Current status of integrating oncology and palliative care in Japan: a nationwide survey.

BACKGROUND: Palliative care (PC) is increasingly recognized as essential for oncology care, and several academic societies strongly recommend integrating oncology and palliative care (IOP) in daily practice. Similarly, the Japanese government encouraged the implementation of IOP through the Cancer Control Act of 2007; however, its detailed progress remains unclear. Therefore, this cross-sectional nationwide survey was conducted to investigate the current status and hospital executive physicians' perception of IOP. METHODS: The questionnaire was developed based on IOP indicators with international consensus. It was distributed to executive physicians at all government-designated cancer hospitals (DCHs, n = 399) and matched non-DCHs (n = 478) in November 2017 and the results were compared. RESULTS: In total, 269 (67.4%) DCHs and 259 (54.2%) non-DCHs responded. The number of PC resources in DCHs was significantly higher than those in non-DCHs (e.g., full-time PC physicians and nurses, 52.8% vs. 14.0%, p < 0.001; availability of outpatient PC service ≥3 days per week, 47.6% vs. 20.7%, p < 0.001). Routine symptom screening was more frequently performed in DCHs than in non-DCHs (65.1% vs. 34.7%, p < 0.001). Automatic trigger for PC referral availability was limited (e.g., referral using time trigger, 14.9% vs. 15.3%, p = 0.700). Education and research opportunities were seriously limited in both types of hospitals. Most executive physicians regarded IOP as beneficial for their patients (95.9% vs. 94.7%, p = 0.163) and were willing to facilitate an early referral to PC services (54.7% vs. 60.0%, p < 0.569); however, the majority faced challenges to increase the number of full-time PC staff, and < 30% were planning to increase the staff members. CONCLUSIONS: This survey highlighted a considerable number of IOP indicators met, particularly in DCHs probably due to the government policy. Further efforts are needed to address the serious research/educational gaps.

Measuring the regret of bereaved family members regarding the decision to admit cancer patients to palliative care units.

OBJECTIVE: The purposes of this study were to develop a bereaved family regret scale measuring decision-related regret of family members about the admission of cancer patients to palliative care units (PCUs) and to examine the validity and reliability of this scale. METHOD: Bereaved families of cancer patients who had died in one regional cancer center from September 2004 to February 2006 received a cross-sectional questionnaire by mail. The questionnaire contained seven items pertaining to decision-related regret about the patient's admission to the PCU, the Care Evaluation Scale (CES), an overall care satisfaction scale, and a health-related quality-of-life (QOL) scale (SF-8). One month after receiving a completed questionnaire, we conducted a retest with the respondent. RESULTS: Of the 216 questionnaires successfully mailed to the bereaved families, we received 137 questionnaires and were able to analyze the responses for 127 of them, as the other 10 had missing data. By exploratory factor analysis and confirmatory factor analysis, we identified two key factors: intrusive thoughts of regret and decisional regret. This scale had sufficient convergent validity with CES, overall care satisfaction, SF-8, sufficient internal consistency, and acceptable test-retest reliability. CONCLUSION: We have developed and validated a new regret scale for bereaved family members, which can measure their intensity of regret and their self-evaluation about their decision to admit their loved ones to PCUs.

Coping strategies and its effects on depression among caregivers of impaired elders in Japan.

The purpose of this study was to explore the coping strategies of Japanese family caregivers and to investigate relationships between coping strategies, caregiving stressors,and family caregivers' mental health. We conducted a survey by mail among family members who provided care for physically or mentally impaired elderly. In this study, we used 166 responses from family caregivers for analysis. Results of exploratory and confirmatory factor analysis indicated three factors,categorized 'Resignation,' 'Consulting and complaining' and 'Distancing'. In addition, results of structure equation modelling suggested a significant effect of 'Resignation' on the mental health of caregivers. Although the factor structure of coping strategies was similar to other studies conducted in Western countries, the effects of coping strategies were quite different. In conclusion, the effects of coping strategies on caregivers' mental health were confirmed in this study, but different types of coping strategies from those of Western countries were found to be associated with mental health of Japanese family caregivers.

[Informed consent on pain management].

Informed consent is an essential concern to provide medical services centered on patient's needs. Its significant role is not to avoid legal responsibility but to respect patient's individuality. It emphasizes the necessities for sharing medical information including its uncertainty, listening carefully to a patient about his/her questions and anxieties and being worried with him/her in regard to the best ways coping with sufferings. In this article we describe important aspects concerning informed consent on pain management at clinical situations. It is necessary for physicians not only to have knowledge for pain management but also to get technique for appropriate explanation about analgesics.

[Hospice and palliative care in the outpatient department].

In the medical environment, information disclosure to patients and respect of autonomy have spread rapidly. Today, many terminally-ill cancer patients wish to spend as much time at home as possible. In such situations the patient who has been informed that curative treatments are no longer expected to be beneficial can now hope to receive home care and visiting care from hospice/palliative care services. The essential concepts of hospice/palliative care are symptom management, communication, family care and a multidisciplinary approach. These concepts are also important in the outpatient department. In particular, medical staff need to understand and utilize management strategies for common symptoms from which terminally-ill cancer patients suffer (ex. cancer pain, anorexia/fatigue, dyspnea, nausea/vomiting, constipation, hypercalcemia and psychological symptoms). They also need to know how to use continuous subcutaneous infusion for symptom management in the patients last few days. The present paper explains the clinical practices of hospice/palliative care in the outpatient department. Also discussed is support of individual lives so that maximum QOL is provided for patients kept at home.

Pain control with morphine for vertebral metastases and sciatica in advanced cancer patients.

Morphine was administered to 56 advanced cancer patients; of that number spinal metastases had induced bone pain in 28 and malignant tumors had induced sciatica in 28. The sciatica was caused in 16 patients by direct invasion of the sacral plexus, in four by lumbar bone metastases, and in eight by pelvic bone metastases. Spinal bone pain was controlled adequately with morphine. However, sciatica required larger dosages of morphine than did bone pain. Among the group with sciatica, rectal cancer patients needed larger dosages of morphine than the other cancer patients. Even with high doses of morphine, it was occasionally difficult to control neuropathic pain of the sciatic nerve caused by intrapelvic cancer.

A clinical survey of controlled-release morphine sulphate for cancer pain relief in a Japanese hospice.

Seventy-six cancer patients were studied on the use of controlled-release morphine sulphate (MS Contin) for cancer pain relief in the hospice of Yodogama Christian Hospital in Japan. The mean initial and maximum dosages were 81.4 mg and 178.6 mg respectively. While 46 patients (61%) did not need an increase in the initial dosage, 26 patients (34%) needed an increase ranging between 8 and 125%. Four patients (5%) required an increment of more than 500% of the initial dosage, because of apparent nerve involvement. This clinical survey showed that the total effectiveness was 92% and that 90% of the patients could experience control of pain with a daily dosage of 240 mg or less of MS Contin. Side effects observed were as follows: drowsiness 21%, nausea 11%, vomiting 8%, constipation 8%, confusion 7%, hallucination 3%. In conclusion, MS Contin offers effective cancer pain relief with minimal side effects in the majority of patients.

[Pain control in terminal cancer].

Pain is a major symptom in more than two-thirds of patients with far-advanced cancer. Pain control is thus one of the most significant ways to enable terminally ill cancer patients to live full lives up until the moment of death. Analgesic drug therapy is the mainstay of cancer pain management. It is effective in more than 90% of patients if used correctly: the right drug in the right dose at the right intervals. A thorough history should first be obtained and the patient examined carefully. For mild to moderate pain, a nonopioid analgesic such as nonsteroidal anti-inflammatory drug or acetaminophen should be prescribed for the patient. If and when this treatment no longer relieves the pain, the patient should receive a strong opioid such as morphine or buprenorphine, together with a co-analgesic, if appropriate. The patient must receive careful and frequent supervision to ensure that the treatment continues to match the pain effectively and to take precautionary measures against side effects.