Oral transmucosal fentanyl has been developed for the management of breakthrough pain in cancer patients. Buccal and sublingual fentanyl tablets have been licensed in Japan. However, the optimal use of oral transmucosal fentanyl has not been elucidated. We describe the treatment of cancer‒related pain using a 100μg fentanyl sublingual tablet and a 12.5μg/hr fentanyl patch in a 77 year‒old man with rectal cancer and thoracic vertebral metastasis. After the first use of the fentanyl sublingual tablet, the patient’s consciousness was impaired for 6 hours, however respiration was stable. This case shows that administration of fentanyl sublingual tablets may not be recommended for breakthrough pain incancer patients who are being treated with 30mg/day of oral morphine equivalent dose (20mg/day oxycodone, 12.5μg/hr fentanyl patch).

Purpose: Paracentesis is one of the most effective techniques to manage malignant ascites in cancer patients. Some patients require frequent repeated drainage because of a rapid reaccumulation of ascites. The indwelling catheter technique is proposed to avoid the procedure risks and complications. Case report: We report a case of 73-year-old male diagnosed pancreatic cancer. The central venous catheter was used for management of his malignant ascites. One liter of ascetic fluid was removed every day for 21 days until death. To prevent a clogging of the catheter, multiple side-holes were opened to the catheter in advance of the paracentesis, and medical cyanoacrylate adhesive (Aron Alpha®) was applied around the indwelling catheter to avoid the leakage of ascites. Conclusion: We propose the use of the central venous catheter for the drainage of ascites, because the technique is less invasive and inexpensive, and also can reduce such complications as a clogging of the catheter and fluid leakage.

Purpose: Pruritus is a rare symptom among advanced cancer patients. This rarity results in limited knowledge about its mechanisms and treatments. Moreover, many previous studies have proposed pharmacological interventions to alleviate pruritus of not malignant disease but chronic liver disease (e.g. primary biliary cirrhosis). Recently, the antipruritic activity of paroxetine has been reported in various systemic disease. Case report: We report a case of 72-year-old female diagnosed hepatocellular carcinoma with liver cirrhosis. On admission, although jaundice was detected on her conjunctiva and skin with high serum total bilirubin level 3.4mg/dL (direct bilirubin 2.3mg/dL), she did not complain of pruritus. Gradually, she suffered from pruritus with no exanthema on her entire skin and perceived no beneficial effect from H1-antihistamine and topical steroid administrations (symptom score 7/10). Significant antipruritic effect was achieved immediately with oral paroxetine 10mg on day 13. On day 14, she scored pruritus on whole body at 0/10, and this antipururitic effect was observed for 2 weeks after administration until her death. No adverse effects were reported. Conclusion: Paroxetine is an antidepressant agent classified selective serotonin reuptake inhibitors. The antipruritic activity of paroxetine is possible due to the involvement of changing itch signal from peripheral serotoninergic receptor to central nervous system and inhibiting the enzyme activation (CYP2D6) of endogeneous opioids as pruritogens. We have observed the beneficial effect of paroxetine to alleviate pruritus due to malignant jaundice.

Purpose; Transdermal fentanyl (TF) has less systemic adverse effects as compared to morphine. However, few patients with cancer related pain obtain insufficient analgesic response despite the dose escalation of TF. The aims of this study were to describe patients with poor analgesic response and to evaluate the efficacy of opioid rotation from TF to oral morphine. Case reports; We conducted a retrospective chart review and analyzed six patients managed with opioid rotation in detail. Before opioid rotation, an average dose of TF was 204μg/hr. A significant decrease in pain score was found in all patients who switched to oral morphine, and five patients were treated with the combination of TF and oral morphine. Conclusion; These results may indicate that patients who are treated with relative high dose TF (over 200μg/hr) tended to response to poor analgesic, and opioid rotation is beneficial to restore the analgesic effects. We speculate that this clinical phenomenon is associated with opioid tolerance.

Some terminally ill cancer patients are treated with palliative sedation（PS）to alleviate their suffering. There have been very few studies in Japan investigating PS in the home. Thus, the aim of the present study was to investigate PS at home for terminally ill patients. A retrospective chart review was performed of 117 cancer patients who died at home between August 2012 and July 2014. Of the 73 who patients died at home, 24（33％）had received PS. The mean duration of PS was 4.4±6.0 days. Patients receiving PS were started on a mean dose of 12.8±6.2 mg/day midazolam；the mean dose at the end of PS was 12.4±6.5 mg/day midazolam. The primary reason for starting PS was delirium（n＝22）. PS in the home was feasible and was an essential treatment for cancer patients at home. We conclude that PS can be used safely and efficaciously to treat terminally ill cancer patients with refractory symptoms in their own home.

Most palliative care units in Japan allow patients to have their own pets visit them and also allow visits by therapy dogs, even though allowing animals into a hospital is not usually permitted. To determine which units allow patients to meet with their pets or have therapy dogs visit, questionnaires were sent 193 palliative care units, and the replies were obtained from the 149 units (77%). From the responses, it was determined that 135 units allowed patients to meet their pets on unit property, 36 units allowed patients to keep their pets with them, 121 units allowed patients to meet their pets in their hospital rooms, and 22 units adopted therapy dogs as animal-assisted therapies. Units established by religious organizations were more likely to allow patients to keep pets than non-religious organizations, and units established earlier more often allowed patients to meet up with their own pets than more recently established units. However, the use of animal therapy was equally likely in all units, regardless of religious affiliation or the age of the establishment. It is clear that being hospitable to patients' needs, and desires can be found in the newer palliative care units.

The aim of this study is to clarify the diet and complementary and alternative medicine among terminal cancer patients followed at home. A cross-sectional survey of bereaved families of 200 cancer patients who were received home care by 5 palliative care clinics in Kobe in 2014. The response rate was 66％. The average age of the patients was 74 years old. The family members received the information about diets from books, magazines, and newspaper（48％）and medical staff（46％）. The patients actively took in tea（64％）, dairy（62％）, and soy（60％）. The patient avoided alcohol（49％）, fat（31％）, and salt（31％）. The question asking the complementary and alternative medicine（CAM）, 32％ respondents answered using CAM, of which 28％ took mineral supplements, and vitamins. Due to the paucity of the evidence about the diet and CAM for cancer patients, the patient and family tend to practice the general diet therapy.

The aim of this study was to clarify diet and meal preparation for terminal cancer patients followed at home. A cross-sectional survey was administered to bereaved caregivers of 200 cancer patients who received home care from five palliative care clinics in Kobe in 2014. The response rate was 66% and the average age of the caregivers was 62 years. Overall, 57% of caregivers reported distress regarding diet and meal preparation for patients. The independent determinants of distress were: the experience of coaching from medical staff （P=0.012）; how to help patients with eating; difficulties in cooking and meal preparation （P=0.001）; and helping with eating for anorexic patients （P=0.004）. Due to the paucity of the evidence about diet and meal preparation for cancer patients, caregivers may not be receiving sufficient specific and practical dietary instruction from medical staff.

Purpose: The aim of this study was to clarify the experience of the bereaved families at the time of death of a patient. Methods: A cross-sectional nationwide survey of the bereaved families of cancer patients was performed at 95 palliative care units in Japan in 2007. Results: Of the 670 questionnaires sent to bereaved families, 492 were returned (73%). There were no significant differences between the level of the families' emotional distress and which doctor pronounced the death and whether the doctor was present at the moment of patients' death. Regarding the perceived need for improvement in the care of a dying patient, there were significant differences with respect to which doctor pronounced a patient's death and whether the doctor was present at the moment of a patient's death. There ware no significant differences between the attendance by doctor at the moment of patient's death and no attendance with frequent visit on that day. Conclusion: The bereaved families desire the patient's primary doctor to be present at the time of death and to then pronounce the death. However, the bereaved families consider an appropriate manner as the frequent visit by doctor on patient's last day even if the doctor do not attend at the moment of patient's death. Palliat Care Res 2010; 5(2): 162-170

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.