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Recently, debates surrounding voluntary assisted dying (physician-assisted suicide or voluntary active euthanasia) have increased. In Europe and North America, the number of jurisdictions legalizing voluntary assisted dying has been gradually increasing. However, many contentious issues surrounding voluntary assisted dying remain unresolved such as the eligibility criteria required to access it and the roles of medical practitioners. On July 1, 1996, the Rights of the Terminally Ill Act 1995 (NT) (ROTTIA) was enforced in Australia's Northern Territory, thus becoming the world's first law permitting physician-assisted suicide and voluntary active euthanasia. However, after a period of less than nine months, it was nullified by the federal government's enforcement of the Euthanasia Laws Act 1997 (Cth). Since ROTTIA's invalidation, numerous bills aiming to legalize voluntary assisted suicide have been introduced in the Australian states' parliaments. Nevertheless, for over 20 years, no such bill had been passed. Then, the Voluntary Assisted Dying Bill 2017 (Vic) was enacted by the Parliament of Victoria. The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act 2017 (Vic)) took effect on June 19, 2019. This Act allows individuals living in Victoria to request access to voluntary assisted dying provided they are aged 18 years or over, possess decision-making capacity, suffer from an incurable disease causing intolerable pain, and have a life expectancy of six months or less, or 12 months or less in the case of patients with neurodegenerative conditions. Victoria's state government described this Act as" the safest and the most conservative model in the world" because of its rigorous framework of safeguards. However, despite its strict eligibility criteria, 52 people ended their lives using voluntary assisted dying in Victoria within six months following the Act's enforcement. Following the enactment of Victoria's VAD Act 2017 (Vic), other Australian states moved toward passing laws that legalized voluntary assisted dying. On December 10, 2019, Western Australia became the second state to pass voluntary assisted dying legislation. The Voluntary Assisted Dying Act 2019 (WA) (VAD Act 2019 (WA)) was heavily influenced by Victoria's VAD Act 2017 (Vic). This paper thus compares Victoria's VAD Act 2017 (Vic) with West Australia's VAD Act 2019 (WA), analyzes in detail the stringent safeguards stipulated by these laws, and discusses the operation and acceptance of these laws within Australian society, including the perspectives of patients and medical practitioners. [ABSTRACT FROM AUTHOR]

It is far beyond the imagination of most parents to have a child with a terminal illness. In such situations, there is little medical staff can do to lighten the parents' pain. Even so, is there anything that can be done when faced with the parents of terminally ill children. This report describes our involvement with one mother in such a situation. Son B of mother A was diagnosed with gastroschisis in the prenatal period. The bowel, which had escaped from the abdominal wall, necrotized at birth, and the baby also suffered from various symptoms attributed to very low birth weight. Treatment was initiated, but his condition steadily deteriorated. Mother A sought out psychiatric support when B was seven months old. Mother A was a nurse. She was courageous and committed to caring for her son, but when we met, her words were filled with distress. Continuing to listen as she expressed her emotions left me overwhelmed and at a loss for words. While wishing to lighten her anguish, A related that talking helped her to feel calm. From this I perceived her need to talk, after which I continued listening to her story and sharing in her silence. This became the experience of sharing in her pain as if it were my own, and coming to accept the pain and distress for what it was. A and her husband decided to take B back home one month later, and parents and relatives were present for his final moments. A’s agony and sadness was strong and deep. I continued to meet with her. The factors of significance in the approach to A appeared to be responding flexibly within a consistent framework, psychiatric assessment, creation of a stable environment for A by listening both passively and actively, remaining silent, and maintenance of unwavering, undivided attention and interest in the subject throughout. [ABSTRACT FROM AUTHOR]

To determine factors related to the effectiveness of red blood cell transfusions in terminally ill cancer patients, we conducted a retrospective cohort study. We studied 27 terminally ill cancer patients who were transfused with red blood cells at our hospitalbetween June 2015 and September 2017. Patients who responded to the treatment("responders"; 16 cases[59%]) were compared with those who did not("non-responders"; 11 cases[40%]). Comparative predictive factor analysis revealed statistically significant differences between responders and non-responders in Eastern Cooperative Oncology Group performance status(PS)(p=0.004)and palliative prognostic index(PPI)scores(p=0.022). Furthermore, a statistically significant difference in median post-transfusion survivaltimes(MST)(p=0.047)was found between responders(69 days; quartile range: 20-141 days)and non-responders(22 days; quartile range: 11-47 days). These results suggested that PPI and PS were significant predictors of the effectiveness of red blood cell transfusions in palliative care, and transfusion effectiveness was related to post-transfusion survivaltime.

To determine the chemotherapy indication of terminal cancer patients, predicting the prognosis is meaningful. We intended to establish a suitable prognosis prediction index for these patients. From June 2015 to January 2016, we examined the prognosis in 7 patients who were administered chemotherapy drugs within 4 weeks before or after the prognosis calculation. Palliative prognostic index(PPI)was calculated prospectively, and prognosis in palliative care study(PiPS)was calculated prospectively or retrospectively. If patients had laboratory data within 4 days before prognosis calculation, they were assessed with PiPS-B. If patients did not have recent data, they were assessed with PiPS-A. The absolute agreement of prognosis index with actual survival was 100% in PPI, and 40.0% in PiPS. All patients who were administered chemotherapy after the PPI calculation were considered to have survived for more than 42 days. We concluded that PPI was a suitable prognosis prediction index for terminal cancer patients with chemotherapy. PPI was useful for determining the chemotherapy indication in these patients.

Withdrawal of chemotherapy because of side effects may be due to"problems with toxicity"or"patient refusal"."Problems with toxicity"is intended to secure patient safety and decisions about it are primarily made by the oncologist. On the other hand,"patient refusal"is influenced by the degree of distress the patient is experiencing and the patient's preference. Providing sufficient medical information is essential in decision making, because it is a decision made by the patient. In addition, the perception of side effects has changed owing to progress in supportive therapy in recent years. In particular, cancer patients are concerned about changes in appearance. In our study(4/2015 to 3/2016), chemotherapy was withdrawn because of side effects during treatment for solid carcinomas in 8%(4/51)of the patients. Two of these patients experienced liver function disorders, and 2 developed interstitial pneumonitis. Patient refusal was observed in 2%(1/51)of the patients.

When anti-cancer treatment should be ended is very controversial. This reviewprovides a narrative summary of recent empirical studies about the potential association between the timing of anti-cancer treatment cessation and patient quality of death and dying. Furthermore, we propose a multifaceted intervention model for Japanese oncology patients based on the evidence available.

Various effective strategies have recently been described in the treatment of breast cancer, including endocrine therapy, chemotherapy, and molecular-targeted therapy, providing long-term survival benefits even after cancer recurrence. However, terminal-stage patients experience side effects and worse quality of life (QOL), in addition to deterioration of their general condition caused by the progression of the disease itself. When providing the best supportive care, use of anti-cancer drugs is not taboo and can represent a good option as long as physical, social, psychological, and spiritual supports are provided to both the patients and their families. Medroxyprogesterone acetate (MPA) is an endocrine therapeutic drug. In Japan, MPA is used only as a late-line endocrine therapy for breast cancer recurrence because many other endocrine therapy drugs are much more effective and MPA increases the risk of thrombosis and obesity. Here, we report 2 patients with breast cancer who reached terminal stage more than 10 years after the first diagnosis. MPA was administered as the final-line treatment. During that time, their appetite and QOL improved and the patients became more active than when they had been undergoing aggressive anticancer treatment. Both patients spent quality time with their families until their death. MPA may be a good option as part of palliative care of breast cancer patients in terminal stage.

Notification of cancer is essential for medical treatment based on patient preference. I studied 45 terminally-ill cancer patients referred to my clinic from January 2012 to December 2013. The data of each patient was retrospectively collected from their medical record. Cancer notification was not done in 4 cases(9%). Notification of cancer metastasis or terminally ill status was not done in 9 cases(20%). The reasons for no announcement of cancer included the family's concern regarding depriving the patient or hope or hospital doctor policy. In home-care situations, cancer notification might be difficult because home-care physicians take over patient care from hospital doctors who may not always inform the patient regarding their cancer status.

Introduction: Communicating with patients is clearly an integral part of physicians' practice, and introducing home hospice care is sometimes a difficult task for oncologists. The primary aims of this study were to clarify family-reported degree of emotional distress and the necessity for improvement in communication when introducing home hospice care, and to identify factors contributing to distress levels., Methods: A multicenter questionnaire survey was conducted involving 1,052 family members of cancer patients who died at home at 15 home-based hospice services throughout Japan., Results: A total of 616 responses were analyzed(effective response rate of 60%). Fifty-nine percent of the bereaved family members reported that they were distressed or very distressed in receiving information about home hospice care, and 30% reported considerable or much improvement was necessary. There were 6 determinants of family-reported degree of emotional distress and the necessity for improvement: 1 ) Family distress was experienced when the physician stated that the disease progression defeated medicine and nothing could be done for the patient. 2 ) The physicians' explanation did not match with the state of family preparation. 3 ) There was no intimacy between hospital physician and home physician. 4 ) Physicians did not make the atmosphere relaxing enough to allow families to ask questions. 5 ) Nurses did not follow up to generate additional ideas to supplement the physician's statement. 6 ) Family members experienced pressure to make a rash decision., Conclusion: In receiving information about transition of home care, a considerable number of families experienced high levels of emotional distress and felt a need for improvement in the communication style. This study proposes 6 strategies to alleviate family distress.

Since the launch of pure oxycodone injections in May 2012, it has been possible to use oxycodone without opioid rotation. Although an extremely important step showing progress, very few studies regarding the use of pure oxycodone injections have been performed. In this study, we evaluated the safety and efficacy of pure oxycodone injections in 31 terminally ill cancer patients receiving home care. The difficulty in oral oxycodone intake was the main reason for changing to pure oxycodone injections. The mean administered period of subcutaneous pure oxycodone was 5.6 ± 6.7 days. One out of 5 patients receiving pure oxycodone injections complained of worsening sleepiness. However, other symptoms improved. In addition, in cases wherein pure oxycodone injection was the initiating opioid, 1 out of 6 patients showed no improvement of respiratory discomfort, while other symptoms improved. It was difficult to evaluate more patients because of the short period for administration. Although 5 patients experienced skin problems, they were successfully managed by changing the injection site. Of these 5 patients, 2 patients had sensitive skin, with a previous history of alcohol rash. In conclusion, our study suggests that pure oxycodone injections are beneficial over oral oxycodone treatment for terminally ill cancer patients. However, further evaluation of skin problems associated with pure oxycodone injections is required by performing larger studies.

We retrospectively examined the actual status and management of sudden changes in end-stage cancer patients receiving home care. We defined "sudden death" as an incident in which patients who had been ambulatory suddenly experienced a change in condition and died within a day. As per this definition, 32 of 130 end-stage cancer patients (24.6%) who died at home during a period of 2 years experienced "sudden death". The reasons for sudden changes included liver rupture, liver failure, hematemesis/melena, and renal failure. It was presumed that 87.5% of patients who experienced "sudden death" had a life expectancy of days or weeks. Those who experienced sudden change in the presence of their family and died immediately thereafter or were found in a state of respiratory arrest accounted for 43.8% of cases. At the time of sudden change, sedation was performed in 34.3% of cases. Patient families were generally able to take action in a calm manner. Healthcare professionals and patient families should always be aware of the possibility of sudden changes in end-stage cancer patients. In addition, it is important for healthcare professionals to confirm how patients and their families perceive the disease condition, provide pain relief, and support families who are upset and anxious at the time of sudden changes.

We evaluated the effects of stenting for malignant bowel obstruction in terminally ill cancer patients. Six terminally ill cancer patients with malignant bowel obstruction underwent gastrointestinal stenting at our department from November 2010 to October 2012. Stent insertion was successful and abdominal symptoms improved in all cases. Oral intake improved in 4 cases. Descending colon perforation occurred in 1 case. The survival time ranged between 10 and 184 days( median, 71.5 days). The palliative performance status (PPS) improved in 4 cases, and the survival time was extended as assessed by the palliative prognostic index (PPI). In cases with a PPI of were more than 6.0, namely cases for which the estimated survival time was less than 3 weeks, survival time and oral intake did not change. These findings suggest that gastrointestinal stenting is clinically useful for malignant obstruction and improving the PPS and prognosis in terminally ill patients with malignant bowel obstruction.

There are various types of families of terminally-ill cancer patients, and care for the family should therefore be individualized. In cases where the primary caregivers have schizophrenia, caring for the patients at home might cause a serious burden to a family. From this aspect, two patients who were cared for by family with schizophrenia were reviewed. Four important factors were obtained. First, assessment of psychiatric conditions of the family collaborating with the psychiatrist or public health nurse; second, confirmation of the patients'/family's wills concerning living through death at home; third, death education given to a family; and fourth, efficient collaboration with social services by an other organization. It was considered that these factors would constitute a model for providing home hospice care to a family with schizophrenia.

We have created an IT network with a chat feature and have provided at-home medical care to one ALS patient through hospital-home cooperation. The IT network was operated by staff involved in hospital and at-home medical care, who recorded the details of the medical care they provided in the chat server installed at the University of Fukui Hospital via cellular phones or personal computers. During the 51-day operating period of the network, information was entered 118 times; all staff could browse this information. Hospital staff supported home medical care staff by sending replies to the questions of home staff. This experience suggested that the use of the IT network could increase the level of contribution by neurology specialists in home medical care.

For clinical treatment of cancer patients, surgical operation, chemotherapy, radiotherapy, immunotherapy and palliative care are available. Among these therapies, the main radical treatments such as surgical operation, chemotherapy and radiotherapy provide patients with anti-cancer-effects, but also cause unwanted invasive influences to normal tissues. Nutritional support is essential for cancer patients because it helps reduce these invasive influences and promotes recovery of damaged non-cancer tissues. Nutritional support for cancer patients receiving any anti-cancer therapies helps decrease the degree of invasion to non-cancer tissues and healthy body functions, helps with the promotion of reproduction and recovery of injured tissues and functions, normalizes metabolic disturbances by anti-cancer therapies, improves malnutrition based by side effects of invasive treatments, promotes immune-function using immune-nutrients, and offers nutritional care for patients at the terminal stage by assisting in metabolic conditioning for patients with cancer cachexia.

The Advance Directive (A.D.) is not prevalent enough in Japan. Under such a situation, it is difficult to withhold and withdraw the life-prolonging treatment. Even among the medical and care specialists, A.D. is not well known yet. From the result of the questionnaires, only 2% of the responders (who work for nursing care) know the exact meaning of A.D. But after the lecture about A.D., 96% of the responders recognized the importance of A.D. Through the experience of making A.D., it is useful not only to respect the patient's Autonomy, but also to be a communication tool among the patients, family and medical specialists.

Aim: Care of families attending patients' deathbeds is important, leading to care of the bereaved. However, we have no knowledge of a causal relationship between factors of care of terminally ill patients' families and care of families attending patients' deathbeds. The aim of this survey was to find out which factors of care nurses provide to terminally ill patients' families affect care of families attending patients' deathbeds in a general ward where many terminally ill elderly patients spend their time., Methods: Questionnaire survey of 978 general ward chief nurses working for hospitals with over 100 beds in the Kyushu district. Data were processed through factor analysis and covariance structured analysis., Results: 236 valid responses were analyzed. Four factors regarding chief nurses providing for families of terminally ill patients were identified. These factors were interpreted as first, mediating communication between families and patients; second, providing information; third, promoting cooperation and understanding among families; and fourth alleviating restrictions. The first factor correlates with the third factor. Especially, the first factor strongly affects the provision of care to families attending patients' deathbeds. The relationships of the second and fourth factors with care of families attending patients' deathbeds were not proved., Conclusion: Care of terminally ill patients' families in a general ward consists of four factors: mediating communication between families and patients, providing information, promoting cooperation and understanding among families, and alleviating restrictions. It was revealed that the more nurses promote cooperation and understanding among families, the more they can mediate communication between families and patients and provide care to families attending patients' deathbeds. It suggests that nurses are able to have a positive effect on the grief process of the bereaved by intervening between patients and families.

Aim: To clarify the clinical features of terminally ill patients in our hospital and elucidate the implications of administering artificial nutrition., Methods: Between April 2004 and March 2005, we assessed 155 patients who died in Nishimaruyama Hospital--a geriatric long-term care facility in Sapporo. We analyzed their clinical backgrounds on admission, the clinical course up to the terminal stage of the illness, and the outcome of patients who received artificial nutrition., Results: In 95 patients, the main cause of the terminal illness was infection. The symptoms of these patients, such as cerebral infarction and cognitive dysfunction, deteriorated progressively, and eventually, eating became difficult. At this point, alternative methods for providing nutrition were discussed. For 60 patients (41 died of acute disease and 19, of advanced cancers), artificial nutrition was not considered. Artificial nutrition was administered to 63 patients; tube feeding was carried out in 30 patients. Because of repeated aspiration pneumonia, 14 of these 30 patients eventually underwent intravenous hyperalimentation (IVH). Thirty-three patients directly underwent IVH. Thirty-two patients did not undergo any feeding course. The mean survival times of the tube feeding and non-artificial nutrition groups were 827 and 60 days, respectively. The difference in the survival times was statistically significant., Conclusion: The outcome of patients who were placed on tube feeding was good. This may be because we selected those patients considered most suitable for tube feeding or IVH. The criteria that were used to select an appropriate method for providing nutrition varied, although the patients in our hospital requested palliative care.

The city of Higashi Yamato is located in the northern part of Tama, Suburbs of Tokyo, and the population of Higashi Yamato is approximately 80,000. The Higashi Yamato visiting nursing station was opened in April 1998. As of April 2006, we have over 100 patients, and the aggregate visiting nursing services have provided more than 600 cases. Our station's uniqueness is that forty percent of the patients have malignant neurological disorders and are terminal stage patients, and that they are all covered by medical care insurance. We also provide nursing services to patients who are expected to be dying peacefully at home averaging 4 patients per month. Higashi Yamato Hospital, attached to the visiting nursing station, is an acute phase hospital and has 274 beds. The average hospital stay for our patients was 13 days in 2005. We promote an early discharge from the hospital for patients who have a high need of medical and nursing care and for the patients who are at the terminal stage. However, there were many cases where visiting nursing care services were provided because of a local care manager's request rather than a visiting nursing care need for patients who will be discharged soon from the hospital and for those expecting to have the service. In reality, we have observed a family being felt that his or her patient was pushed out from the hospital, a family who has no confidence in taking a nursing task at home, and a family who could not cope with the patient's changing condition. Therefore, we wanted resolve these observed problems urgently to create close cooperation with the hospital in order to provide continued nursing care after a patient is discharged from the hospital and to have home medical care safely. As a result, we planned a visit to the ward on a weekly basis starting on February 2006. We report here because we had a good result.

A visiting nursing service was provided for an 87-year-old male patient with terminal stage of chronic renal failure. Although his primary doctor told us that the patient's prognosis is no good with general prostration, the patient was cared at home because his family strongly wanted him in a home care environment. The patient, who is having a right nephrostomy catheter and urethrovesical indwelling catheter and is in an unstable condition due to dehydration caused by an aggravation of renal failure, left the hospital in the end of August in 2005. Meanwhile, a family care giver was feeling uneasiness due to a lack of experience in giving medical treatment and to care for the patient. Therefore, a visiting nurse provided support to reduce the caregiver's anxiety and taught how to observe the patient's conditions, to give medical treatment and a method to care the patient at home. As a result, the patient's symptom was little improved to a lesser degree of stable condition. The family caregiver's anxiety was also reduced as well. The roles of a visiting nurse for a terminal stage patient are: (1) to urge the family care giver to obtain basic self reliant home care techniques, (2) to create a division of clear roles among the family members, (3) to execute an individualized life for the patient and family, (4) to try to establish a system to cooperate with a medical support group.

We provided consultations with pharmacists to a terminally ill patient with radicular pain at his home. Before pharmaceutical intervention, the patient's compliance had been poor and consequently he had not achieved stable pain. The pharmacists suggested changes in the pharmacological and physical regimen that satisfied both the patient and his family. These changes were instructed with the help of the patient's doctors, home-visiting nurses and family, and subsequently the patient's compliance improved. The patient achieved good pain control and maintained excellent quality of life up to the time of his death. By providing home consultations to a terminally ill patient, we have contributed to maintaining an acceptable quality of life for him by building a team that consisted of doctors, nurses and pharmacists.

Although a number of terminal stage cancer patients exist who strongly desire their last moment to be at home, there are many cases where patients die at the hospital. One of the factors that patients die at the hospital is due to inadequacy in providing home care services. Because of a recent revision of the nursing care service insurance, a terminal stage cancer patient now could use this service as a specially designated disease patient. We also received candid ideas and suggestions from the bereaved families who were home care givers, on how to help maintain the patients' QOL at the last stage of their life at home. As a result, we acknowledged that the most urgent solution to the problem is to establish a local cooperation system to support a patient whose final stage of life is to be meaningful.

Despite of a terminally ill cancer patients' state of illness being stable, there will be a case where a patient loses his or her chance to be discharged due to an increase in length of hospitalization. We studied a questionnaire survey that was provided by medical staff at the cancer center hospital, and discussed how to support or encourage patients to cooperate with medical staff in order to attain shorter hospitalization.

Due to a payment system based on Comprehensive Medical Evaluation has been adopted, both a shorter hospitalization and the use of home nursing care have been increasing. A good cooperation between hospital and home visiting nurses is desired in order to transfer continued nursing. Regarding a home nursing care service for the most terminal cancer patients, we conducted a survey of 459 home visiting nurses with twelve questions in five categories: (1) Before transferring to home care, (2) Right after the transfer to home care, (3) Patient in a stable period, (4) Time of near death and (5) Other (Requests to hospital nurses). The following issues became clearer in terms of how hospital and home visiting nurses should be cooperating with the handling of last stage terminal cancer patients: (1) A home visiting nurse should have a coordinating role with a hospital nurse when the patient is discharged from the hospital. (2) A participation of home visiting nurses on the coordination guidance at the time of a patient discharge is influenced by a manpower of the nursing station. (3) Even though home visiting nurses found a discrepancy between the hospital information and what patients and their families were getting from the hospital, home visiting nurses have learned through the job to clarify what patient and family needs were, and they responded accordingly. (4) A coordination between hospital and home visiting nurses was needed quite often when the patient's time has come to die at home.

In the case of home care treatment of breast cancer patient, it is necessary to consider both social and medical problems based on the characteristics of breast cancer and associated its problems.

Terminally ill cancer patients with complicated bowel obstructions often have poor quality of life (QOL) due to gastrointestinal symptoms such as nausea and vomiting. Many of these patients are inoperable because of poor general conditions, and half of these patients can't be managed by conventional antiemetics. There are many reports indicating octreotide is effective for these patients. In the present study, 13 patients (5 patients without a nasogastric tube and 8 patients with) were administered octreotide at 300 microg/day by 24 hours continuous subcutaneous infusion. Among the effectively evaluable 10 cases, 6 cases (60.0%) were assessed as effective according to the efficacy criteria based on the JCOG toxicity scale. In the 6 cases who had nasogastric tubes, the nasogastric aspirates decreased from 890 ml (550-1,950) to 480 ml (180-1,790). Vomiting was successfully controlled after the removals of nasogastric tubes in 4 out of 6 cases (66.7%), regarding safety, 2 out of 13 cases (15.4%) showed an excess of liver enzymes but no clinically suspected adverse effect was observed. Octreotide is effective and well tolerated in terminally ill cancer patients with malignant bowel obstruction.

Seventy-nine terminal patients with gynecological cancer treated in the past 5 years in our hospital or their families were interviewed on where those patients died and the reason why they chose to die in the place. Fifty-two patients (65.8%) died at our hospital, 18 patients (22.8%) at other hospitals, 5 (6.3%) at other hospice and 4 (5.1%) at home. The 52 patients who died at our hospital were asked why they chose to die there. 42 of them (80.8%) wanted care at our hospital to the death. 10 (20.2%) had no time to think of home care or other institutions because of the sudden change of the condition. The 18 patients who died at other institutions were also asked about the reason. 9 of them (50%) wanted to die in their hometown or close to their home. 5 of them (27.8%) were referred to other hospitals due to brain metastasis or the necessity of undergoing dialysis. 2 of them (11.1%) were referred to the institutions which provide long-term care. 2 of them (11.1%) were brought into a nearby emergent care hospital and died after the sudden change of the condition. The palliative care ward in our university hospital can provide continued relationship with cancer patients. We had time to talk enough with carcinoma patients and their family in the ward, which widened choices of their death place, including home death.

There are many problems associated with the discharge and management of terminally-ill patients with cancer, A 70-year-old patient with gastro-intestinal cancer obstructing his intestinal tract, who is receiving total parenteral nutrition through a central intravenous catheter is being prepared for his discharge from hospital. The effective management of the discharge of this patient and introduction to home care, consisting of visits by physicians and community nurses is described.

A home medical service should be promoted as an individual medical plan which proactively copes with health problems in daily living. It is categorized into 3 phases: Health for a patient without long-term disabilities, QOL for a patient with long-term disabilities and Peaceful Death for a terminal patient.

We investigated the opinions of medical doctors and nursing staff about desirable medical treatment for terminally ill geriatric patients. The purpose of the present study is: 1) to examine the recent opinion of doctors and nurses, 2) to examine discrepancies of opinions between doctors and nurses on treatment for terminal geriatric patients. Doctors and nurses working in long-term care wards in four hospitals were enrolled. They were asked to fill in a questionnaire which asked about desirable medical treatments for a typical bedridden terminally ill geriatric patient. The difference of answers between doctors and nurses were analyzed. The most common opinion of the 18 doctors and 84 nurses were as follows: 1) for the treatment of relapsing pneumonia, they would perform oxygenation, antibiotic injections, and continuous intravenous infusion during the period of discontinuation of enteral nutrition, 2) for the treatment of relapsing urinary tract infection, they would catheterize patients for a brief period and would irrigate the bladder, and would perform antibiotics injection, 3) for chronic anemia, they would perform iron replacement, 4) for decubitus ulcer, they would treat conventionally, and 5) at the final stage just before death, they would avoid special therapy for shock after obtaining informed consent from patient's family. To most questions, the proportion of each answer was almost identical between doctors and nurses; however, there were discrepancies concerning "way of nutrition in patients with relapsing pneumonia" and "irrigation of the urinary bladder" (p = 0.0544 and 0.0531, respectively). We expect that the present study will activate a discussion of what constitutes appropriate medical treatment for terminally ill geriatric patients.

Background: Patients with intractable cancer pain often require non-pharmacological analgesic treatment that is accompanied by procedure-related pain. Previous works have shown that propofol infusion in adjunction to regional anesthesia provides appropriate sedation during such painful procedures. However, there are a few reports of its use to reduce procedure-related pain in terminal cancer patients. We report cases of propofol sedation during percutaneous vertebroplasty (PVP) in patients with metastatic vertebral compression fracture., Methods: Propofol was infused during PVP in eleven cancer patients after obtaining written informed consent. The infusion rate of propofol was adjusted using a target-controlled infusion pump to achieve appropriate sedation levels under monitoring bispectral index of the electroencepharogram. Hepatic and renal functions were evaluated using common serum markers, which were determined using standard hospital laboratory methods., Results: The duration of the procedure was 65.5 +/- 5.5 (mean +/- SD) min. The required infusion rate was 8.66 +/- 1.50 mg.kg-1.hr-1. The interval from the termination of the infusion until emergence was 10.7 +/- 4.2 min. No life-threatening complications or significant changes in liver and renal functions were observed., Conclusions: Propofol can be used effectively and safely for sedation during PVP in terminal cancer patients.

We present a case of a terminally ill child with cancer pain which was treated with intrathecal phenol block. A 13-year-old boy felt severe pain in the right buttock and leg due to osteosarcoma. Despite treatment with nonsteroidal anti-inflammatory drugs, intravenous injection of morphine, continuous infusion of ketamine or continuous lumbar epidural block, his pain increased progressively. Therefore, we performed intrathecal block with 10% phenol glycerine 0.2 ml. After the block, his pain was markedly relieved. He sometimes came back home and joined school events. He did not complain of the pain until his death. We suggest that intrathecal phenol block should be performed in terminally ill children with cancer pain if they do not respond to the usual therapeutic modalities including administration of morphine and continuous epidural block.

Accurate estimation of survival is important for effective palliative medicine of patients with cancer. In most clinical practice, however, the life expectancy has been predicted based on subjective evaluations. The purpose of this study was to find objective biological markers that can contribute to accurate prediction of survival in terminally ill cancer patients. Consecutive terminally ill cancer patients admitted to the Palliative Care Center in Tohoku University hospital from January to May 2001 were approached for this study. Forty-eight blood samples were obtained from 25 patients who provided a written informed consent. Common serum enzyme markers were determined using standard hospital laboratory methods. Cellular immunity status was evaluated by peripheral blood lymphocyte-subset analysis using flow cytometry. Mean patient survival was 33.5 +/- 21.6 (1-80) days. Multiple regression analysis revealed that lactate dehydrogenase (LDH) and the CD4+/CD8+ ratio were significantly associated with survival (r = 0.64, p < 0.0001). Further prospective studies are warranted to validate the usefulness of these determinants for accurate prediction of survival.

Since in a home care nurse station the arrangement of personnel is planned to carry out patient's home care in accordance with the individual patient's Care Plan, to provide palliative home care to end-stage cancer patients who frequently require extraordinary visits, it is necessary to employ full-time nurses. On the other hand, to make ends meet there must be at least two full-time nurses for every seven end-stage cancer patients in a home care nurse station monthly. However, a home care nurse station taking care of seven end-stage cancer home patients monthly is very rare. According to these circumstances only several special home care nurse stations are able to provide palliative home care to end-stage cancer patient; thus, palliative home care for such patients is generally provided by hospital or doctor's office staff members. Therefore, if the authorities concerned intend to accelerate to care the end-stage cancer patient at home, several additional charges which are able to be claimed in ordinary home care nurse station must be able to be claimed in hospital or doctor's office in the same way.

We have started the visiting nurse system in our Kimitsu Central Hospital since September 1990, and have currently had 33 patients with 4 visiting nurses as of February 2001. Out of these 33 patients with the visiting nurse system, 9 patients are at a terminal stage of diseases. In the present study, we reported here a case of a 63 year-old female patient, who was at a terminal stage of stomach cancer and wished to have a regular home life, having a visiting nurse at home. The patient was not informed of her diagnosis as a cancer, but was convinced of her symptoms by her primary care physician that she was under a good care. Meanwhile, the patient showed less pain than that she was expected to have as a patient at the terminal stage of cancer. A daughter of the patient (actual caretaker) was first considering of hospitalization as an inpatient. However, since the patient strongly desired to stay and get care at home, the caretaker started a dual life of taking care of her mother at home and of raising children in parallel, in aware of a case of pronouncing death at home. While the patient's condition was relatively stable, the good quality of life (QOL) was maintained as she could make a trip of one-night stay. As the symptom progressed, however, the caretaker had a high anxiety with a pressure of accepting her own mother's death. On the other hand, a visiting nurse, who understood the patient's strong desire to stay at home and live her life as usual, also assisted in reducing the caretaker's high anxiety. Therefore, the visiting nurse basically assumed one possibility that the patient would die at home, but also prepared for the another possibility that the caretaker could choose to send her mother back to hospital whenever she felt her limit for being a caretaker. Moreover, the visiting nurse supported the patient and her family with an encouragement that they could live their favorable life till the end. As a result, the caretaker could continue to keep the patient at home, although she had a tremendous fear about taking care of her at home. When the patient's condition suddenly changed and got worsened, however, the caretaker desired to have her mother stay and get medicated in the hospital. Thus, the patient was sent to our hospital by ambulance. Although the caretaker did not have her mother die at home under her direct care, she recognized the great advantages in having a visiting nurse, who really assisted them well. Thus, it was confirmed that participation of a visiting nurse in the home healthcare could give the patient and her family a better, satisfactory life till the end. In general, although the patients or their family members wish to stay home and to have a home healthcare service, their desire or mind can be easily changed according to their situation. Especially in a case of the patient at a terminal stage, the family can be easily influenced by the condition of progression of the disease. One of the major roles of visiting nurses is always to understand the feelings of the patients and family and to prepare for the best as they can.

Aim: To evaluate the prognosis of the patients who had visiting nurse service and discuss the place of death (life at the terminal stage). To determine the roles of visiting nurses in providing the patients at a terminal stage with their desirable life till death., Methods: A total of 180 patients, who were registered for their home healthcare service in our Shonan Kamakura General Hospital and died between January 2000 and February 2001, were subjected to the study. All the subjects were classified into 3 groups according to the places of their death, 1) death at home, 2) death in the hospital and 3) death upon arrival after the admission to the hospital. Moreover, the following items were also surveyed and analyzed: 1) diagnosis (name of diseases), 2) cause of death, 3) age, 4) family structure, 5) whether their primary care physicians explained the prognosis and possible expected conditions to the patients and their family before hand, and 6) how the visiting nurses interact with the patients and their family members., Results: Sixty-six patients died at home, 105 in the hospital and 9 upon arrival at the hospital. During this survey period, there were a total of 5,274 and 5,574 visits by primary care physicians and visiting nurses, respectively. The patients who died at home were more often observed in the patients whose primary care physicians explained their conditions to them and whose visiting nurses closely related to them. Moreover, the patients with malignant tumor also more often died at home. On the contrary, there were very few patients with chronic diseases, with whom death at home was accepted and agreed before hand, and there were some cases with chronic diseases who died inside of the ambulance transported on the way to the hospital after a sudden change in their conditions., Discussion and Conclusion: In order to have the patients live their desirable life till their death, it is required for the caretakers to prepare their mind for the day of the patient's death in addition to the patient's own wishes. For the patients with malignant tumor, it is easy to predict their prognosis, thus the caretakers can get prepared for the day of the patient's death. On the contrary, in case of the patients with chronic diseases, it is more difficult for the caretakers to experience an indefinite time with the patients since their prognosis is generally longer but the sudden change in their conditions may give the caretakers a high anxiety. Thus, it is essential for the visiting nurses to play a role as a mediator to interact between the patients and their family members, and their primary care physicians, and to establish a trustful relationship with the patients while their conditions are still stable. Moreover, similar to the malignant patients, the visiting nurses should explain the situations to the patients with chronic diseases, that they can choose the place of their own death and specific medical treatment at emergency and can decide the detail for their terminal stage with their family members. Thus, it was considered to be very important that the visiting nurses should frequently confirm these issues with the patients and their family according to their conditions.

Recently, it is gradually getting easier to change a life-style of the patients with cancer-pains from the conventional hospitalized way to the home healthcare system, because of the progress in technique of reducing pains and symptoms and because of prevalence of visiting nurse system. Home healthcare system or hospice is aimed at the improvement of the quality of life (QOL) of the patients. We had 3 patients who died at home after home healthcare service and whose cancer-pains were well controlled till their death at home by continuous subcutaneous injections of opioids (painkiller) when these patients could not take oral medications any more. Therefore, in order to determine the factors that enable the patients to live the terminal stage of their life at home until death by controlling their cancer-pain with continuous subcutaneous injections of opioid, we examined 3 patients who died of cancer at home under a good pain control. The subjects of the present study were 3 patients, who initially had oral or rectal medication of opioid for their pain control, eventually switched to subcutaneous injection of opioid and then died at home under a good pain control between April 1998 and December 2000. We collected all the information through nursing diaries, regarding painkiller care, and interaction of the patients, their family members and other people, and discussed the factors which enabled to maintain a good pain control in these patients at home by continuous subcutaneous injection of painkiller (opioid). As a result, the following 7 items were notified as the factors common in these 3 patients. 1) The patients themselves understood the diagnosis of their diseases and symptoms and could openly discuss the issues such as "how the patient and his/her family would like to live his/her life from now on" among family members, and also between family and medical associates. 2). The patients received detailed explanation of continuous subcutaneous injection at the time of admission to the hospital and chose to receive the continuous subcutaneous injection with their own will. 3) The patients had no other painful symptoms except cancer pains or had them well controlled if they had any, and had much stronger desire to live their life at home than above all. The family member agreed with the patients and respected their choice. 4) The family members had enough nursing capability, so they could properly handle medications and medical equipment as well as they could take care of the patients. 5) Both primary care physicians and visiting nurses had enough knowledge of home healthcare service for painkiller, and were able to frequently interact with the patients and their family in order to reduce their pains. 6) Visiting nurses supported the family by 24 hr-system and assisted the family in nursing the patients at home without worry. 7) Pharmacists also participated in the home healthcare system, thus, they could smoothly provide and manage opioids without any trouble.

We studied on the points of that a management of dyspnea and pain by morphine for a terminal cancer patient at Home care. It was suggested that a necessary on management of symptoms for a terminal cancer patient before home drug therapy, a education to patient and his family by drug consultation before and after home drug therapy, a confirmation of dyspnea and pain for a terminal cancer patient from one drug to the next, and a importance of communication between medical staffs.

In the home care for terminal stage cancer patients, the quality of life of patients has been regarded as more important than the QOL of their family. Now, however, we think the QOL of the family of the patients is as important as that of the patients themselves. We investigated the opinion of the families and nurses by questionnaire in the HPN care for terminal stage cancer patients and compared them. The family answered positively about HPN, but they had a negative opinion in that they do not want to undergo HPN because they felt a heavy burden and responsibility in caring for patients, and they do not want to cause these feelings in others in their family. The nurses also answered positively about HPN, and they answered that they want to undergo HPN if they have terminal stage cancer. These results suggest that the family feels a greater burden and responsibility in caring for patients at home than the medical staff realize. The medical staff should support the family as well as terminal stage cancer patients and should not force our own opinions as medical staff.

Accurate estimation of survival is vital for effective palliative care. To verify the value of clinical prediction of survival (CPS), a prospective study was performed on 150 terminally ill cancer patients. The CPS was highly correlated with actual survival (AS), but the accuracy was not significantly superior to the prediction by performance status alone. Serious pessimistic error, defined as AS was at least 28 days and twice as long as CPS, was recognized in 13%, while serious optimistic error, defined as AS was less than 28 days and half as long as CPS, in 15%. The frequency of serious error was not significantly different by physicians' experiences, patients' age, sex, primary disease, and metastatic locations, but was significantly higher in cases with better performance status. Also, unexpected changes resulting in death were experienced in 42% of another 186 cases. The main underlying causes were pneumonia, bleeding, heart failure, intestinal perforation, cerebrovascular disease, hepatic/renal failure, hypoglycemia, sepsis and electrolyte imbalance. Clinical prediction was not sufficiently reliable and must be further improved.

In 1997, home care was provided for thirty-seven terminally ill cancer patients, fifteen patients with gastric cancer, nine patients with colorectal cancer, four patients with breast cancer, and nine patients with other miscellaneous cancer. The shortest period of home care was three days, the longest was six hundred seventeen days, and the average was one hundred eight days. Medical treatment at home consisted of dosage of morphine for 30 patients, parenteral nutrition for 30 patients, dosage of steroids for 29 patients, infusion of haloperidol for 8 patients, continuous draining of ascites for 6 patients, and continuous draining of intestinal fluid through nasogastric tube for 3 patients. As of May 31, 1998, 3 patients were alive but 34 patients had died, 31 of them at home. The characteristic trends in this year were reinforcement of the home care system in our hospital, prolongation of mean at-home days, inhalation of nebulized morphine for management of dyspnea, restriction of indication of home infusion therapy and active cooperation with public health center and welfare office.

Some 129 cancer patients were taken care of at home by the visiting nurse team of our hospital since 1994 to 1997; 116 patients have already died, 50 of them at home (group A), and 66 at the hospital (group B). We analyze the differences the between two groups in nutritional assistance, pain control and manpower in looking after a patient. Twice as many patients in group A took nutritional medication (drip infusion or intravenous hyperalimentation, for example) than group B. More patients in group A used oral and suppository morphine than group B. In group A 70% of patients (56% in group B) had more than two persons looking after at home. The important factors for a good recuperation at home are: 1. Available nutritional assist available. 2. Good control. 3. Less burden and anxiety of the person looked after. To spend pain desirable last moments together, it is important for the visiting nurse team to take proper care and to confirm the wishes of the patient and family, considering the rapidly changing conditions of the individual patient.

Since May in 1994, we have started to take care of terminally-ill patients at home to support patients who want to die at home and their family. Many patients in the terminal stage become stable temporarily from being back home, and their family are happy to care for them. Their family tend to think that they may well escape death, so they are sometimes confused when patients become worse suddenly. The author learned something important from the visiting care system in connection with two cases. Although case 1 had a short period of time at home and case 2 died in the hospital, their families were satisfied with our system and could accept patient's death without a big problem. It was very important to educate the family about death because it is very difficult to foresee a sudden change in terminal cancer patients. From the nursing standpoint, it remains to consider how to judge the patient's conduct and when to call the doctor. Another problem is whether to inform patients of their cancer or not.

We surveyed 21 terminally-ill patients with cancer pain who received continuous injection therapy of morphine at home in the three years from 1995 to 1997. The period of home therapy was 179.3 +/- 257.5 (mean +/- SD) days. The period of morphine injection was 39.2 +/- 29.1 days. Morphine solution was injected intravenously via a catheter inserted in a central vein in all patients. The instrument used most frequently for injection was the seven-day type disposable balloon pump (n = 17, 81.0%). The maximum dosage of morphine in the period of home therapy was 57.3 +/- 30.6 mg per day. Nine patients (42.9%) seldom used supplemental analgesics, while 11 patients (52.4%) used them sometimes. Nine patients had some trouble with continuous injection therapy of morphine. The following were problems: accidents with the injection instruments (insufficient injection volume, delay of drug supply, etc.) and of the intravenous catheters (accidental removal of catheter, occlusion of catheter, etc.). Eleven patients (52.4%) died at home, and 10 patients (47.6%) were hospitalized again. Continuous morphine injection therapy is an effective strategy for cancer pain management at home.

We gave 44 patients palliative care at home for a period of six years from June 1992 to May 1998. Judging from the satisfaction with medical staff caring for the peaceful passing of 37 cancer patients at home, we considered the factors that prevent patients from gaining access to QOL (Quality of Life) enrichment. In most cases, it is too late to switch from hospital care to home care for the sake of QOL enrichment. We believe it better that a home doctor or visiting nurse have access to such patients as early as possible. To make this possible, it is necessary for the patients, his or her family and the medical staff at the hospital to be aware of the realities and possibilities of palliative care at home. At the same time, it is imperative that the staff working in home medical care endeavor to enhance their readiness to accept the patients and to improve their medical standard.

Planning effective palliative care requires accurate estimation of survival. A prospective study was performed on 150 hospice inpatients to identify prognostic factors in terminally ill cancer patients. By univariate analysis, eleven factors were found to be significantly associated with shortened survival: poor performance status, dyspnea at rest, death rattle, appetite loss, dysphagia, dry mouth, general malaise, edema, stomatitis, fever, and delirium. Multiple regression analysis showed that five factors were independent predictors of survival: performance status, dyspnea at rest, appetite loss, edema, and delirium. We discussed current problems and future directions of survival prediction for terminally ill cancer patients.

From April 1987 to May 1997, ninety-six advanced cancer patients including ninety-one among 159 home care patients and five outpatients were administered parenteral nutrition or hydration. Eventually, 67 patients died at home. We concluded through our experience that advanced cancer patients who were unable to eat or drink might live at home with the support of parenteral nutrition or hydration. But four conditions are needed for satisfactory home care of these patients. First, patients understanding their disease condition therefore together with their family hope for home care. Second, the home care support team is organized in an institution. Third, the home care support team is on call for emergencies. Fourth, the home care support team can not only manage home parenteral nutrition but also provide palliative care, including pain control.

Generally hospitalization is regarded as a prerequisite for patients with cancer who require terminal care. Recently, special attention has been directed to home care for these patients from the standpoints of patients quality of life (QOL) and health economics. In the case of home care for patients with terminal cancer, effective pain control, careful nutrition administration, psychological care for the patient and his/her family members and emergency care are indispensable. Due to the number and extent of these requirements, home care for terminal patients is not yet common. We have been promoting the adoption of home enteral nutrition as a method to meet the nutritional needs of patients with terminal cancer. In this report, we discuss home enteral nutrition focusing on its indication and methodology, as well as related problems and nutrition administration in the future.

For end-stage patients with malignant disease, home parenteral nutrition (HPN) is an effective and useful treatment in terms of pain control and nutritional support. Therefore, these patients are able to spend their final days at home with their family. In 1990, we started the treatment and have been experienced 109 cases. In this report, we evaluate these cases and which condition or circumstance are necessary to perform HPN for the terminal patients.