get worse (52%)" in that order. From the multivariate logistic regression model, respondents who expressed "Opioids cause addiction (OR, 95% confidential interval (CI):0.29, 0.09-0.99)" and "Artificial hydration and nutrition should be continued as the minimum standard until death (OR, 95%CI:0.39, 0.16-0.95)" were more likely to perceive that they could live at home until death. Conclusion: The empowerment activity for the general population regarding correct knowledge about palliative care, benefit and disadvantage of life-sustaining treatment, and correct knowledge about home care is important for the end-of-life patients who want to live at home until death to achieve their wish.

As measuring the quality of palliative care is considered to be important, quality indicators (QIs) that are able to extracted from medical database or from medical chart review have recently been developed in Western countries. In this paper, we reviewed the development of QIs and actual measurements collected in palliative care settings. The present results indicate that QIs based on data extracted from such sources as the cancer registry, medical claim, and palliative care databases, include items regarding aggressive treatment, hospice use, and intensive care units visits. Furthermore, QIs based on data extracted from medical chart reviews were developed for use with community-dwelling elderly patients. As with other QIs, QIs utilized at ICUs, QIs utilized at nursing homes, and evaluation of care from the perspective of bereaved families was conducted. In the future, QI items and methods appropriate for Japanese medical settings should be developed and their feasibility, reliability, and validity should be examined.

Objectives:To determine the factors that influence the decision maker regarding end-of-life (EOL) care and to disclose how aggressive care in the last week before death, place of death, and quality-of-life (QOL) affected the decisions made. Methods:The subjects were 409 bereaved family members (cause of death included cancer, stroke, heart disease, and pneumonia) that registered with an internet research agency. Decision-making was controlled either by the patient, family, or physician or shared by the patient, family, and physician. Results:The results of a multinomial logistic regression analysis demonstrated that when a family controlled decision-making, they were less likely to report patient-family EOL discussion [odds ratio (OR)=0.52], and that the patient had good communication with the physician (OR=0.77); they were also likely to report that the patient had dementia (OR=1.94). Families who reported physician-controlled decision-making (vs patient controlled) were less likely to report that the patient had good communication with the physician (OR=0.62). Cardiopulmonary resuscitation in the last week and place of death were not associated with the decision maker. EOL QOL was associated with EOL care of the decision maker. When a physician controlled decision-making, patient EOL QOL was at its lowest. Conclusion:To improve patient-controlled decision-making, it is critical that patients, families, and physicians have more communication regarding EOL care.

Objectives: This study aimed to evaluate the consequences of caring for end-of-life elderly patients from the bereaved family’s perspective. Methods: We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members by web survey. Outcomes were caregiving consequences (Caregiving Consequences Inventory). We compared the outcomes between with and without dementia. Results: 163 and 224 dying elderly patients with and without comorbid dementia were analyzed from bereaved family members’ responses. The outcomes were not significantly different (burden, 5.24±1.12, 5.32±1.24, p=0.487; fulfillment, 4.53±1.06, 4.59±1.29, p=0.627; growth, 4.94±0.93, 5.00±1.04, p=0.523). Fulfillment was significantly associated with spouse, family visitation, and mental health. Growth was significantly associated with age, spouse, end-of-life discussion, and family preference of treatments. Conclusion: The evaluation of the consequences of caring for end-of-life elderly patients from the bereaved family’s perspective were not significantly between the informal caregivers of those with and without comorbid dementia.

Objectives: This study aimed to evaluate good death (end-of-life quality of life) from the perspective of bereaved family members. Methods: We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members by web survey. Outcomes were achievement of a good death (Good Death Inventory, GDI). We compared the outcomes between with and without dementia. Results: 163 and 224 dying elderly patients with and without comorbid dementia were analyzed from bereaved family members’ responses. The achievement of good death were significantly different (GDI scores, 4.2±1.0, 4.4±0.9, Adj P=0.053) as regards “maintaining hope and pleasure,” “good relationship with family,” and “independence.” Conclusion: The achievement of good death was not significantly different between the dying elderly patients with and without comorbid dementia. Psychosocial care for informal caregivers would be important for better quality of dying in the terminally ill elderly patients with dementia.

Purpose：To explore a methodology for evaluating end-of-life （EOL） cancer care using diagnosis procedure combination （DPC） administrative data. Methods： We investigated care provided to inpatients whose deaths were attributed to cancer and occurred between August 2010 and December 2012. We measured the quality of palliative care by dividing the decedents into two groups： those who died in the palliative care unit （PCU） and those who died in the general wards（GW）. Results： A total of 311 inpatient deaths were identified as cancer deaths. Of these, 147 patients were included in the PCU group and 164 in the GW group. We calculated the DPC data as follows： the rates of chemotherapy administered within 30 days before death （PCU 0％, GW 27％） and within 14 days before death （PCU 0％, GW 10％）, admission to the intensive care unit （PCU 0％, GW 2％）, life-sustaining interventions （PCU 0％, GW 3％）, rehabilitation sessions （PCU 10％, GW 26％）, emergency admission （PCU 2％, GW 27％）, and antibiotics （PCU 32％, GW 28％）. In the PCU group, rates of chemotherapy and emergency admission were significantly lower（＜0.0001；＜0.0001, respectively）, and rehabilitation sessions were significantly higher （p＝0.0002） than in the GW group. Conclusion： EOL care in a university hospital can be easily investigated using DPC data. Some limitations are the single-site study design, the health insurance system, and secondary use of administrative data. However, this methodology may be adapted to investigate the entire Japanese claim database and to evaluate EOL cancer care.

Purpose: This survey aimed to develop a methodology for measuring the quality indicators of end-of-life care for cancer patients using the Japanese National Database, which was comprised of the health insurance claim data of all Japanese people. Methods: Life-sustaining treatment (LST) and chemotherapy near the time of death are accepted as reliable indicators of poor quality end-of-life care. To measure these, the Sampling Data Set (SDS) from the National Database (NDB) was used. Results: 1,233 cancer patients were studied, who had died from 14th to 31st October, 2012. The rates of LST and chemotherapy in the final 14 days of life were 8.2% (95%CI 6.7-10.1), 3.5% (2.6-4.8) for inpatients (n=1,079) respectively. In the SDS, 27-70% of chemotherapy drugs were not named, in order to prevent identification of patients receiving rare treatment. Discussion: The figures for rates of chemotherapy might be underestimated in the sampling data set, because of the anonymization of rare treatment. And in-patient and out-patient data may in some cases have been duplicated when entries applied to the same person. In the future using the NDB, it might be possible overcome some of these limitations.

We performed cardiac resynchronization therapy (CRT) in addition to aortic valve replacement (AVR) in a 74-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 15%), complete right bundle branch block (CRBBB), left posterior hemiblock (LPH), and aortic valve insufficiency. Tissue Doppler echocardiography showed synchronicity of the septum and posterior segments in the left ventricle, and that contraction of the septum was in the systolic phase of the cardiac cycle after CRT. The New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in a patient with CRBBB and LPH can improve regional cardiac function and synchronicity.

We performed cardiac resynchronization therapy (CRT) in addition to mitral valve replacement (MVR) in a 66-year-old patient with dilated cardiomyopathy (DCM) associated with complete left bundle branch block (CLBBB) and mitral valve insufficiency. Tissue Doppler echocardiography showed synchronicity of the septum and lateral wall in the left ventricle after CRT. New York Heart Association functional class improved from III to I after CRT and MVR. CRT of the dyssynchronic myocardium in a patient with DCM associated with CLBBB improves regional cardiac function and synchronicity.