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Refractory Diarrhea Associated with Carcinoid Syndrome Improved after Opioid Switching from Fentanyl to Morphine

Madoka ITO ; Ryo MATSUNUMA ; Haruka HARANO ; Junichi TASAKI ; Takashi YAMAGUCHI

Palliative Care Research.2023;18(3):171-176. doi:10.2512/jspm.18.171

Background: In the case of refractory diarrhea that cannot be treated with loperamide only, drugs such as octreotide and serotonin receptor antagonists are generally recommended. We have reported a case of refractory diarrhea associated with carcinoid syndrome in which symptoms improved only with opioid switching, without octreotide. Case: We experienced a case of a 28-year-old female with cervical cancer. She was diagnosed with recurrence after cervical cancer surgery and presented with pain and diarrhea. Her diarrhea did not improve sufficiently after taking loperamide. She was admitted to the palliative care hospital for symptom control due to persistent diarrhea and right lower extremity pain associated with bone metastasis. We diagnosed the cause of her diarrhea as carcinoid syndrome by some laboratory examination. For pain management, we switched opioids from transdermal fentanyl to continuous subcutaneous infusion of morphine. It resulted in pain relief and improvement in the frequency of diarrhea, and she was able to be discharged home. Conclusion: In cases of refractory diarrhea and in patients who need opioids, there is one option to use morphine. If it is effective, it may simply resolve both pain and diarrhea and reduce the use of multiple medications.

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A Case of Withdrawal Syndrome after Opioid Discontinuation Following Pain Relief of Bone Metastases

Ayaka ISHIKAWA ; Sayaka ARAKAWA ; Hiroto ISHIKI ; Koji AMANO ; Yuka SUZUKI ; Nami IKENAGA ; Shun YAMAMOTO ; Tairo KASHIHARA ; Tetsuhiko YOSHIDA ; Eriko SATOMI

Palliative Care Research.2023;18(3):159-163. doi:10.2512/jspm.18.159

Introduction: In patients receiving opioids, relief of cancer pain by palliative radiation therapy or other means can lead to opioid discontinuation and subsequent withdrawal symptoms, such as agitation, insomnia, and diarrhea, due to opioid-related physical dependence. Appropriate steps should be taken to prevent these symptoms. Case: A 72-year-old man underwent surgery for esophageal cancer. He developed low back pain and right lower limb pain, and was diagnosed with sacral and right iliac bone metastases. His pain was resistant to oxycodone (OXC), so he was simultaneously treated with methadone (MDN) and palliative radiotherapy. His pain gradually decreased, and MDN was tapered and switched to OXC, which was in turn discontinued at 20 mg/day at the patient's strong request. After OXC discontinuation, akathisia, anxiety, and diarrhea appeared as withdrawal symptoms. These were treated with immediate-release OXC, transdermal fentanyl, and suvorexant. Discussion: When discontinuing opioids, dose reduction below 10% per week is recommended, de-escalation to the lowest possible dose should be followed by cessation. In case of withdrawal symptoms, immediate-release opioids may be used, and opioid tapering should be attempted in parallel with symptom control.

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Sheeted Mohs Paste for Alleviating Symptoms of Malignant Tumors in Home Care

Hiroki MOCHIHARA ; Yoshihiro YAMAMOTO ; Yukiko KAWAMURA ; Hiroya KINOSHITA ; Tomoyuki KOGA

Palliative Care Research.2023;18(3):165-170. doi:10.2512/jspm.18.165

Mohs paste (MP) is a topical treatment that can help relieve the symptoms of self-destructive skin lesions caused by malignant tumors. Despite the potential benefits of MP in improving the quality of life of patients, its use in home-based care is limited due to various obstacles. In this study, we developed a 1-mm-thick MP gauze sheet, which allowed us to apply the MP treatment at home to a patient with breast cancer. After three weekly treatments, the patient’s main symptoms, including itchiness, odor caused by exudates, and mobility issues, showed improvement. By using MP as a sheet, we overcame the obstacles associated with its use, such as alterations in the physical properties and the risk of damage to healthy skin tissue. Additionally, we reduced the treatment duration and need for trained personnel. Our findings suggest that the MP treatment can effectively control the symptoms of patients in home-based care, consistent with prior research.

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Current Status of Do-not-resuscitate Discussions for Terminal Cancer Patients in Japan

Yosuke MATSUDA ; Sachiko OHDE ; Masanori MORI ; Isseki MAEDA ; Takashi YAMAGUCHI ; Hiroto ISHIKI ; Yutaka HATANO ; Jun HAMANO ; Tatsuya MORITA

Palliative Care Research.2024;19(2):137-147. doi:10.2512/jspm.19.137

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.

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Difficulties Faced by Physicians Working at a Designated Cancer Hospital in Practice of Advance Care Planning (ACP)

Kumiko YAMAGUCHI ; Miwa SAKAGUCHI ; Mayumi TSUJIKAWA

Palliative Care Research.2024;19(2):121-128. doi:10.2512/jspm.19.121

Objectives: There are known barriers to advance care planning practices for both health care providers and patients. Since physicians were the main occupations that introduce ACP, the goal of this study was to clarify where the difficulties were felt in the practice of ACP by looking back on the practice of physicians who were working in a designated cancer hospital. Methods: Semi-structured interviews were conducted with 10 physicians who were recommended by the palliative care team as physicians who clinically practice ACP for cancer patients. Interviews were transcribed verbatim, coded, and analyzed using content analysis by Graneheim et al. Results: We finally classified into 6 major categories as follows: Insufficient readiness of patients/Insufficient readiness of medical staff/Discrepancy in communication/Lack of evaluation index of ACP/Dilemma with professional ethics. Conclusion: Patients and health care providers each lacked readiness for ACP, and physicians found it difficult due to the resulting communication discrepancies and lack of colleagues with whom they could collaborate.

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Experiences of Advance Care Planning in Epileptic Patients with Intellectual Disability

Fumihito NOZAKI ; Sayoko HARUYAMA

Palliative Care Research.2024;19(2):129-135. doi:10.2512/jspm.19.129

Introduction: Epileptic patients have a higher risk of death than healthy individuals. Advance care planning (ACP) is also important for epileptic patients, but is not well recognized. We experienced two cases in which ACP was performed by family and medical staff for epileptic patients with intellectual disability. Case1: The patient was a 29-year-old male. It was important to continue spending his daily life as he currently did. Although his family wanted to provide palliative care at the end of life, there were no decisions about which medical interventions may not work at his end of life. It was decided that the family and medical staff would continue to make shared decision making. Case2: The patient was an 18-year-old female. It was important to continue spending her daily life as she currently did. Her family and medical team decided to provide palliative care at the end of life. Based on the opinions of the family members in both cases, the importance and widespread use of ACP in epileptic patients were obtained. Conclusions: ACP enabled families and medical staff to make shared decisions about what is best for epileptic patients with intellectual disability. ACP for epileptic patients seems to need to be promoted.

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Development of a Concern Scale for Cancer Patients Receiving Outpatient Radiotherapy

Tomohiro HIASA

Palliative Care Research.2024;19(3):149-156. doi:10.2512/jspm.19.149

Purpose: The purpose of this study was to develop a scale that can measure the concerns of cancer patients undergoing outpatient radiation therapy. Method: First, items were created based on a review of the literature, and a draft scale was created by examining content validity using the Item-level Content Validity Index (I-CVI). In the main study, researcher conducted an anonymous, self-administered questionnaire survey on 400 cancer patients undergoing outpatient radiation therapy at five institutions, and examined the reliability and validity of the scale. Result: Exploratory factor analysis identified nine items with two factors (concern about living with cancer and concern about living with irradiation). The Cronbach's alpha coefficient for the entire scale was 0.848. The goodness of fit in confirmatory factor analysis showed GFI=0.930, AGFI=0.879, CFI=0.926 and SRMR=0.058. No correlation was observed with STAI Y-1, and a certain level of discriminant validity was confirmed. Conclusion: We generally confirmed the reliability and validity results of a concern scale for cancer patients receiving outpatient radiotherapy.

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Changes in the Quality of Life of Ambulatory Patients with Locally Advanced/Distant Metastatic Cancer Who Underwent Two Weeks of Rehabilitation in a Palliative Care Unit

Ryo SOEDA ; Takuya YAMAGUCHI ; Yu FURUKAWA

Palliative Care Research.2024;19(3):169-174. doi:10.2512/jspm.19.169

Objective: To clarify changes in the quality of life (QOL) of ambulatory patients with locally advanced/metastatic cancer who underwent rehabilitation in a palliative care unit. Methods: Patients aged 18 years or older who were admitted to the Palliative Care Unit, had a Functional Ambulation Category of 1 (assisted ambulation) or higher, and were assessed at admission and two weeks after admission using the Comprehensive Quality of Life Outcome (CoQoLo) short version, were included in the study. Results: Twenty-one patients completed the 2-week assessment. Ten subjects were male, with a median age of 78 years. The Functional Independence Measure cognitive items significantly declined 2 weeks after admission, but the CoQoLo total score was not significantly different. In addition, the rate of change in the CoQoLo item “Being respected as an individual” was significantly higher in the ≥4 days/week rehabilitation intervention group than in the <4 days/week group. Conclusion: This study has shown that it is possible to maintain the QOL of ambulatory patients with cancer who received rehabilitation in a palliative care unit.

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A Case of Refractory Cancer-related Neuropathic-pain Caused by Intracranial Invasion of Left Nasal Cavity Carcinoma Successfully Treated with Goreisan

Takako IKEGAMI ; Naho MATSUBARA ; Ayaka ISHIKAWA ; Naruaki KAWASAKI ; Sayaka ARAKAWA ; Hiroto ISHIKI ; Mai ITOYAMA ; Kazuki YOKOYAMA ; Eriko SATOMI

Palliative Care Research.2024;19(3):175-180. doi:10.2512/jspm.19.175

Introduction: Intracranial tumors cause various neurological symptoms and neuropathic pain, which are often refractory to opioids. In some of these cases, the combination of Kampo medicines can be effective. Case: The case was a 44-year-old patient who underwent surgery for a suspected papilloma. After resection, pathological examination revealed squamous cell carcinoma, positive for margins, and then, the left intraorbital metastasis was observed. Due to the intracranial invasion of the tumor, he had pain in the second and third branches of the trigeminal nerve in the left face and paresthesia in the second branch of the trigeminal nerve bilaterally (Numerical Rating Scale: NRS 10/10). Hydromorphone was introduced, and the pain was relieved, but the paresthesia remained (NRS 8/10). Both paresthesia and pain worsened during the course of chemotherapy, but MRI showed no tumor progression, thus, the cause of symptom aggravation was diagnosed edema of the tissue around the tumor. Therefore, Goreisan was started, and both paresthesia and pain were relieved. Discussion: Goreisan has been shown to be effective in cerebral edema due to its water-regulating effect by inhibiting aquaporin. In the present case, the reduction of edema in peritumoral tissues by Goreisan may have contributed to the symptomatic relief.

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A Survey on QT Correction for Methadone Administration

Asako KOSHIBU ; Takashi IGARASHI ; Maho NAKAMURA ; Tomofumi MIURA ; Naoko KUMAZAWA

Palliative Care Research.2024;19(3):157-162. doi:10.2512/jspm.19.157

We investigated the impact of Bazett (B) and Fridericia (F) correction formulas on the evaluation of QT prolongation in patients during methadone administration and to explore the relationship between heart rate and corrected QT interval (QTc) according to both correction formulas. This study was conducted as a single-center, retrospective observational study. Subjects were cancer patients who underwent electrocardiographic evaluation for methadone therapy at our institute from April 1, 2013, to August 31, 2023. The study assessed the incidence of QT prolongation and analyzed the correlation between heart rate and QTc derived from the B and F formulas. The mean QTc of 430.3±25.8 msec for the B formula and 409.2±20.8 msec for the F formula. The incidence of QT prolongation was significantly lower with the F formula (8.4%) compared to the B formula (27.7%), indicating a 19.3% reduction in QT prolongation cases (p<0.001). Additionally, the difference in QTc between the two formulas increased with an increase in heart rate (p<0.001). These results suggest that the F formula for QT interval correction in methadone therapy potentially expands the eligible patients for this therapy.

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