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Pain is an unpleasant experience and a subjective term that is associated with tissue damage. Cancer patients experience pain for a myriad of reasons, from disease related to treatment causes and unrelated to both of these categories. Opioids are the mainstay in the treatment of moderate to severe cancer pain. Progressive opioid dose increases can cause opioid-induced hyperalgesia (OIH). OIH has no definite management, here we present a 47-year-old cancer patient with OIH and her management.

Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare primary liver tumor that affects young adults, with unknown biology. We present a case of 21‐yr‐old female with a liver tumor revealed by hemangioma feature at first presentation, after few months, presented with metastatic liver cancer. In pathologic investigation fibrolamellar hepatocellular carcinoma was confirmed. In spite of liver mass resection and lung metastasectomy, after short time, tumor recurrence was occurred. In 18F-FDG PET-CT scan ,lung, ovary, colon and peritoneal invasion was reported. Unfortunately, The patient died one year after diagnosis with rapid progression and multiple unusual metastatic site. Here, we also review the literature concerning FLHCC in many aspects.

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Background: In the recent years, advances in medical technologies for end stage cancer patients’ care have affected the end-of-life decision-making in clinical practice and exposed oncologists to serious ethical dilemmas. But little is known about oncologists' viewpoints in our country regarding their ethical problems in this mention. We aimed to clarify the ethical dilemmas which Iranian oncologists may face in our health care setting and to determine factors influencing decision-making process.Methods: In this qualitative study, a phenomenological approach was used. We interviewed 8 cancer specialists in teaching hospitals in Iran and used content analysis to identify codes and categorize themes in the data.Results: During the process of analysis, three main themes emerged about ethical dilemmas in end of life care for advanced cancer patients: illness factors, socio-cultural context and patient-physician relationship. Cancer specialists identified ethical problems on several main issues, the most important of which were telling the truth in Iranian cultural context, uncertainty in end stage definition, multidisciplinary team working and cost consideration in Iranian health care system.Conclusion: Health care and insurance system in Iran face to end of life care challenges; therefore, health care providers and policy makers need to allocate appropriate resources and programs to improve quality of care in terminal stages. Appropriate physicians’ communication skills training, multidisciplinary team working and supplementary insurance services that provide essential health care can improve the quality of care of patients with end stages of cancer. The findings of this study can help us to provide ethical policies for decision-making in end-of-life care.

"nObjective: Bad news disclosure is one of the most complex tasks of physicians. Recent evidences indicate that patients' and physicians' attitude toward breaking bad news has been changed since few years ago. The evidence of breaking bad news is different across cultures. The aim of this study is to evaluate the attitude of medical staff toward breaking bad news to provide a clinical guideline in Iran."nMethods: A descriptive study was conducted during 2008-2009 on a sample of 100 medical staff (50 physicians and 50 nurses) at Cancer Institute of Imam Khomeini hospital. The subjects' demographic characteristics and their attitudes toward the manner of revealing the diagnosis were registered in a questionnaire."nResults: The majority of the physicians (86%, n=43) and nurses (74%, n=37) , mostly the older and more experienced, tended to reveal the diagnosis to patients . Only a few physicians (8%, n=4) had been trained how to disclose bad news, which discloused diagnosis more than non trained ones."nPhysicians and nurses preferred to inform the patients about the diagnosis when either the patients were alone or in the presence of their spouse respectively .Only a few physicians (14%) and nurses (24%) agreed to explain life expectancy to patients."nConclusion: Compared to past, physicians and nurses are more willing to share cancer diagnosis with patients. However, lack of adequate communication skills in caregivers, and their concerns about managing patients' emotional reactions reduce their tendency to disclose bad news to the patients. Therefore, training physicians and nurses to expose bad news to the patients seems to be necessary.

Recent advances in life-sustaining treatments and technologies, have given rise to newly-emerged, critical and sometimes, controversial questions regarding different aspects of end-of-life decision-making and care. Since religious values are among the most influential factors in these decisions, the present study aimed to examine the Islamic scholars' views on end-of-life care. A structured interview based on six main questions on ethical decision-making in end-of-life care was conducted with eight Shiite experts in Islamic studies, and was analyzed through deductive content analysis. Analysis revealed certain points in Islamic views on the definition of death and the persons making decisions about end-of-life care. According to the participants, in addition to conventional criteria ('urf) such as absence of heartbeat and respiration, the irreversible cessation of human voluntary acts (as a sign that the soul has control over the body and the faculty of thinking) are considered to be the criteria in establishing death. The participants also recognized physicians as the main authorities in verifying signs of death. Furthermore, it was emphasized that life preservation and continuation of care must be sensible, and the patient can request not to have death-prolonging procedures started or continued. In the view of participants, patient's autonomy cannot be the sole basis for all measures, but Islamic ethical and jurisprudential principles should be relied upon to make correct and sensible decisions whether to continue or stop terminal patients' care. Final decisions should be made by a team of experts, and physicians must be at the center of such a team. Finally, we suggest that a guideline in keeping with Islamic norms on human life and death, purpose of life, God's will, boundaries of man's authority, and the physician's ethical duties and obligations should be developed.

Background: Family-centered care is an essential concept in cancer but there is no consensus about its meaning and it remains an abstract concept. This study was conducted with the purpose of analyzing the concept of family-centered care in cancer. Methods: Concept analysis of family-centered care was conducted using hybrid model that has 3 phases: theoretical, field work and final analytical phase. For the theoretical phase attributes of family-centered care were identified through a review of the literature (without time limitation). In second phase 6 nurses were interviewed. In third phase final analysis were extracted from the first and second phase. Results: In general, original categories in the family-centered care context encompass; existence of family in clinic, family security and family support, communication between nurse and family, family participation in care, exposure to tension and family participation in decision making. Conclusion: By identifying the facilitating and preventive factors about the concept of family care center in cancer, we will be able to run our activities based on scientific findings which could provide the necessary conditions for good implementation of family care center in cancer.

Palliative care is still a topic under discussion in the Iranian healthcare system, and cancer patients require palliative care. Moreover, nursing ethics has an important role in caring for these patients. The purpose of this study was to identify the perception of Iranian nurses regarding ethics-based palliative care in cancer patients. This study was done with a qualitative approach and by using content analysis. In this study, 14 nurses were selected through purposive sampling, and a face-to-face semi structured interview was conducted with each of them. After data collection, all interviews were transcribed and reviewed, and categories were extracted. At first, similarities in meaning were reviewed and based on centralization arranged in sub-categories. Then, relevant sub-categories were arranged in a category after a second review. In general, original categories in the ethics-based palliative care in cancer patients encompass the following: “human dignity”, “professional truthfulness” and “altruism”. Human dignity has 3 sub-categories consisting of ‘respecting patients’, ‘paying attention to patient values’ and ‘empathizing’. Professional truthfulness has 2 sub-categories consisting of ‘truthful speech’ and ‘truthful action’. Lastly, altruism has 3 sub-categories consisting of ‘complete and multi-dimensional patient acceptance’, ‘supportive behavior’ and ‘responsibility’. Content analysis of ethics-based palliative care in cancer patients revealed the required conditions for this type of care based on the perception of nurses. The results of this study suggest that in nurses’ point of view, human dignity, professional truthfulness and altruism all have important roles in ethics-based palliative care in cancer. The findings of this study will give nurses a greater knowledge about ethics-based palliative care in cancer patients, leading to a better understanding of the ethical needs of these patients, and may ultimately help improve the nursing practice.

Objective: Bad news disclosure is one of the most complex tasks of physicians. Recent evidences indicate that patients' and physicians' attitude toward breaking bad news has been changed since few years ago. The evidence of breaking bad news is different across cultures. The aim of this study is to evaluate the attitude of medical staff toward breaking bad news to provide a clinical guideline in Iran. Methods: A descriptive study was conducted during 2008-2009 on a sample of 100 medical staff (50 physicians and 50 nurses) at Cancer Institute of Imam Khomeini hospital. The subjects' demographic characteristics and their attitudes toward the manner of revealing the diagnosis were registered in a questionnaire. Results: The majority of the physicians (86%, n=43) and nurses (74%, n=37), mostly the older and more experienced, tended to reveal the diagnosis to patients. Only a few physicians (8%, n=4) had been trained how to disclose bad news, which discloused diagnosis more than non trained ones. Physicians and nurses preferred to inform the patients about the diagnosis when either the patients were alone or in the presence of their spouse respectively. Only a few physicians (14%) and nurses (24%) agreed to explain life expectancy to patients. Conclusion: Compared to past, physicians and nurses are more willing to share cancer diagnosis with patients. However, lack of adequate communication skills in caregivers, and their concerns about managing patients' emotional reactions reduce their tendency to disclose bad news to the patients. Therefore, training physicians and nurses to expose bad news to the patients seems to be necessary.