Combination of Radiation Therapy, Wim's Tumor 1 (WT1) Dendritic Cell Vaccine Therapy, and α-Galactosylceramide-Pulsed Dendritic Cell Vaccine Therapy for End-Stage Small Bowel Cancer.

There is no established treatment for terminal cancer patients who no longer respond to surgery, radiotherapy, or chemotherapy, and palliative care is the standard worldwide. We performed intensity-modulated radiation therapy for pain relief in a 40-year-old male patient with end-stage small intestinal cancer who had been diagnosed with a life expectancy of two months after chemotherapy had been ineffective. Subsequent administration of seven doses of dendritic cell vaccine recognizing Wim's tumor 1 (WT1) and α-galactosylceramide antigens resulted in significant shrinkage of the cancer and marked improvement of the patient's general condition. The combination therapy of radiotherapy and dendritic cell vaccine therapy may suppress cancer progression and prolong survival, even in patients with chemotherapy-refractory terminal cancer. In particular, double dendritic cell vaccine therapy with WT1 and α-galactosylceramide-pulsed dendritic cell may provide an anti-tumor immune effect that is superior to that of the respective monotherapy.

High prevalence of severe pain is associated with low opioid availability in patients with advanced cancer: Combined database study and nationwide questionnaire survey in Japan.

OBJECTIVES: Opioid availability for the palliative care of patients with advanced cancer is increasing globally. However, opioid availability remains extremely low in Japan. We investigated whether pain is appropriately controlled by low-dose opioid prescriptions in patients with advanced cancer in Japan. METHODS: A web-based nationwide survey for caregivers from 2000 community comprehensive support care centers was performed in Japan to assess details about pain in the 30 days before patients died of end-stage cancer. Separately, the data for opioid prescription doses and medical services in the 90 days before the death of patients with cancer were extracted from a health insurance claim database. RESULTS: Responses from 1034 responders were retrieved and 665 patients were included. In total, 254 patients (38.2%) complained of severe-to-intolerable cancer-related pain. The median cumulative prescription dose of opioids in the 90 days before patient death was 311.0 mg by oral morphine equivalent doses. Multiple regression analyses across prefectures revealed that the proportion of patients with severe-to-intolerable cancer-related pain was negatively associated with the cumulative opioid consumption expressed as morphine-equivalent doses within 90 days before death. CONCLUSIONS: The very low availability of opioids for patients with end-stage cancer could result in high rate of severe-to-intolerable cancer-related pain patients. There were several limitations in this study, and the interpretations of the findings should be carefully. However, the increase in the absolute dose of opioids could improve the palliative care framework to the pain control levels of the global standard.

Estimating the Costs of End-of-Life Care in Patients With Advanced Cancer From the Perspective of an Insurance Organization: A Cross-Sectional Study in Iran.

OBJECTIVES: Cancers are significant medical conditions that contribute to the rising costs of healthcare systems and chronic diseases. This study aimed to estimate the average costs of medical services provided to patients with advanced cancers at the end of life (EOL). METHODS: We analyzed data from the Sata insurance claim database and the Health Information System of Baqiyatallah hospital in Iran. The study included all adult decedents who had advanced cancer without comorbidities, died between March 2020 and September 2020, and had a history of hospitalization in the hospital. We calculated the average total cost of healthcare services per patient during the EOL period, including both cancer-related and noncancer-related costs. RESULTS: A total of 220 patients met the inclusion criteria. The average duration of the EOL period for these patients was 178 days, with an average total cost of $8278 (SD $5698) for men and $9396 (SD $6593) for women. Cancer-related costs accounted for 64.42% of the total costs, including inpatient and outpatient services. Among these costs, hospitalization was the primary cost driver and had the greatest impact on EOL costs. This observation was supported by the multiple linear regression model, which suggested that hospitalization in the final days of life could potentially drive costs in these patients. Notably, no specialized palliative care was provided to the patients included in this study. CONCLUSIONS: The results demonstrate that there is a significant rise in costs of care in patients receiving routine cancer care rather than optimized EOL care.

The efficacy and safety of apatinib in patients with heavily pretreated end-stage cancer: a retrospective study.

Background: Anti-angiogenesis therapy has been a vital treatment option in a variety of cancers. Assessing the efficacy and safety of apatinib in patients with heavily pretreated end-stage cancer is essential. Methods: Thirty patients with end-stage cancer who were heavily pretreated were enrolled in this study. All patients received oral administration of apatinib (125-500 mg/d) between May 2015 and November 2016. Dose reduction or elevation was conducted based on adverse events and doctors' judgments. Results: Prior to the apatinib treatment, the enrolled patients received a median of 1.2 surgeries (range, 0-7), 1.6 sessions of radiotherapies (range, 0-6), and 10.2 cycles of chemotherapy (range, 0-60); 43.3% of patients had uncontrolled local lesions, 83.3% of patients had uncontrolled multiple metastases, and 30.0% of patients had both. After the treatment, 25 patients had valuable data, 6 (24.0%) patients achieved partial response (PR), and 12 (48.0%) patients had stable disease (SD). The disease control rate (DCR) was 72.0%. The PR and SD rates were 20.0% and 40.0%, respectively, and the DCR was 60.0% in the intent-to-treat (ITT) analysis. Meanwhile, the median progression-free survival (PFS) was 2.6 (range, 0.7-5.4) months, and the median overall survival (OS) was 3.8 (range, 1.0-12.0) months. Furthermore, the PR rate and DCR in patients with squamous cell cancer (SCC) were 45.5% and 81.8%, respectively; those in patients with adenocarcinoma (ADC) were 8.3% and 58.3%, respectively. The adverse events were generally mild. The most common adverse events were hyperbilirubinemia (53.3%), elevated transaminase (36.7%), anemia (30.0%), thrombocytopenia (30.0%), hematuria (30.0%), fatigue (26.7%), and leukopenia (20.0%). Conclusions: The results of this study demonstrate the efficacy and safety of apatinib and support the further development of apatinib as a potential treatment option for patients with heavily pretreated end-stage cancer.

Antibiotic Treatment in End Stage Cancer Patients; Advantages and Disadvantages.

Aim: In this study our aim was to elucidate whether advanced cancer patients benefit from antibiotic treatment in the last days of life in addition to reviewing the relevant costs and effects. Materials And Methods: We reviewed medical records from 100 end-stage cancer patients and their antibiotic use during the hospitalization in Imam Khomeini hospital. Patient's medical records were analyzed retrospectively for cause and periodicity of infections, fever, increase in acute phase proteins, cultures, type and cost of antibiotic. Results: Microorganisms were found in only 29 patients (29%) and the most microorganism among the patients was E. coli (6%). About 78% of the patients had clinical symptoms. The highest dose of antibiotics was related to Ceftriaxone (40.2%) and in the second place was Metronidazole (34.7%) and the lowest dose was related to Levofloxacin, Gentamycin and Colistin (1.4%). Fifty-one patients (71%) did not have any side effects due to antibiotics. The most common side effect of antibiotics among patients was skin rash (12.5%). The average estimated cost for antibiotic use was 7 935 540 Rials (24.4 dollars). Conclusion: Prescription of antibiotics was not effective in symptom control in advanced cancer patients. The cost of using antibiotics during hospitalization is very high and also the risk of developing resistant pathogens during admission should be considered. Antibiotic side effects also occur in patients, causing more harm to the patient at the end of life. Therefore, the benefits of antibiotic advice in this time is less than its negative effects.

General Ward Nurses' Self-Efficacy, Ethical Behavior, and Practice of Discharge Planning for End-Stage Cancer Patients: Path Analysis.

General ward nurses play a key role in discharge planning for end-stage cancer patients. It is necessary to assess the factors regarding their practice to promote discharge planning in accordance with end-stage cancer patients' wishes. This study aimed to investigate the relationships between general ward nurses' practice of discharge planning for end-stage cancer patients, self-efficacy, ethical behavior, attitude, knowledge and experience, perceived skills, and perceived barriers. A total of 288 general ward nurses from nine hospitals in a city in Japan completed the questionnaire. Path analysis was conducted to test the hypotheses. The results showed that nurses' self-efficacy, ethical behavior (do-no-harm, do-good), knowledge (experience of attending home care seminars), and perceived skills (assertiveness) were positively and directly related to the practice of discharge planning. Nursing experience and perceived skills (assertiveness) were positively associated with discharge planning practice, while perceived barriers (death discussion) and attitude (degree of leaving it to discharge planning nurses (DPNs)) were negatively associated, with self-efficacy acting as a mediator. Thus, our findings show that it is important to enhance self-efficacy and nursing ethical behavior to improve the practice of discharge planning. Accordingly, education regarding home care, assertive communication skills, death discussion, and ethics is needed for general ward nurses.

Potentially inappropriate medication discontinued or changed based on pharmacists' recommendations in older end-stage cancer patients receiving palliative care: a cross-sectional study.

BACKGROUND: Avoiding potentially inappropriate medications (PIMs) can reduce adverse events in older cancer patients receiving palliative care. However, studies have not examined the extent to which pharmacists' recommendations reduce the prescription of PIMs. Therefore, we designed a cross-sectional study to determine the extent to which their recommendations play a role in reducing the prescription of PIMs for older cancer patients receiving palliative care. METHODS: Patients brought their medications with them upon admission to the hospital. These medications were examined by pharmacists and deemed inappropriate based on the Screening Tool of Older People's Prescriptions version 2 (STOPP2). In this study, these 220 patients were surveyed, and the percentage of medications that were discontinued or changed based on pharmacists' recommendations was compared with previously published results of similar studies on older non-cancer inpatients, using univariate analysis. RESULTS: A total of 218 PIMs were detected in 1261 medications administered to 220 patients. Of these, 61 medications were discontinued or changed based on the recommendation of pharmacists (rate of discontinuation/change of medications: 28.0%). The univariate analysis results showed that this rate of discontinuation or change of medications was significantly lower than that of a previous report intended for non-cancer patients (40.6%). The rate of discontinuation/change of medications for benzodiazepines was extremely low, but for other drugs it was almost the same as in the previous report. CONCLUSIONS: In the case of older end-stage cancer patients receiving palliative care, compared with older patients hospitalized for other diseases, it was more difficult, on pharmacists' recommendations, to discontinue or change PIMs detected by STOPP2. The low significance of discontinuing or changing benzodiazepines in subjects was a major reason it was difficult to reduce the prescription and, eventually, administer PIMs based on pharmacists' recommendations.

Cytokine Profiling of End Stage Cancer Patients Treated with Immunotherapy.

Published data suggest that immunotherapy plays a role even in patients with very advanced tumours. We investigated the immune profile of end-stage cancer patients treated with immunotherapy to identify changes induced by treatment. Breast, colon, renal and prostate cancer patients were eligible. Treatment consisted of metronomic cyclophosphamide, low-dose interleukin-2 (IL-2) and a single radiation shot. A panel of 16 cytokines was assessed using automated ELISA before treatment (T0), after radiation (RT; T1), at cycle 2 (T2) and at disease progression (TPD). Receiving operating characteristic (ROC) analysis was used to identify cytokine cut-off related to overall survival (OS). Principal component analysis (PCA) was used to identify the immune profile correlating better with OS and progression-free survival. Twenty-three patients were enrolled. High IL-2, low IL-8 and CCL-2 correlated with OS. The PCA identified a cluster of patients, with high IL-2, IL-12 and IFN-γ levels at T0 having longer PFS and OS. In all cohorts, IL-2 and IL-5 increased from T0 to T2; a higher CCL-4 level compared to T2 and a higher IL-8 level compared to T0 were found at TPD. The progressive increase of the IL-10 level during treatment negatively correlated with OS. Our data suggested that baseline cytokine levels may predict patients' outcome and that the treatment may affect their kinetic even in end-stage patients. Cytokine profiling of end-stage patients might offer a tool for medical decisions (EUDRACT: 2016-000578-39).

Actual Situations and Factors Related to Nursing Activities in Supporting the Transition to Homecare Settings for End-Stage Cancer Patients in General Wards in Japan.

This study aimed to investigate actual situations of nursing activities in supporting the transition to homecare settings for end-stage cancer patients and to determine factors related to executing such nursing activities from the perspectives of communication skills and interprofessional collaboration. A cross-sectional study was conducted with 513 nurses who worked at designated cancer care hospitals in Japan. A total of 318 valid responses were obtained (valid response rate: 62.0%). Scores for nursing activities were higher for the following items: sharing information regarding the transition to homecare settings, intentionally engaging with patients after their medical conditions were explained, providing care for families, and understanding a patient's will about the transition to homecare settings. On the other hand, scores were lower for items that were related to guiding juniors and self-improvement. A multiple regression analysis was performed with nursing activities as the dependent variable. 8 factors related to nursing activities were determined: experience in supporting the transition to homecare settings as a primary nurse, contribution to a team (Team Approach Assessment Scale [TAAS]), years of nursing experience, function of a team (TAAS), regulation of interpersonal relationship (ENDCOREs communication skills scale), experience of participation in homecare nursing education or seminars, verbal communication skills for good communication (End-of-life Care Nurses' Communication Skills scale), and educational background. Future challenges include developing an educational program based on the results of the present study and promoting educational intervention studies.

Risk factors of hypermagnesemia in end-stage cancer patients hospitalized in a palliative care unit.

Despite the fact that hypermagnesemia is a relatively common electrolyte abnormality among end-stage cancer patients, a clinical approach to avoiding hypermagnesemia in these patients has yet to be identified. Thus, we designed a cross-sectional study to identify a clinical approach to avoiding hypermagnesemia in end-stage cancer patients receiving palliative care and considered whether these risk factors could be avoided in end-stage cancer patients. Patients with end-stage cancer who were hospitalized in a palliative care unit at Himeji St. Mary's Hospital, Japan, between January 2017 and December 2019 were included in the study. Laboratory results of the blood samples collected from the subjects were examined. Participants' medical records were assessed to identify previously reported risk factors of hypermagnesemia and evaluate the physical status specific to end-stage cancer patients. Logistic regression analysis was used to analyze the relationship between risk factors and physical status. During the study period, 674 end-stage cancer patients were hospitalized in the subject palliative care unit. Serum magnesium levels were measured in 533 patients, and hypermagnesemia was observed in 123 (23.08%) of them. Renal dysfunction, short prognosis prediction, and oral magnesium oxide laxative were all significant predictor variables of a higher rate of hypermagnesemia. Patients who had all three risk factors had a significantly higher incidence of hypermagnesemia. Thus, it is important not to use magnesium oxide laxatives on end-stage cancer patients to prevent hypermagnesemia-especially when renal dysfunction is observed and a short prognosis is predicted.

Serotonergic hallucinogens/psychedelics could be promising treatments for depressive and anxiety disorders in end-stage cancer.

In a recent issue of the BMC Psychiatry, the evidence of effectiveness of treatments for psychiatric conditions in end-stage cancer patients was reviewed (Johnson, 2018). The review was comprehensive, and included traditional and non-traditional/alternative treatments, including herbal medicines and spirituality. However, evidence showing that classic or serotonergic hallucinogens/psychedelics such as psilocybin and lysergic acid diethylamide (LSD) could be effective treatments for depressive and anxiety disorders in end-stage cancer was not included. In this commentary, we expand the information available on the original article by briefly reviewing data from recent placebo-controlled, double-blind, cross-over clinical trials showing evidence that administration of single (or few) doses of LSD and psilocybin was associated with rapid and sustained reductions in depressive and anxiety symptoms in patients with end-stage cancer and other life-threatening diseases (e.g., Bechterew's disease, Parkinson's disease, Celiac disease). Since these substances seem to produce rapid and sustained therapeutic effects with single (or few) doses and well tolerated, large-scale, prospective, multi-site studies of end-stage cancer and classical/serotonergic hallucinogens/psychedelics should be performed to improve our understanding of the therapeutic potentials of these drugs and their use on clinical practice.

Quality of life improves after palliative placement of percutaneous tunneled drainage catheter for refractory ascites in prospective study of patients with end-stage cancer.

OBJECTIVE: Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC. METHOD: Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test. RESULT: Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope -0.43 to -0.26, p = 0.055; sodium slope -2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%). SIGNIFICANCE OF RESULTS: QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.

Intravenous Chlorpromazine for the Short-Term Treatment of Insomnia in End-Stage Cancer Patients With Difficulty in Oral Administration.

The objective of the study was to evaluate effectiveness and safety of intravenous chlorpromazine for the short-term treatment of insomnia in end-stage cancer patients. Insomnia occurs as one of distressing symptoms in 70% of end-stage cancer patients. End-stage cancer patients often have difficulty in oral administration because of disease progress. We retrospectively evaluated 30 end-stage cancer patients with difficulty in oral administration who received intravenous chlorpromazine for the short-term treatment of insomnia. A primary end point was sleep quality based on St. Mary's Hospital Sleep Questionnaire 3 days after the treatment. Improved sleep quality was observed on the day after the treatment and later (P < .001), and the effective rate mean was 0.63 (95% confidential interval: 0.45-0.81) 3 days after the treatment. Increased total sleep time and decreased sleep latency time were observed 3 days after the treatment (P < .001); however, no improvement in depth of sleep was achieved (P = .231). There was no adverse event except for two delirium cases. The study indicated that intravenous chlorpromazine can be applied safely and effectively for the short-term treatment of insomnia in end-stage cancer patients with difficulty in oral administration.

A research study review of effectiveness of treatments for psychiatric conditions common to end-stage cancer patients: needs assessment for future research and an impassioned plea.

BACKGROUND: Rates of psychiatric conditions common to end-stage cancer patients (delirium, depression, anxiety disorders) remain unchanged. However, patient numbers have increased as the population has aged; indeed, cancer is a chief cause of mortality and morbidity in older populations. Effectiveness of psychiatric interventions and research to evaluate, inform, and improve interventions is critical to these patients' care. This article's intent is to report results from a recent review study on the effectiveness of interventions for psychiatric conditions common to end-stage cancer patients; the review study assessed the state of research regarding treatment effectiveness. Unlike previous review studies, this one included non-traditional/alternative therapies and spirituality interventions that have undergone scientific inquiry. METHODS: A five-phase systematic strategy and a theoretic grounded iterative methodology were used to identify studies for inclusion and to craft an integrated, synthesized, comprehensive, and reasonably current end-product. RESULTS: Psychiatric medication therapies undoubtedly are the most powerful treatments. Among them, the most effective (i.e., "best practices benchmarks") are: (1) for delirium, typical antipsychotics-though there is no difference between typical vs. atypical and other antipsychotics, except for different side-effect profiles, (2) for depression, if patient life expectancy is ≥4-6 weeks, then a selective serotonin reuptake inhibitor (SSRI), and if < 3 weeks, then psychostimulants or ketamine, and these generally are useful anytime in the cancer disease course, and (3) for anxiety disorders, bio-diazepams (BDZs) are most used and most effective. A universal consensus suggests that psychosocial (i.e., talk) therapy and spirituality interventions fortify the therapeutic alliance and psychiatric medication protocols. However, trial studies have had mixed results regarding effectiveness in reducing psychiatric symptoms, even for touted psychotherapies. CONCLUSIONS: This study's findings prompted a testable linear conceptual model of co-factors and their importance for providing effective psychiatric care for end-stage cancer patients. The complicated and tricky part is negotiating patients' diagnoses while articulating internal intricacies within and between each of the model's co-factors. There is a relative absence of scientifically derived information and need for more large-scale, diverse scientific inquiry. Thus, this article is an impassioned plea for accelerated study and better care for end-stage cancer patients' psychiatric conditions.

Symptoms in Advanced Cancer Patients in a Greek Hospital: a Descriptive Study

Background: Advanced cancer patients experience several physical or psychological symptoms which require palliative care for alleviation. Purpose: To assess the prevalence and intensity of symptoms among cancer patients receiving palliative care in a Greek hospital and to examine the association between reported symptoms and social clinical and demographic characteristics. Material-methods: This descriptive research was conducted during a sixmonth period using a convenient sample of 123 advanced cancer patients. All participants were assessed for their symptoms using the Edmonton Symptom Assessment System (ESAS) with a questionnaire covering demographic and clinical characteristics. Results: The mean age was 63.8± 10.8 years, with lung and breast (58.5% and 11.4%, respectively) as the most common primary cancer types. The most severe symptoms were fatigue, sleep disturbance, dyspnea, depression and anxiety. Negative correlations were revealed between age and the following symptoms: pain (r = -0.354, p = 0.001), fatigue (r = -0.280, p = 0.002), nausea (r = -0.178, p = 0.049), anorexia (r = -0.188, p = 0.038), dyspnea (r = -0.251, p = 0.005), and depression (r = -0.223, p = 0.013). Advanced breast cancer patients scored higher in pain, fatigue and dyspnea compared to those with other cancers. Conclusions: Hospitalized cancer patients in Greece experience several symptoms during the last months of their life. These are influenced by demographic characteristics. Appropriate interventions are strongly advised with appropriate recognition and evaluation of symptoms by health professionals.

Characteristics of and Factors Related to Nurses’ Decision-making Support for Transition to Home Care Settings for End-stage Cancer Patients

This study aimed to clarify the current status of and factors related to support by general ward nurses for transition to home care settings for end-stage cancer patients. A questionnaire was sent to 1,019 general ward nurses. Multiple regression analysis was performed to determine related factors. The 17-item scale to evaluate nurses’ decision-making support for transition to home care settings was used as a dependent variable. A total of 653 valid responses were obtained (valid response rate: 64.0%). The following factors were correlated with decision-making support for transition to home care settings: “experience supporting transition to home care settings” (β=0.26), “professional autonomy in nursing: concrete judgment” (β=0.23), “professional autonomy in nursing: performance” (β=0.18), “learning experience with home care nursing” (β=0.13), “belief in an afterlife” (β=0.12), and “learning experience with family nursing (β=0.07)” (adjusted R2=0.27). The results suggest the practical abilities of nurses, i.e., relevant experience, knowledge, and views on death and dying are related to nurses’ decision-making support for transition to home care settings for patients with end-stage cancer.

Oncologists' End of Life Treatment Decisions.

BACKGROUND: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists' attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists' perspectives on how patient age affects their treatment decisions. METHODS: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. RESULTS: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. DISCUSSION: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists' chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.

A Case Whose Delirium Improved with Discontinuation of Continuous Deep Sedation Initiated for Refractory Delirium at the End Stage of Cancer

<p>Introduction: We herein report a case whose terminal refractory delirium improved after discontinuation of continuous deep sedation for several days. Case: A 57-year-old head and neck cancer woman with brain parenchymal invasion was consulted to our palliative care team for delirium accompanied by sudden abnormal behavior. Her abnormal behavior did not improve with opioid switching or drug treatment. She was diagnosed as refractory end of life delirium, and her family wanted her to be sedated. We started intermittent sedation with midazolam and then shifted to continuous deep sedation. Several days later, her family expressed the conflict of continuing sedation. Ten days later we stopped sedating her according to her family’s will. She awoke from deep sedation and her abnormal behavior disappeared, although there was mild consciousness disturbance. The patient died 2 months later while maintaining communication with her family. Discussion: Cessation of various drugs which may provoke delirium is considered to be one of the causes of delirium improvement in this case. The guidelines of the Japanese Society of Palliative Medicine do not clearly state the criteria for suspension of deep sedation other than confirming the feelings of family members. A criterion for withdrawal of sedation should be discussed based on higher evidence level.</p>

A Case Where Administration of Venlafaxine Alleviated Depressive Symptoms and Neuropathic Pain in a Patient with Bone Metastasis of Lung Cancer

<p>The current authors encountered a case where administration of venlafaxine alleviated depressive symptoms and neuropathic pain in a patient with bone metastasis of lung cancer. This case involved an 84-year-old woman. The woman suffered a fracture of her right femur due to bone metastasis of lung cancer, so she was transferred to this Department. Upon transfer, pain and depression were noted. The patient was given an increased dose of extended-release oxycodone, but bone pain, neuropathic pain remained. Depression persisted. Venlafaxine was administered, and depression, bone pain, neuropathic pain were alleviated. The current case suggested that venlafaxine is highly efficacious in treating depressive symptoms and neuropathic pain in patients with cancer.</p>