Changes in Pediatric Hospital Staff’s Sense of Difficulty Toward Palliative Care:A Single-pediatric Hospital Survey Report

The purpose of this study was to clarify the changes in the sense of difficulty hospital staff felt toward palliative care before and after a palliative care team of the pediatric hospital started in-hospital consultation. A self-administered questionnaire about the difficulty, consisting of 21 items in five areas, was used to conduct a survey in 2015 for the pre-consultation period, and in 2018 for the post-consultation period. Responses were obtained from 222 people in the pre-consultation period (response rate of 70.9%) and from 384 people in the post-consultation period (response rate of 87.3%). Over 70% of the respondents were nurses and midwives. A lower sense of difficulty was observed in three of the items including “relief of painful symptoms”, “family care during caregiving”, and “support when oneself and surrounding staff feeling inadequate and lost”. Further, a significant decrease was observed in the sense of difficulty in six items reported by nurses and midwives in departments receiving the interventions. Eleven of the 16 cases in which the palliative care team intervened involved multiple requests for intervention for 2 patients with pain control difficulties, suggesting that the consultation activities contributed to the decrease in the sense of difficulty experienced by nurses and midwives.

A Strategy for Inpatient Evaluation and Improvement of the Quality of Our Palliative Care Team: Iterative Evaluations of Changes in a Palliative Screening Tool

To introduce early palliative care to patients, we have proactively used a palliative care screening tool to identify needs. We have emphasized not doing work in a routine manner, rather seeking to improve by continuous reevaluations. Because of a lack of feedback regarding changes in screening scores and actionable solutions derived from it, we executed a retrospective study about the effectiveness of our palliative care team and the identification of problems. All 91 cases studied meaningfully ameliorated their focused symptoms. However, we could not verify our team’s effectiveness because the backgrounds of patients who were eligible but not involved with our team differed significantly. The current study suggested that some patients missed opportunities to receive palliative care. We need to strengthen the system used with our patients as a safety-net so as not to overlook care opportunities by utilizing more effective screening methodology.

Five Years of Activity in Our Palliative Care Team and Coronavirus Disease

Purpose: We investigated the activity of our palliative care team over the past five years and how the new coronavirus infection (COVID-19) affects palliative care in our hospital. Methods: We retrospectively compared and analyzed patient data intervened by the Tokyo Medical University Hospital Palliative Care Team from April 2016 to March 2021. Results: There were no major differences in the total number of requests, patient background, reasons for request, and reasons for intervention from FY2016 to FY2020. In FY2020, the number of patients with PS0 at the time of request and who discharged from the hospital at home increased significantly compared to other years. Discussion and Conclusion: From the results of this survey, it was found that the introduction of palliative care from an early stage is progressing. On the other hand, because the outbreak of COVID-19 has restricted visits to inpatients at our hospital, it is possible that the proportion of patients who choose home care is increasing. Intervention requests to the palliative care team did not change significantly over the 5-year period without the impact of the COVID-19 pandemic. Strict visitation restrictions for inpatients have become barriers to the practice of palliative care.

Development of a Patient Registry System for Specialized Palliative Care Quality Assessment Using Patient-reported Outcomes: A Multicenter Pilot Study

Objective: This study aimed to investigate the feasibility of a patient registry system for assessing PCT (palliative care team) by PRO (Patient-reported outcome) in Japan. Methods: We operated a patient registry system with electronic data collection at eight hospitals in 2021 in Japan. We consecutively included newly referred patients for a month and followed up with them for a month. IPOS or ESAS obtained as PRO at the start of the intervention, three days later, and every week after. The primary endpoint was the response rate to the symptom rating scale by patients and providers. Results: 318 patients were enrolled. The patient response rate was 59.1% at intervention and 37.0% after intervention, and the medical provider response rate was 98.4% at intervention and 70.3% after intervention. Interviews with PCT members indicated that participants required support to input PRO responses required support and paper questionnaire was better and that managing the survey date and overall management was burdensome. Discussion: Although only about half of the patients were able to respond to the PRO, this was the same level as in previous studies. The system and its operation method have many problems. We found that improvements such as reducing items and making the patient interviews paper-based are necessary to expand the system nationwide.

Percepciones de un equipo de cuidados paliativos pediátricos acerca del clown de hospital / Pediatric palliative care team perceptions' about hospital clowns / Percepções de uma equipe de cuidados paliativos pediátricos sobre o clown de hospital

Resumen La presente es una síntesis de resultados de una investigación mayor, cuyo objetivo principal fue conocer las perspectivas de familias y equipo de salud respecto de la presencia de clowns de hospital trabajando en cuidados paliativos pediátricos en una unidad en Chile. Guiado por un paradigma interpretativo, estrictos criterios de calidad y éticos, la metodología utilizada fue de tipo cualitativo, aplicando las técnicas de recolección de datos de entrevistas en profundidad, análisis de documentos y grupos de discusión. La sección de datos sobre el equipo aquí presentados, se analizó a través de las técnicas análisis de contenido y análisis crítico del discurso. Los resultados indican que la figura del clown es percibida como un mediador y valorada como terapia complementaria, especialmente por las competencias socioemocionales de esos profesionales y el juego que se utiliza como herramienta de intervención. Las conclusiones señalan que las competencias socioemocionales que promueve el clown de hospital son fundamentales para el trabajo en cuidados paliativos.

Abstract This is a synthesis of results of a major research which main objective was to know the perspectives of families and the health team regarding the presence of hospital clowns working in pediatric palliative care in a unit in Chile. Guided by an interpretivist paradigm, strict quality and ethical criteria, the methodology used was qualitative, applying in-depth interviews, document analysis and discussion groups as data collection techniques. The data section presented here about the health team was analyzed through content analysis and critical discourse analysis techniques. The results indicate that the figure of the clown is perceived as a mediator, valued as complementary therapy, especially due to the socio-emotional competences of these professionals and play used as an intervention tool. The conclusions indicate that the socio-emotional competences promoted by the hospital clown are fundamental to work in palliative care.

Resumo A presente é uma síntese de resultados de uma investigação maior, cujo objetivo principal foi conhecer as perspectivas de famílias e equipe de saúde a respeito da presença de clowns de hospital trabalhando em cuidados paliativos pediátricos em uma unidade no Chile. Guiado por um paradigma interpretativo, critérios estritos de qualidade e éticos, a metodologia utilizada foi de tipo qualitativo, aplicando as técnicas de coleta de dados de entrevistas em profundidade, análise de documentos e grupos de discussão. Os dados sobre a equipe aqui apresentados, foram analisados através das técnicas de análise de conteúdo e análise crítica do discurso. Os resultados indicam que a figura do clown é percebida como um mediador e valorizada como terapia complementar, especialmente pelas capacidades sócio-emocionais desses profissionais e o jogo que se utiliza como ferramenta de intervenção. As conclusões apontam que as capacidades sócio-emocionais que promovem o clown de hospital são fundamentais para o trabalho em cuidados paliativos.

Screening for Distress and Its Impact on Palliative Care Referral at a General Medical Center: Retrospective Cohort Study

Purpose: Distress screening is mandated by Ministry of Health, Labor and Welfare of Japan, however there is few data available on its effect in actual practice. We examined the impact of distress screening on palliative care referral at Hyogo Prefectural Amagasaki General Medical Center in Japan. Materials and Methods: We implemented distress screening on cancer patients who were given chemotherapy from February 2018. Patients were referred to the palliative care team when the physicians judged the need on the basis of the screening results or when the patients themselves wanted to receive the palliative care service. We examined the number of the patients referred to the palliative care team, then we researched the changes of the number after implementation of the screening, using the regression discontinuity analysis. Results: The distress screening didn’t increase the number of the patients who were referred to the palliative care team: the estimated difference of the number was 3.32 (95% confidence interval: −3.19〜9.82). Conclusion: We implemented distress screening at our hospital but it didn’t increase palliative care referral. Only a few studies have examined how routine screening impacts clinical outcomes. We expect our study helps to research the effectiveness of screening in each healthcare facility.

Retrospective Survey of Palliative Sedation Therapy at the End-of-life at a Tertiary Cancer Center in Japan

Although palliative sedation therapy (PST) is considered to alleviate intolerable and refractory symptoms in dying patients with advanced cancer, there have been few studies regarding the situation of tertiary cancer center. We conducted a retrospective survey of the medical records of the patients who died between April 2015 and March 2016 at the National Cancer Center Hospital in Japan. PST was conducted in 75 out of 431 patients (17.4%). The patient demographics were as follows: sex (male/female), 48/27; median age, 61 years (range 5-83; 11 patients (14.7%) were aged under 39 years); and primary sites were lung, 18 (24.7%)/ pancreas, 11 (14.7%)/ hematopoietic organs, 11 (14.7%)/ bones and soft tissues, 8 (10.7%)/ and the others, 27 (36.0%). The main target symptoms for PST were dyspnea (38, 50.7%) and delirium (30, 40.0%). The most commonly used sedative agent was midazolam (72, 96.0%). Continuous deep sedation was intended in 61 patients (81.3%) at the death. Median survival from the start of PST were 2 days (range 0-54). The differences between palliative care team (PCT) intervention group and control group were lower age (58 vs. 62.5, P=0.048) and uniformity of initial midazolam dose (5-12 vs. 9.6-25.2 mg/day). Distinctive feature in this study was large proportion of adolescent and young adult patients with rare cancers. PCT might have different approaches to sedation in comparison to non-PCT medical staffs.

Multi-center Study to Assess the Feasibility of the Self-Check Program for Palliative Care Team

Introduction: Number of palliative care team increase every year, but the quality of team might differ from each other. We developed “Self-Check Program for Palliative Care Team” to assess and improve the quality of palliative care team. We report the result of the multi-center study to assess the feasibility of this program. Methods: We underwent the “Self-Check Program” as a trial at seven hospitals in Japan in February 2016. We took a questionnaire survey to team leaders and participants to assess the feasibility of this program. Results: Fifty-two medical staffs in six hospitals accomplished this program. Time scheduling and the integration of opinions from each team members were the difficulties came up from questionnaire survey. All team leaders and 87.8% of the participants answered that this program was effective to extract and improve the problem of the team. Also 83.3% of the team leaders were satisfied with the process of planning. Conclusion: Despite some difficulties, majority of the participants considering useful, this program is considered feasible.

Participation of the Nurses Who Are Certified Aromatherapist in Palliative Care Team and Their Offering Aromatherapy Massage to Cancer Patients in the General Ward

<p>Purposes: This report describes our activities of performing aromatherapy massage for cancer patients in the general ward. Methods: The number of patients, sex, age, aroma treatment times, outcome, disease type, performance status (PS), treatment phase, symptoms, massage site, and oil type were investigated using the clinical records from March 2014 to March 2016. Results: Aromatherapy massage was performed for 116 patients a total of 301 times. With regard to the final outcome, 50 patients were moved to the palliative care unit (PCU), whereas 49 patients died in the general ward. The main symptoms were general malaise, edema, pain, and anxiety. The popular massage sites were lower limbs, back, and upper limbs. The preferred oils were citrus and relaxation-inducing type. Discussion: By joining the palliative care team, certified aromatherapy nurses were allowed to perform the aromatherapy massage on more patients in the general ward than before. The need for aromatherapy massage was found not only in terminally ill patients but also in chemotherapy patients with good PS. In addition, for patients who were moved to the PCU, aromatherapy massage functioned as bridge between the general ward and PCU because one of the aromatherapy nurses worked in the PCU.</p>

Investigative Analysis of Inappropriate Opioid Use for Cancer Outpatient

Objectives: The purpose of this study was to investigate current fact of cancer outpatients’ opioid pain management and its possible abusive applications and to establish corrective treatments by the palliative care team. Methods: Our palliative care team investigated cancer outpatients’ prescribed opioid clinical records for 4 months in 2014, and the result revealed inappropriate opioid use which could lead to further abuse or dependency. Through this the team recommended attending physicians viable options including decrease of opioid eventually leading to final withdrawal. Results: Among 67 cancer outpatients, the finding of inappropriate opioid use which could lead to further abuse or dependency was in 5 patients (7.4%). The details are as follows: (1) Three patients were treated with opioid analgesia for initial pain relief but the application continued in spite of recovering from a cancer which had been responsible to the pain. (2) Two patients were medicated with opioid for pain but further diagnosis revealed the disease which caused pain was benign. Four out of 5 patients were successfully withdrawn from opioids. Conclusion: In cancer outpatient settings, it can be overlooked or undetected inappropriate use of opioids which may lead to abuse or dependency without a team approach. To prevent opioid abuses, it is imperative to find the cause of pain as accurately as possible.

Rehabilitation Outcomes for Patients Receiving Intervention from a Palliative Care Team

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.

Increased Cooperation with Dentistry by the Palliative Care Team

Recently, the palliative care team (PCT) at our hospital has included dentists. Among a total of 127 cancer patientsand required PCT intervention from 2009 to 2014, 17 patients (13.3%) had oral symptoms. Therefore, the PCT held discussions in order to determine the optimal way to treat each patient. Various symptoms, including oral pain, dry mouth, taste disturbance, furred tongue, excessive amounts of saliva, appetite loss, and trismus were treated by the dentists. As a result, the oral findings improved in all patients, while the oral symptoms improved in 16 of the 17 patients (94%). Thanks to the fact that dentists have joined the PCT, oral symptoms are effectively relieved, and PCT members now have an increased interest in oral cavity complications. Furthermore, conducting thorough examinations of the oral cavity by the PCT not only results in an improved QOL, but it has also increased the interest in the oral cavity on the part of the PCT. Therefore, more effective palliative care is expected to be achieved by promoting increased cooperation with more clinical departments.

Effects of opioid rounds as part of palliative care team activity

This study analyzed the outcomes of palliative care team（PCT）activity in Tottori Municipal Hospital. The PCT, consisting of doctors, nurses, pharmacists, and cancer consultants, made an“opioid round”weekly to evaluate the effects of pain management for inpatients and make proposals in cooperation with ward nurses and pharmacists. Excluding those treated through PCT intervention, inpatients receiving opioid for the management of cancer-related pain were targeted. Proposals were made, following the WHO guidelines for the management of cancer-related pain, and the results of each round were reported to the primary doctor. The effects of continuous rounds were examined 4 years after their initiation, in September 2009, by evaluating improvements in pain management by the primary doctor. The annual rate of proposals made during rounds steadily decreased:Year 1:16.7％, Year 2:12.6％, Year 3:8.1％, and Year 4:7.5％. These results might support the educational effect of opioid rounds as part of PCT activity to optimize pain management by feeding back the results to the primary doctor.

The approach for development of palliative care team database

In 2011, we reported the usefulness of a database（DB）that was established by the members of a palliative care team（PCT）. Since then, we updated DB depending on the requests of PCT. We revised DB mentioned below. We developed a form for keeping a record of PCT members’care for patients, their family members or others, and a record of recommendation for each problem list. We also updated another form so that the evaluation of Support Team Assessment Schedule of Japan（STAS-J）had been showed sequentially, added an entry form of Palliative Prognostic Index, and extracted data required by Japan Society for Palliative Medicine in order to evaluate the activity of PCT. The database could be used by many hospitals, because it was created by the commercially available software.

Excretion environment adjustment for a terminal cancer patient: excretion care given by a team

<b>Purpose:</b> With a decreasing degree of independence in excretion movement, terminally-ill cancer patients experience an emotional distress and a lower sense of self-esteem. We herein report a case in which a patient received an effective excretion care by a palliative care team.<b> Case:</b> A female patient in her 60s was diagnosed with lung cancer and multiple bone metastases. On admission, she maintained her basic ADL (Activities of Daily Living) and walked independently; following a fall in the bathroom, however, she sustained a pathological fracture in the left humerus that was treated conservatively from a prognostic point of view. Despite concerns about pain and fracture risks during her trips to and from the bathroom, she wanted to excrete “on the toilet.” Out of respect for her wish and sense of pride, we gave her movement, lifting, and undergarment operation trainings in addition to adequate pain control. We also adjusted the equipment and increased the carers for her. With a gradual worsening of pain and a decline in ADL, she nevertheless had been able to perform excretion movement until the last moment when she was placed under sedation. <b>Conclusion:</b> This case suggests that an effective excretion care is possible by team approach respecting patients’ QOL and sense of dignity.

Effectiveness of the etiology-based antiemetic recommendations by a palliative care team for nausea in cancer patients

<b>Purpose</b>: To clarify the effect of a palliative care team intervention for nausea of cancer patients. <b>Methods</b>: The study participants were all cancer patients who were referred to a palliative care team in Yodogawa Christian Hospital in 2010, and had nausea with score 2 or over of the Support Team Assessment Schedule Japanese version (STAS－J). The causes of nausea were classified into 4 categories. Etiology－based antiemetic medications were recommended, and the intensities of nausea were assessed using the STAS－J on the day of referral, and 7 days after. <b>Result</b>: Among 27 patients were recruited for this study, 24 were assessed 7 days after. Nine patients had chemically induced nausea, eight had impaired gastric emptying, four had vestibular and central nervous system disturbance, and three had bowel obstruction. The mean STAS－J score significantly decreased from 3.0 (SD, 0.55) on the day of referral to 1.1 (0.80) after 7 days (<i>p</i>＜0.001). Two patients had mild drowsiness. <b>Conclusion</b>: The recommendations of etiology－based antiemetics by the palliative care team may be effective for managing nausea in cancer patients.

Support system probability using IT cloud for a palliative care team to support a home palliative care

<b>Purpose and Methods</b>: Aiming at the relief of suffering by the palliative care team and prompt information sharing between healthcare professionals with various specialties, We introduced new IT cloud system, carried out questionnaire survey and examined the usefulness to 11 persons of healthcare professionals. Five cases where the palliative care team was concerned during the hospitalize became a home palliative care to the tried half a year. <b>Results</b>: All the members were using the personal computer as an input device. Four persons were using the iPhone. Two persons had the experience inputted on the spot. Nine persons of the input time were 5 or less minutes. All the members were perusing at various places by various device. Urgently and vital mail was useful: 3 in six, 2 in three, 1 in one, 0 in one. Information content were suitable: 3 in nine, 2 in two. Cooperation were completed in the smooth: 3 in nine, 2 in two. Have you utilized EIR for the home palliative care?: 3 in nine, 2 in two. <b>Conclution</b>: To the support of information sharing and palliative care team by IT cloud system transduction, the useful probability was suggested in the home palliative care.

Development and introduction of a regional cooperation clinical pathway for home palliative care

In order to promote regional cooperation in palliative care, we developed a regional cooperation clinical pathway for home palliative care that offers simple support and is easy to use. We then administered a questionnaire survey to 14 healthcare professionals with various specialties who were involved in the introduction of the pathway, and we revised the pathway on the basis of the survey results. The revised pathway was then tested in 13 patients who were discharged from 3 designated cancer care hospitals in Toyama City to home care, and another questionnaire survey was conducted afterwards in the same manner. The mean overall score on the questionnaire was 2 in seven, 3 in seven (on a scale of 0 to 3) at the time of introduction, whereas the score after trial use was 1 in one, 2 in four, 3 in five. We believe that more innovative approaches to the implementation of such pathways are required.

Evaluation of QOL in cancer patients under intervention by a palliative care team

<b>Purpose</b>: We assessed the efficacy of a palliative care team (PCT) in improving quality of life (QOL) among Japanese cancer patients. <b>Patients and methods</b>: This prospective study involved adult patients treated in the Division of Respiratory Medicine and Medical Oncology/Hematology at Kobe University Hospital between November 1, 2009 and March 30, 2010. Every patient had requested intervention by the PCT. Patients were asked to complete the EORTC QLQ-C15-PAL questionnaire at baseline and 1 and 4 weeks after initiation of the PCT intervention. <b>Result</b>: Of the 35 patients enrolled, 26 patients and 15 patients completed the assessments at 1 and 4 weeks after starting the intervention, respectively. Pain subscale (PA) was improved at 1 week after starting the intervention (p<0.05). Dyspnea subscale (DY) and PA were improved at 4 weeks after starting the intervention (p<0.05). <b>Conclusion</b>: We prospectively showed that QOL of cancer patients was improved with the intervention of the PCT, using the Japanese version of the EORTC QLQ-C15-PAL. Even if the PCT can only provide short-term care for cancer patients, this intervention appears worthwhile to improve QOL of cancer patients.

Advantages of a shared database on conference and ward round performed by the palliative care team

<b>Purpose</b>: We developed a database that can be shared by the members of our palliative care team (PCT) before the conference and ward round (CR) to make these activities more efficient. <b>Methods</b>: The database was developed using Microsoft Access®. The condition of patients was evaluated using a Japanese version of the Support Team Assessment Schedule (STAS-J). The database allows any member of the team to input patient information. We also developed a form that allows us not only to share the information but to continuously observe the progress of the patients. To evaluate the advantages of the database on CR, we compared the number of patients observed in one CR and the number of CR's per patient before and after the introduction of the database. <b>Results</b>: The number of patients observed in one CR and the number of CR's per patient were significantly increased after the introduction of the database. <b>Conclusion</b>: The database had positive effects on CR by making the patient information available in advance and by allowing continuous evaluation of patients. Palliat Care Res 2011; 6(1): 209-215