Beliefs About Spiritual Pain among Palliative Care Physicians and Liaison Psychiatrists: A Nationwide Questionnaire Survey

Objectives: Spiritual pain is not formally defined. The aim of this study was to clarify the beliefs about spiritual pain among Japanese palliative care physicians and liaison psychiatrists and to compare their beliefs. Methods: A nationwide questionnaire survey was conducted by mail August, 2019 on certified palliative care physicians and liaison psychiatrists. We asked 9 questions about spiritual pain (i.e. current status, definition, and the delivery of care) using a 5-Likert scale. Result: 387 palliative care physicians (response rate, 53%) and 374 psychiatrists (45%) responded. 72% (76% of the palliative care physicians/69% of the psychiatrists) reported that spiritual pain was distinct from depression, but 69% (66/71) reported that it was not defined adequately; and 59% (59/60) perceived the risks of using the words ambiguously. Only 43% (40/47) recommended the universal definition of spiritual pain, and opinions about how spiritual pain should be defined (i.e, higher being, meaning/value, or specific terms) differed among physicians. Perception about spiritual pain of the physicians were significantly associated with their religion, while beliefs about spiritual pain were essentially similar between palliative care physicians and psychiatrists. Conclusion: Although physicians regarded the definition of spiritual pain as being inadequate, the opinions about preferable definition differed among physicians. Discussion about the value of developing a consensus of spiritual pain is needed.

The Use of Intravenous Fentanyl for the Palliation of Refractory Dyspnea in an End-stage Heart Failure Patient with Renal Insufficiency

Introduction: We report a case of dyspnea in the patient with end-stage heart failure with renal insufficiency, which was refractory and was successfully controlled with intravenous fentanyl. Case: The patient was a 76-year-old man with dilated cardiomyopathy who repeatedly had been in and out of the hospital. He was admitted to the hospital because of heart failure exacerbation and treated with all available heart failure therapies, but his dyspnea was refractory. We implemented the team-based palliative care intervention and used intravenous fentanyl as a substitute for morphine due to renal insufficiency. His dyspnea was relieved in dose-dependent without heart failure recovery. Conclusion: In this case, we used intravenous fentanyl to relieve dyspnea in patients with end-stage heart failure. Under careful observation, fentanyl may be used as an alternative drug to relieve dyspnea in patients with end-stage heart failure.

A Giant Cranial Sebaceous Adenocarcinoma Which Responded to Multi-modal Therapy Including Palliative Radiotherapy

Introduction: We report a case in which multidisciplinary treatment including palliative radiotherapy reduced the size, exudate production and symptoms of a sebaceous carcinoma that had been neglected and allowed to form into a large destructive lesion. Case: A 48-year-old unemployed man who lived alone, was estranged from his family and socially isolated presented with a cranial tumor which had been present for three years. He did seek medical attention on one occasion. But a definitive diagnosis was not made, and he neglected to seek further treatment. The tumor became very large, painful and began to ooze exudate, and the patient became unwell with difficulty mobilizing. He was transported to the hospital by ambulance. The tumor was centered on the vertex of the scalp and had a maximum diameter of 30 cm. It was diagnosed pathologically as a sebaceous carcinoma and was inoperable. The tumor was treated with palliative radiotherapy, a total dose of 27 Gy　　/　　9 Fr, causing it to shrink by approximately 30% and markedly reduced the rate of exudate production. His condition improved markedly and he was able to go out on leave. Discussion: This case highlights the management and clinical course of an uncommon and large cranial sebaceous carcinoma.