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Background: Pain is one of the most common symptoms in cancer patients. The Japanese Society for Palliative Medicine (JSPM) first published its clinical guidelines for the management of cancer pain in 2010. Since then, more research on cancer pain management has been reported, and new drugs have become available in Japan. Thus, the JSPM has now revised the clinical guidelines using a validated methodology. Methods: This guideline was developed through a systematic review, discussion, and the Delphi method, following a formal guideline development process. Results: Thirty-five recommendations were created: 19 for the pharmacological management of cancer pain, 6 for the management of opioid-induced adverse effects, and 10 for pharmacological treatment procedures. Due to the lack of evidence that directly addressed our clinical questions, most of the recommendations had to be based on consensus among committee members and other guidelines. Discussion: It is critical to continue to build high-quality evidence in cancer pain management, and revise these guidelines accordingly.

Background: When the suffering of a terminally ill patient is intolerable and refractory, sedatives are sometimes used for symptom relief. Objective: To describe the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Design: Consensus methods using the Delphi technique were used. Results: The main principles of the guidelines that were newly defined or developed are as follows: (1) palliative sedation was defined as "administration of sedatives for the purpose of alleviating refractory suffering" (excluding the aim of reducing patient consciousness); (2) palliative sedation was classified according to the method of administration of sedatives: respite sedation versus continuous sedation (including (continuous) proportional sedation and continuous deep sedation); (3) a description of state-of-the-art recommended treatments for difficult symptoms such as delirium, dyspnea, and pain before the symptom was determined as refractory was included; (4) the principle of proportionality was newly defined from an ethical point of view; and (5) families' consent was regarded as being desirable (mandatory in the previous version). Conclusions: We described the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Further consensus building is necessary.

Background: Gastrointestinal symptoms, including nausea, vomiting, bowel obstruction, ascites, constipation, and anorexia, are common and often refractory in advanced cancer patients. The palliation of gastrointestinal symptoms is important in improving the quality of life of cancer patients, as well as that of their families and caregivers. Currently published clinical guidelines for the management of gastrointestinal symptoms in cancer patients do not comprehensively cover the topics or are not based on a formal process for the development of clinical guidelines. Methods: The Japanese Society for Palliative Medicine (JSPM) developed comprehensive clinical guidelines for the management of gastrointestinal symptoms in cancer patients after a formal guideline development process. Results: This article summarizes the recommendations along with their rationale and a short summary of the development process of the JSPM gastrointestinal symptom management guidelines. We established 31 recommendations, all of which are based on the best available evidence and agreement of expert taskforce members. Discussion: Future clinical studies and continuous guideline updates are required to improve gastrointestinal symptom management in cancer patients.

"Death rattle" is a term used to describe the noisy sound produced by dying patients caused by the oscillatory movements of secretions in the upper airways. Antimuscarinic drugs, including atropine, scopolamine (hyoscine hydrobromide), hyoscine butylbromide, and glycopyrronium, have been used to diminish the noisy sound by reducing airway secretions. We report on the effectiveness of sublingual atropine eyedrops in alleviating death rattle in a terminal cancer patient. We present a 58-year-old man with pancreatic cancer who was admitted to our hospital because of severe dyspnea, cough, and death rattle with excessive bronchial secretion as a result of multiple lung metastases. We administered 1% atropine eyedrops sublingually to obviate the need for subcutaneous infusions and to prevent somnolence. On the basis of our experience, we conclude that atropine eyedrops, administered sublingually for distressing upper respiratory secretions, may be an effective alternative to the injection of antimuscarinic drugs, or as an option when other antimuscarinic formulations are not available.

Certain physical signs can be useful in predicting impending death. We present four terminally ill patients with malignancy who developed petechiae on their bilateral palms and fingers during the week prior to their deaths. Drug-induced eruption, injury, and mechanical stimuli were thought to be unlikely causes of the petechiae. While the phenomenon has not previously been reported, we speculate palmar petechiae may be a clinical cutaneous sign of systemic deterioration in terminally ill patients.

Objectives: The aim of this study is to clarify the actual experiences and preferences of the bereaved family for the care of their deceased family member., Methods: At 95 palliative care units in Japan, a cross-sectional nationwide survey of the bereaved families of cancer patients was performed in 2007., Results: Of the 670 questionnaires sent to bereaved families, 492 were returned (response rate of 76%). The overall requirement to improve the end-of-life care was rated as follows: improvement needed (42.7%) and no improvement needed (58%). In total, 9.4% of the families reported that they experienced problems with the deceased body after leaving the hospital, including a change in the facial appearance (8.5%), stains on the body (8%), and an odor emanating from the body (4%). Regarding the preferences for treatment procedures, over half the families preferred not to have traditional procedures performed in which the deceased's hands are joined with a band, the jaws are tied with a band around the face to close the mouth, and the body is wrapped in a sheet. The most preferable treatment procedure was to have makeup applied lightly and moderately. Maintaining the appearance of the deceased body was related to the overall care evaluation of end-of-life care., Conclusions: As the preferences for the care of deceased bodies are changing, end-of-life care needs to be improved with respect to culture, religious views, and the wishes of the patient and their family.

Surgical treatment for internal fistula is rarely indicated for terminally ill patients with cancer because of their poor prognoses. Reports of surgical or pharmacologic treatment of vesicoenteric fistula in terminally ill patients with cancer are rare. A 73-year-old woman with rectal cancer that had directly invaded the bladder and metastasized to the liver was admitted to our hospital with high fever and severe perineal pain. Retrograde urography indicated an enterovesical fistula. Although the urinary tract infection was treatable with antibiotics, frequent episodic pain, due to urethritis secondary to the fistula, was not alleviated with opioid and topical treatment. Three days after starting octreotide 0.3 mg/d, the severe pain was alleviated, and follow-up retrograde urography revealed closure of the fistula. This suggests that treatment with octreotide may have enabled closure of the fistula. Thus, octreotide should be considered a viable therapeutic option in terminally ill patients with inoperable internal fistula.