Continuous subcutaneous injections of medication are effective in controlling symptoms of the terminal stage of cancer. Chlorpromazine and levomepromazine occasionally cause skin irritation. We examined all patients who underwent continuous subcutaneous administration of psychotropic drugs (chlorpromazine, levomepromazine, midazolam) at the palliative care unit of our hospital from April 2010 to March 2013, the frequency of adverse skin reactions of Common Terminology Criteria for Adverse Events (CTCAE) v4.0 grade 3 or above. Of the 603 hospitalized patients, 389 (64.5%) underwent continuous subcutaneous administration of one of the three drugs. The frequency of grade 3 or above (ulceration or necrosis) adverse skin reactions was 4 out of 345 chlorpromazine cases (1.2%; 95% CI: 0.0-2.3%), 2 out of 90 levomepromazine cases (2.2%; 95% CI: −0.8-5.2%), and 0 out of 210 midazolam cases (0.0%; 95% CI: 0.0-0.0%). The frequency of serious adverse skin reactions caused by continuous subcutaneous administration of psychotropic drugs was low, suggesting that this treatment is relatively safe for the skin.

Objective: To determine nurses’ and care workers’ role in caring for the dying on wards for recuperation under health insurance. Methods: The analysis was performed using semi-structured interviews involving 9 nurses and care workers working on wards for recuperation under health insurance and having experience of caring for dying patients. Results: As for nurses’ roles in caring for dying patients, 6 categories were extracted, including ‘support patients’ families to have a feeling that they were fully involved in the process of dying’. As for care workers’ roles in caring for dying patients, 5 categories were extracted, including ‘support nurse through the care worker activities’. Conclusion: In order to provide quality care for the dying, it is important to put the following points into practice: providing feedback and seculity on effects of daily life support, the provision of opportunities to enhance the independence of the care worker.

Introduction: SEIQoL-DW is a method of measuring the subjective QOL of each patient by focusing on five areas considered important by the patient in a semi-structured counseling session. The objective of this study was to longitudinally evaluate the shift in areas considered important by advanced-cancer patients along with the shift in the subjective QOL. Methods: Patients who underwent SEIQoL-DW at the time of palliative care visit (first session) and after palliative care hospitalization (second session) within 1 year, in addition to also meeting the inclusion criteria such as a pain level of STAS 1 or lower, were included as the study subjects.Results: A total of 5 cases (mean age of 67.6 years among 1 male case and 4 female cases) were included. The P.S. was 1 for all cases at the first session, among which 3 cases were undergoing chemotherapy. At the second session, the P.S. was 3 or 4 for all cases. The mean time between the two sessions was 164 days. In all cases, 3 or more of the 5 important areas changed at the time of the second session. The SEIQoL-index, which is a comprehensive subjective QOL, improved in 3 cases but decreased in the other 2 cases. Conclusion: The areas considered important by terminal phase patients widely change. The shift in subjective QOL of each patient does not necessarily correspond to the decrease in the P.S. level.

Introduction: Among various predicting tools of survival developed for terminally ill cancer patients, Palliative Prognostic Score (PaP) is used very frequently. The target diseases of PaP are solid malignancies other than renal cancer; thus hematological malignancies are not included in them. Objective: To demonstrate that it is appropriate and useful to apply PaP to patients with terminally ill hematological malignancies. Methods: We used PaP to predict the survival of 18 patients with terminally ill hematological malignancies hospitalized in our hospice ward and compared the prediction accuracy with that of the previous studies. Results: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 21-day survival probability were 91.7%, 83.3%, 91.7%, 83.3%, and 88.9%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 30-day survival probability were 72.7%, 85.7%, 88.9%, 66.7%, and 77.8%, respectively. Conclusion: Our results suggest that it may be possible to apply PaP to patients with terminally ill hematological malignancies.

Introduction: The opioid-to-methadone conversion ratio is not constant. Thus, exacerbation of pain associated with switching of these drugs is a concern. We report two cases in which methadone was introduced in combination with epidural block. Case 1: The patient was a 55-year-old man who complained of perineal pain due to recurrent colorectal cancer. Diagnostic imaging could not be performed because of severe persistent pain and breakthrough pain even under treatment with oral oxycodone 600 mg/day. Methadone administration (starting dose, 45 mg/day) was started in combination with continuous lumbar epidural block. The persistent pain mostly dissipated after an approximately 2-week treatment period with methadone 75 mg/day, making magnetic resonance imaging measurement possible. Case 2: The patient was a 62-year-old man who complained of pain in both lower limbs due to spinal metastasis of prostate cancer. Pain impairing body movement persisted even during treatment with oral oxycodone 300 mg/day. The pain was reduced by combination treatment with continuous lumbar epidural block and methadone (starting dose, 30 mg/day), making it possible to perform radiotherapy. At the time of discharge from the hospital while being treated with methadone 45 mg/day, the patient complained minimally of pain. Conclusion: Owing to epidural block, switching to methadone was achieved smoothly without exacerbation of pain.

Purpose: The goal of rehabilitation for advanced cancer patients is to improve their quality of life (QOL). The meaning of QOL can only be determined by an individual patient. Rehabilitation begins with exploring the patient's hope. Here, we report a case suffering to express hope with difficulties by terminal stage lung cancer with brain metastases. Case: An 83-year-old male who was diagnosed with lung cancer (adenocarcinoma) and brain metastases admitted to palliative care unit because of progressive disease against chemo-radiotherapy. On admission, he could eat independently and walk to bathroom with slight assistance. A few weeks later, he had an epileptic seizure, right-hemiplegia and disturbance of consciousness. This episode made it drastically difficult for us to communicate orally with him. And, we tried hard to know the patient's hope by assessment using activities of daily living (ADL) observation and non-verbal communications. He revealed to be eager to eat even in a PS grade 4. He sometimes could talk a few words and, by rehabilitation techniques, he started to enjoy eating independently. For about three weeks, he could eat until the day before he died. Discussion: Eating behavior could be influenced by proper way of rehabilitation. Conclusion: ADL observation and non-verbal communication could be an effective rehabilitation approach to stimulate feeding behavior resulting in the improvement of patient's QOL.

Purpose: To investigate the present situation and to explore future problems in bereavement care. Methods: A questionnaire survey was mailed to approximately 1,000 home-visit nursing stations throughout Japan. Results: A total of 296 (29.8%) valid responses were returned. Of the responding stations, 6.1% answered that they “positively perform” bereavement care, 73.1% “perform [it] when necessary,” and 20.7% “seldom perform” bereavement care. A total of 91.4% of the responding stations provided bereavement care by visiting nurses after a patient’s death. A total of 73.6% of the responding stations always performed care in the form of appreciation for their efforts. A total of 32.4% of the responding stations contacted related organizations to request that the organizations watch bereaved family members who suffered from dementia but lived alone. Reasons for not contacting related organizations included not knowing which organization to contact (17.5% of the responding stations). Conclusion: Approximately 90% of the responding stations provided bereavement care by visiting nurses after the patient’s death, with emotional support as the main activity. Visiting nurses were asked to acquire abilities: 1) to provide bereaved families with information about health and welfare services that could be used in addition to long-term care insurance to rebuild their lives, 2) to ascertain which bereaved families would need continuous support, and 3) to assign these bereaved families to relevant organizations.

Objectives: The purposes of this study are to assess the prevalence and tasks of bereavement services in Japanese hospices/PCUs and to explore these changes through comparison of survey data in 2002 and 2012. Methods: A postal survey of all government-approved hospice and care units in Japan was conducted in 2012. Two hundred twenty-seven questionnaires were dispatched, of which 156 were retuned (response rate, 68.7%). Results: The results of 2012 survey showed that 78% of respondents sent memorial cards, and 73% provided memorial services. The ratios of hospices/PCUs offering diverse bereavement serveces in general decreased over the last decade. “Organizational support” was perceived by 71% of respondents as one of the tasks of bereavement services in 2012 survey. The responses of “caregiver training” and “research on the demands of bereaved individuals” as perceived tasks were declined significantly over the past decade from 2002. Conclusion: These findings in 2012 survey revealed present status of bereavement services in Japanese hospices/PCUs, and suggested that some perceived tasks has been slightly dealt with through comparison with results of 2002 survey.

Introduction: We report a case of acute-phase reaction of denosumab which was difficult to exclude aggravation of original cancer pain. Case: A 65 year-old man with severe pain from right back to upper abdomen due to mid thoracic vertebral metastases of small cell lung cancer was consulted to palliative care team. Denosumab 120 mg was administered subcutaneously three times every four weeks. On the next day of first administration, pyrexia occurred. At all three administrations, pain worsened for four days after the next day of administration. The pain was worsened from numerical rating scale 2 to 6. Same phenomenon was observed each time denosumab was administered for three consecutive times. Although the area of pain overlapped with that of original vertebral metastases, the repetition of the pain exacerbation soon after the denosumab administration suggested acute-phase reaction. Conclusion: Pain aggravation caused by acute phase reaction of denosumab might be overlooked in patients with cancer pain. More investigation is needed for details of acute-phase reaction caused by denosumab.

Purpose: Approximately 30% of the patients who received intervention from a palliative care team for problematic symptoms (e.g., pain, nausea, depression) also underwent rehabilitation at our acute hospital. We investigated their changes in activities of daily living (ADLs) and outcomes (i.e., death, changing hospitals, or being discharged to their homes). Method: We retrospectively analyzed the patients’ medical records data to examine patient training content, Barthel Index (B.I.) scores, and outcomes. Results: For one year, 86 patients received rehabilitation and 42 (48%) underwent anticancer therapy. B.I. scores increased for 35% of the patients, were stable for 20%, and decreased for 45%; 95% of the patients with decreased B.I. scores could not be discharged home. Conclusion: Advanced cancer patients are likely to experience a decline in ADLs and require longer rehabilitation periods to improve. A team approach is important for preventing disuse syndromes within a palliative care setting.