Bathing in Terminal Care of Cancer Patients and Its Relation to Perceptions of a "Good Death": A Nationwide Bereavement Survey in Japan.

Background: Bathing in a tub is integral to Japanese culture. It improves palliative care patients' symptoms and may improve quality of life. Objectives: This study aimed to determine the prevalence and impressions of bathing for terminally ill cancer patients and its relations to the evaluations of perceived end-of-life care and achievement of a good death. Design: This was a cross-sectional, anonymous, self-report questionnaire survey. Setting/Subjects: The questionnaire for this study was sent to bereaved family members who had lost loved ones in 14 general hospitals and 187 palliative care wards in Japan. Measurements: The bereaved family members of the patients who had actually bathed were asked about their impression of bathing. The short version of the Good Death Inventory (GDI) and the Care Evaluation Scale were used to evaluate "achievement of a good death." In total, 1819 surveys were sent between July and September 2018 to bereaved family members of patients who had died between February 2014 and January 2018 in 14 general hospitals and 187 palliative care wards in Japan. Overall 885 questionnaires (valid response rate 48%) returned by bereaved family members were analyzed. Results: Overall, 85% of bereaved family members of patients who bathed evaluated the experience positively, 86% reported that the patient's face seemed to become calm after the bath, and 28% of bereaved family members whose loved one had not bathed reported regretting it. The total GDI score for the bereaved family's desired death was 82.7 ± 13.0 for the bathing group and 75.4 ± 15.7 for the no bathing group, a significant difference (effect size = 0.52, p < 0.01). Conclusions: Bathing before death was evaluated positively and was associated with the achievement of a good death.

The Lived Experience of Persons with Terminal Cancer: A Qualitative Study.

This study aims to elucidate the life and death experiences of patients with terminal cancer. The researchers interviewed 18 terminal cancer patients, for a total 3,118 min. A psychophenomenological approach was used for analysis. Three themes were derived: a new appreciation for the gleam of an ordinary life after experiencing extreme suffering, a desire to at least pass away peacefully when sensing impending death, and a desire to remain useful to loved ones and other suffering patients like them. The novelty of this research derives from its finding that life and death are not in conflict and can lead to hope.

Avoiding the incompatibility of peripheral parenteral nutrition solution and midazolam injection for intravenous sedation.

OBJECTIVES: We have observed white turbidity when a midazolam injection is administered from a lateral tube during the administration of a peripheral parenteral nutrition (PPN) solution. The aim of the current study was to determine how to avoid compound changes when co-administering a midazolam injection and a PPN solution. METHODS: Midazolam solutions were prepared by diluting a midazolam injection with a 5% glucose intravenous infusion. We examined the formulation of the midazolam injection and a PPN solution at the concentrations used in a clinical setting for changes in appearance, pH, and midazolam content in test tubes and during administration conditions. RESULTS: With a 1/4.8 dilution of midazolam in undiluted solution, clouding occurred. A strong correlation was revealed between the midazolam content as measured through high-performance liquid chromatography and the mixture's midazolam concentration (R2=0.9918). The capture rate of midazolam infused with PPN solution was 91.0% at a 1/6 dilution, whereas it decreased to <90% at a 1/4.8 dilution. CONCLUSIONS: Our results suggest that the administration of a midazolam injection solution diluted by ≥6-fold with glucose solution or saline from a side tube during the administration of a PPN solution did not cause changes in composition.

Pharmacist's Intervention Considering the Prognosis for a Terminal Cancer Patient: A Case Report.

Prognostic prediction has been reported to affect the decision of doctors and non-physician health care providers such as nurses, social workers, pastors, and hospice volunteers on the selection of appropriate medical interventions. This was a case of a 65-year-old woman who presented with a poor oral intake. The patient had a history of sigmoid colon cancer with abdominal wall metastasis and peritoneal dissemination. On the day of admission, nausea, anorexia, and malaise were noted, requiring immediate intervention. The patient's prognosis was predicted using the Palliative Prognostic Index. The pharmacist suggested the use of dexamethasone tablets in order to alleviate the patient's symptoms. Indeed, the administration of dexamethasone alleviated the symptoms of nausea, loss of appetite, and malaise. To the best of our knowledge, this is the first case report to demonstrate that prognosis prediction is important not only for other medical staff but also for pharmacists when deciding the need to initiate a treatment and continue such treatment, and when providing pharmacist interventions.

The efficacy of specialised rehabilitation using the Op-reha Guide for cancer patients in palliative care units: protocol of a multicentre, randomised controlled trial (JORTC-RHB02).

BACKGROUND: Although rehabilitation is recommended for terminal cancer patients, the specific components and methods of such programs are poorly documented. No studies to date have examined the effectiveness of rehabilitation for terminal cancer patients. This study aims to evaluate the efficacy of a new intervention for rehabilitation therapists, using the Op-reha Guide (Guide to Optimal and Patient-Centred Rehabilitation Practice for Patients in Palliative Care Units [PCUs]) in rehabilitation practice. This guide consists of recommended actions and attitudes for rehabilitation therapists and aims to optimise therapists' actions according to the patient's needs and condition. It shares goals with terminal cancer patients to maintain their activities of daily living (ADL). METHODS: This study uses a multicentre, prospective, randomised controlled trial (RCT) design with two parallel groups in PCUs where specialised rehabilitation will be routinely performed for terminal cancer patients by rehabilitation therapists. Participants will be randomised (1:1) to intervention (the Op-reha Guide) and control groups (usual rehabilitation). We will then conduct an observational study in PCUs that do not perform specialised rehabilitation for terminal cancer patients; this will be considered the usual care group, and the efficacy of usual rehabilitation will be quantitatively evaluated. Inclusion criteria are hospitalisation in PCU, European Cooperative Oncology Group Performance Status of 2 or 3, and clinical estimation of life expectancy of 3 weeks or more. Patients with severe symptom burden will be excluded. We hypothesise that the Op-reha Guide will be more effective in maintaining the ADL of terminal cancer patients hospitalised in PCUs than usual rehabilitation. The primary endpoint is defined as the change in (total) modified Barthel Index from baseline to Day 22. Quality of life will be a secondary endpoint. In total, 135 patients will be recruited from 16 Japanese sites between July 2019 and December 2021. DISCUSSION: This will be the first trial to evaluate the efficacy of specialised rehabilitation for terminal cancer patients hospitalised in PCUs, and will contribute to the evidence on the efficacy of implementing rehabilitation for terminal cancer patients. TRIAL REGISTRATION: UMIN-CTR, UMIN000037298 R000042525 (date of registration 7 July 2019).

Influence of muscle mass on the estimation of glomerular filtration rate in Japanese terminal cancer patients.

BACKGROUND: Estimated glomerular filtration rate (eGFR) based on serum cystatin C (Scys) is useful for patients with decreased muscle mass, but has been also reported to be affected by cancer. The usefulness of Scys in eGFR in terminal cancer patients with decreased muscle mass is unknown. Therefore, we analyzed appropriate eGFR formulae for terminal cancer patients. METHODS: Study design was a retrospective observational study. Based on creatinine height index (CHI), 184 terminal cancer patients were stratified into CHI ≥ 90% (normal muscle mass, 59 patients); CHI 60-89% (mildly to moderately decreased muscle mass, 64 patients); and CHI < 60% (severely decreased muscle mass, 61 patients) groups. Twenty-four-hour creatinine clearance was measured and converted to the glomerular filtration rate (GFR) as a renal function measure. To estimate GFR, various eGFR formulae for Japanese were used: eGFRScys, eGFRScr5 and eGFRScr3, eGFRaverage and eGFRScys-Scr, and eGFRCG, based on Scys, serum creatinine (Scr), Scys and Scr combined, and Cockcroft-Gault formula (CG), respectively. Errors between measured and estimated values of renal function were verified using mean prediction errors (ME). When a 95% confidence interval (CI) of ME included 0, the accuracy of the eGFR formula was graded as good. RESULTS: eGFRScys ME was 0.2 (95% CI lower limit - 3.7, upper limit 4.0) mL/min/1.73 m2 in CHI 60-89% group and 9.2 (6.1, 12.9) mL/min/1.73 m2 in CHI < 60% group. eGFRScys was most accurate among the eGFR formulae. CONCLUSIONS: eGFR based on Scys was demonstrated as useful in terminal cancer patients with decreased muscle mass.

Practical Abilities of Discharge Planning Nurses in Supporting Discharge of Terminal Cancer Patients

The aim of this study was to investigate the practical abilities of discharge planning nurses to support discharge of terminal cancer patients. A survey was mailed to 477 discharge planning nurses (DPNs) who were employed at 120 designated regional cancer centers in Japan. Responses from 198 (valid response rate 41.5%) DPNs were subjected to analysis. The median number of years of DPN experience of the subjects was 2.5 years, and 90.2% of them had more than 10 years of nursing experience. Among the discharge planning abilities, “To Coordinate Post-discharge Care Balance” was significantly higher in the group with more nursing experience and in the group with longer DPN experience; “To Estimate Post-discharge Care Balance” and “To Prepare for Transition from the Hospital to a Care Facility” was significantly higher in the group with longer DPN experience and in the group with more experience working in home and community care. But “To make an agreement with the patient and their families” was not significantly different for experienced DPNs. It was suggested that in order to improve the quality of discharge planning, it is necessary to create a system that allows staffing based on individual experience and sharing of knowledge and experience of veteran DPNs.

Efficacy and Safety of Subcutaneous Levetiracetam Injection for Terminally-ill Cancer Patients: A Case Report

Introduction: Antiepileptic drugs were occasionally administered to manage seizures in terminally-ill cancer patients. When enteral route is no longer feasible due to dysphagia or depressed level of consciousness, subcutaneous route could be an option. We reported three cases of terminally cancer patients who received subcutaneous levetiracetam (LEV) due to an inability to administer via intravenous route. Cases: The age of 3 cases was 83, 75, 82 years, respectively. In all cases, the prognosis prediction at the start of subcutaneous LEV was about 1 month. In all cases, the route of administration of LEV was changed from intravenous to subcutaneous. No exacerbation of convulsions, or injection site reaction was confirmed after subcutaneous LEV administration. Discussion: We believe that subcutaneous LEV administration may be one of the treatment options for seizures in patients with terminal cancer for whom intravenous administration of LEV is no longer feasible.

Bereaved Family Members' Perceptions of the Distressing Symptoms of Terminal Patients With Cancer.

BACKGROUND: Few data are available on bereaved family members' perspective on the frequency of symptoms and degree of distress among terminal patients with cancer. METHODS: We sent a questionnaire to 1472 bereaved family members of terminal patients with cancer in 20 general hospitals. The questionnaire asked them (1) to indicate which symptoms the patients had, (2) to rate on a 4-point scale the extent to which the symptom was distressing, as follows: 1 = not distressing, 2 = slightly distressing, 3 = quite distressing, and 4 = very distressing at the point of 2 weeks before the patient had died. RESULTS: We analyzed 805 questionnaires for this study. Anorexia was the commonest symptom among terminal patients with cancer experienced by bereaved family members, followed by somnolence, weight loss, fatigue, and pain. Anorexia was the most distressing symptom among terminal patients with cancer experienced by bereaved family members, followed by weight loss, pain, edema, and dyspnea. CONCLUSIONS: Anorexia and weight loss were frequent symptoms and bereaved family members felt very distressing. Furthermore, there are not means of effective treatment now. Thus, we think that further study in this field is necessary.

A Retrospective Analysis of Early Death after Admission in Advanced Cancer Patients at the End-of-life in Single-institution

<p>Little is known about early death after admission during the terminal phase in advanced cancer patients. We retrospectively analyzed data from 510 advanced cancer patients who were at the end-of-life between August 2011 and August 2016, and found that 83 patients (16.3%) died within 3 days after admission to our institute. We divided the deceased patients into those who died within 3 days (early death group) and those who died after more than 4 days (non-early death group) after admission. Prevalence of delirium, cancer pain, dyspnea, nausea and vomiting, and fatigue patients showed no significant differences. Mean hydration at the end of life was significantly more per infusion for early death group than non-early death group. Continuous sedation and mean opioid use was significantly less for early death group than non-early death group. The risk factor of age, sex, clinical stage, histological state, overtreatment of chemotherapy, comorbidity had no significant associated with early death. The primary site of cancer, the number of metastatic sites, the consciousness level, and the performance status might be predictors for early death after admission in advanced cancer patients at the end-of-life.</p>

The Predictive Risk Factors for Bedsores of Terminal Cancer Patients Receiving Home-based Care

<p>Aim: To clarify the predictive risk factors for bedsores of terminal cancer patients receiving home-based care. Methods: A retrospective study was conducted involving 95 terminal cancer patients receiving home-based care, including people using services provided by home-visit care providers until death. Results: The numbers of patients with and without bedsores were 31 and 64, respectively. Bivariate analyses revealed that significant variables were the Ohura-Hotta scale (P=0.02), hyperactive delirium (P=0.005), contracture (P=0.008), and anemia (P=0.02). According to multivariable logistic analysis, significant variables were contracture (OR=16.55, P=0.0002) and hyperactive delirium (OR=4.22, P=0.008) as independent risk factors for bedsores. Discussion: For terminal cancer patients receiving home-based care, hyperactive delirium should also be considered as a predictive risk factor for bedsores.</p>

How Should ICDs Be Stopped in the Terminal Phase of Cancer?: Five Cases of Patients in a Palliative Care Unit

<p>From January 2015 to January 2017, we encountered five terminal cancer patients with implantable cardioverter defibrillators (ICDs) in the palliative care unit of our hospital. Due to delirium or dementia, four of these five patients did not have the decision-making capacity to stop their ICD. Although one patient was capable of making his own decisions, his family did not agree with the medical professional considering the patient’s decision. The families of all five patients made decisions on behalf of the patients. The procedure for stopping the ICD was first discussed with the families at 2–21 days prior to the patients’ deaths. The ICDs were stopped between 3 h and 11 days prior to the patients’ deaths, following the consent of the families, which was obtained after 1–5 consultations. Through these experiences, we became aware of the following problems with regard to stopping ICDs: (1) the lack of experience of medical professionals in decision-making, (2) the lack of recognition of medical professionals to the distress caused to patients by ICDs, (3) the psychological burden and time constraint of discussions, and (4) the lack of knowledge of ICDs among patients and their families. These problems need to be addresses as part of advance care planning for cancer patients. </p>

Difficulties Faced by Family Caregivers for Terminal Cancer Patient Cessation of Home-based

<p>The aims of this study were to clarify difficulties experienced by families facing the cessation of home-based care for terminal cancer patients, and to review the associated necessary nursing practices. We conducted semi-structured interviews with ten families. A qualitative research design was selected for this study, and the data was interpreted using content analysis techniques. The results were integrated into seven major categories: “unable to assess present symptoms for lack of understanding terminal cancer symptoms,” “feeling emotional pain during the patient’s aggravated condition,” “difficulties in coping with various patients’ physical symptoms: problems regarding inexperienced care,” “exhausted by living 24 hours a day with patient: lack of support, because of constraints from important people in the caregiver’s life,” and “difficulties faced by primary family caregivers in preparing a treatment environment.” Family caregivers were not able to prepare a treatment environment, because of a lack of understanding the symptoms of terminal cancer and an unwillingness to admit experiencing mental and physical burdens. The findings of this study suggested that the role of a nurse is to understand the family’s condition and values, provide required information in advance, and to adjust and prepare the treatment environment.</p>

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.

The Influencing Factors on the Degree of Nurse's Suffering Experience Caring for Terminal Cancer Patient / 성인간호학회지

PURPOSE: The study was undertaken to examine the degree of nurse's suffering experience and to identify the influencing factors on nurses' suffering experience in Korea. METHOD: Data were collected using a questionnaire for 271 nurses working at 5 general hospitals in Daegu and Kyung-book province from Sep. 1, to Sep. 30, 2003. The questionnaire consists of 54 items, general characteristics(10) and nurse's suffering experience(44). All surveys were sorted and studied by frequency analysis, mean score, standard deviation, range, independent t-test, one way ANOVA, Pearson's correlation coefficient and Multiple regression. RESULT: The findings of this survey indicate 1) The degree of suffering experienced by nurses caring for terminal cancer patients was 2.96; 2) Demographic variables affecting the degree of nurses' suffering experience were age(F=5.62, p=.000), marital status(F=20.53, p=.000), religion(F=5.44, p=.020), career of clinical experience(F=6.96, p=.000), and feelings of end-life care(F=3.11, p=.016); 3) There were slight correlation between the subitem of nurse's suffering experience and general characteristics of subjects. For 'expanding self consciousness', age, career duration, and position; for 'forming empathy with family', age and career duration ; for 'spiritual sublimation', age, and career duration were affected variables. 4) As a result of the multiple regression analysis for predictable variables affecting nurses' suffering, it was found that 'career of clinical experience' was most significant(F=23.100, p=.000). The explanatory power of this regression formula was 17.6%. CONCLUSION: This study can provide the basic data useful towards improvement of nursing services for terminal cancer patients and the health of the nurse.

A Comparison of Nursing Interventions with Terminal Cancer Patients in a Hospice Unit and General Units / 성인간호학회지

PURPOSE: The purpose of the study was to compare symptoms, medical therapies, and nursing interventions with terminal cancer patients during the last four weeks of their lives in a hospice unit and general units. METHOD: For the descriptive survey study, data were collected by reviewing the medical records of 243 patients who died of terminal cancer at K hospital in Seoul. The data was analyzed by using Chi-square test and t-test. RESULT: The study findings are summarized as follows: There were higher frequencies in physical symptoms of constipation, itching sensation, pain, sleeping disturbance, soreness and dysuria for those patients in the hospice unit than those patient in general units. All emotional symptoms were recorded significantly higher for those patients in the hospice unit than those in general units. Regarding the major medical interventions, pain management was used more significantly for those patients in the hospice unit, but antibiotic therapy and resuscitation were used more significantly for those patients in general units. CONCLUSION: The hospice unit provided more comprehensive nursing interventions including psychological, spiritual, and family cares as well as physiological care for terminal cancer patients. The facts showed that those patients who would need hospice care in general units should be referred to the hospice unit at an appropriate time.

Discrepancies of the Values on the Withholding Futile Interventions between Physician and Family Members of Terminal Cancer Patients.

PURPOSE: To analyze the controversies surrounding therapeutic decision-making and the withholding of life- sustaining treatments, values held concerning therapeutic interventions of terminal cancer patients are compared between physicians and family members. MATERIALS AND METHODS: 42 advanced or terminal stage cancer patients were enrolled for the study. The questionnaires were administered to the duty doctor and the family of the patients. Questions included whether to use new agents with a 15% partial efficacy and whether to use opioid analgesics, intravenous nutrition, a feeding tube, antibiotics, and hemodialysis. Additionally, we asked about the administration of CPR, ventilator application, and euthanasia. If the family permitted, the same questionnaires were given to the patients. RESULTS: Of the 42 cases, 5 families refused to answer the questionnaire. Of the available 37 families, only 5 families permitted access to the patients. Of the 5 patients, 2 patients refused the questionnaire. Only 67.6% and 8.1% of families and the patients clearly understood the stage of cancer. The use of a new agent was accepted by 45.2% of the physicians and 45.9% of the families. The rankings of the acceptance of treatment in the physicians and in the families were similar. The concordance rate between the physicians and the families was lowest on ventilator application and CPR. 31% of the physicians and 43.2% of the families agreed on the issue of euthanasia. CONCLUSION: Values held on issues like therapeutic decision-making and the withholding of life-sustaining treatments in terminal cancer patients are discordant between physicians and family members. In order to resolve controversies on the role of physicians in end-of-life decisions, the values of physicians as well as patients and their family members should be considered in the final decision-making process.

Discrepancies of the Values on the Withholding Futile Interventions between Physician and Family Members of Terminal Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: To analyze the controversies surrounding therapeutic decision-making and the withholding of life- sustaining treatments, values held concerning therapeutic interventions of terminal cancer patients are compared between physicians and family members. MATERIALS AND METHODS: 42 advanced or terminal stage cancer patients were enrolled for the study. The questionnaires were administered to the duty doctor and the family of the patients. Questions included whether to use new agents with a 15% partial efficacy and whether to use opioid analgesics, intravenous nutrition, a feeding tube, antibiotics, and hemodialysis. Additionally, we asked about the administration of CPR, ventilator application, and euthanasia. If the family permitted, the same questionnaires were given to the patients. RESULTS: Of the 42 cases, 5 families refused to answer the questionnaire. Of the available 37 families, only 5 families permitted access to the patients. Of the 5 patients, 2 patients refused the questionnaire. Only 67.6% and 8.1% of families and the patients clearly understood the stage of cancer. The use of a new agent was accepted by 45.2% of the physicians and 45.9% of the families. The rankings of the acceptance of treatment in the physicians and in the families were similar. The concordance rate between the physicians and the families was lowest on ventilator application and CPR. 31% of the physicians and 43.2% of the families agreed on the issue of euthanasia. CONCLUSION: Values held on issues like therapeutic decision-making and the withholding of life-sustaining treatments in terminal cancer patients are discordant between physicians and family members. In order to resolve controversies on the role of physicians in end-of-life decisions, the values of physicians as well as patients and their family members should be considered in the final decision-making process.

Development of an Education Program for Hospice Care and Its Performance / 간호학회지

The purpose of this study was to develop an education program for hospice care and to examine the effect of program. The education program for hospice care was developed based on the philosophy and principle of Hospice and integrated with various professional areas related to the problems with witch terminal patients and their family might be associated. The program was continued for 16 weeks and consisted of lectures and practices. The courses of this program were The Concept and Principle of Hospice, The Role of the Hospice Nurse, The Characteristics of Terminal Disease, Physical Care in Terminal Patients, Death Orientation, Psychological care for Terminal Patients, Spiritual care for Terminal Patients, and Care for the Family. To identify the effect of the education program for hospice care, the difference in death orientation of subjects between the pre and post performance of the education program was examined using the t-test. The finding of this statistic indicated that this education program for hospice care was effective in terms of changing the death orientation of subjects with positive direction. The education program for hospice care was performed several times at Kwangrim Hospice Missionary, Chungbuk University Hospital, and Wooam Church. Case studies were reported for a description after the performance of education. put this at the beginning 8 the sentence. In conclusion, the education program for hospice care was developed effectively. Therefore, this program should be used to educate and activate the subjects in community to be participants in hospice care.

Behavior patterns of health care utilization in terminal cancer patients

BACKGROUND: In order to improve the quality of life of dying patients so that they may die with dignity, they need to receive not only the physical, psychological, social, and spiritual care, but also systematic and continuous care. However, their is no adequate medical service at present. We studied terminal cancer patients'behavior patterns of health care utilization, the problems of caring for the patient, and medical services that bereaved families suggested for terminal cancer patients and their families. METHODS: From 271 patients'families who participated in our hospice program from March 1991 to February 1996, 108 bereaved families whom we able to had been contact were interviewed by three student nurses with a structured questionnaire. RESULTS: The terminal cancer patients received their medical care through admission to hospital(45.4%), outpatient clinic(22.2%), emergency room(16.7%), and oriental medicine(12.0%). But during their terminal phase of the illness, 32.4% of patients never received medical care including oriental medicine, and 28.7% received alternative medicine care such as intake of mushroom and elm tree. 26 bereaved families(24.1%) pointed out the indifference of the medical team as a problem receiving proper hospital care, and 22 bereaved families(20.4%) emphasized emotional strain of their helplessness with the patient's suffering as a problem of caring for the patient at home. Over 90% of bereaved families from their experience suggested needs of continuous care, hospice care, home care, and 24hr telephone service. CONCLUSIONS: There were inappropriate behavior patterns of health care utilization which resulted in large proportion of terminal cancer patients received alternative medicine never receiving proper medical care. Therefore, there is a need to develop the continuous and comprehensive care for terminal cancer patients and their family, such as hospice.)