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Objective The objective of this survey was to identify areas where doctors have divergent practices in pharmacological treatment for hyperactive delirium in terminally ill patients with cancer. Methods We conducted a survey of Japanese palliative care physicians and liaison psychiatrists. Inquiries were made regarding: (i) choice of drug class in the first-line treatment, (ii) administration methods of the first-line antipsychotic treatment, (iii) starting dose of antipsychotics in the first line treatment and maximum dose of antipsychotics in refractory delirium, and (iv) choice of treatment when the first-line haloperidol treatment failed. Respondents used a five-point Likert scale. Results Regarding choice of drug class in the first-line treatment, more doctors reported that they ‘frequently’ or ‘very frequently’ use antipsychotics only than antipsychotics and benzodiazepine (oral: 73.4 vs. 12.2%; injection: 61.3 vs. 11.6%, respectively). Regarding administration methods of the first-line antipsychotic treatment, the percentage of doctors who reported that they used antipsychotics as needed and around the clock were 55.4 and 68.8% (oral), 49.2 and 45.4% (injection), respectively. There were different opinions on the maximum dose of antipsychotics in refractory delirium. Regarding the choice of treatment when the first-line haloperidol treatment failed, the percentage of doctors who reported that they increased the dose of haloperidol, used haloperidol and benzodiazepines, and switched to chlorpromazine were 47.0, 32.1 and 16.4%, respectively. Conclusions Doctors have divergent practices in administration methods of the first-line antipsychotic treatment, maximum dose of antipsychotics, and choice of treatment when the first-line haloperidol treatment failed. Further studies are needed to determine the optimal treatment.

BackgroundPalliative sedation is sometimes needed for refractory symptoms, and the Richmond Agitation-Sedation Scale (RASS) is one of the key measures. The primary aim of this study was to explore the association between the RASS score and degree of distress quantified by other measures: Support Team Assessment Schedule, item 2 (STAS), Discomfort Scale for Dementia of Alzheimer Type (Discomfort Scale), and Non-communicative Patient’s Pain Assessment Instrument (NOPPAIN), as well as a communication capacity measured by the Communication Capacity Scale, item 4 (CCS).MethodsThis was a prospective observational study on terminally ill cancer patients who received continuous infusion of midazolam to relieve refractory symptoms in a palliative care unit of a designated cancer hospital. Primarily responsible palliative care physicians rated RASS, Discomfort Scale, NOPPAIN, and CCS just before starting infusion, and 1 hour, 4 hours, 24 hours, and 48 hours after midazolam infusion, and ward nurses rated STAS at the same time. Since the ward nurses regularly evaluated STAS to titrate midazolam during palliative sedation as routine work, we regarded STAS rated by ward nurses as a standard of distress measure.ResultsA total of 249 assessments were performed for 55 patients. The RASS score was moderately to highly associated with symptom intensity measured by STAS, discomfort measured by the Discomfort Scale, and pain measured by NOPPAIN (r = 0.63 to 0.73). On the other hand, communication capacity measured by CCS is not parallel with the RASS score, and demonstrated a valley-shape. In 82 assessments with RASS of -1 to -3, 11 patients (13%) were regarded as having physical symptoms of STAS of 2 or more.Conclusions RASS can roughly estimate physical distress in patients receiving palliative sedation, but a measure to more precisely quantify the symptom experience is needed.

Summary: Background & Aims: The prevalence of artificially administered nutrition and hydration (AANH) in different age groups among patients with advanced cancer remains unknown. The present study investigated the current utilization of AANH according to age groups in palliative care units. Methods: This was a secondary analysis of a prospective cohort study. We obtained information on primary nutritional administration routes during the first week of admission and data on the averaged calorie sufficiency rate or total calorie intake on the 7th day of admission. Patients were divided into five age groups (18–39, 40–59, 60–74, 75–89, and 90- years). Among patients receiving AANH, the proportions of higher-calorie AANH were compared between the five age groups. Results: A total of 1453 patients were included. The proportion of patients categorized as receiving nutrition and hydration via the parenteral route was the highest in the 18–39 and 40–59 groups (52.4 and 41.1%, respectively). Among patients receiving AANH (n = 534), the proportions of patients categorized into the

Parenteral morphine is widely used for dyspnea of imminently dying cancer patients (terminal dyspnea). However, the efficacy of other opioids such as oxycodone remains largely unknown.To explore the efficacy of parenteral oxycodone vs. morphine by continuous infusion over 24 hours in cancer patients with terminal dyspnea.This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were advanced cancer patients admitted to palliative care units, Eastern Cooperative Oncology Group performance status = 3-4, and a dyspnea intensity ≥2 on the Integrated Palliative care Outcome Scale (IPOS) for which oxycodone or morphine was initiated by continuous infusion. We measured dyspnea IPOS scores over 24 hours.We analyzed 164 patients who received oxycodone (n = 26) and morphine (n = 138) for dyspnea (median survival = 5 days). The mean age was 70 years, 58 patients (35%) had lung cancer, and 97 (59%) had lung metastases. Complete case analysis revealed that mean dyspnea IPOS scores decreased from 3.0 (standard deviation = 0.7) to 1.5 (0.7) in the oxycodone group (difference in means = 1.5; P 0.001), and from 2.9 (0.7) to 1.6 (1.0) in the morphine group (difference in means = 1.3; P 0.001). No significant between-group differences existed in the IPOS scores at 24 hours (P = 0.753). Adverse events were seen in no and 5 patients in the oxycodone and morphine groups, respectively.Parenteral oxycodone may be equally effective and safe as morphine in the treatment of terminal dyspnea in cancer patients. Future randomized controlled trials should confirm the efficacy and safety of opioids other than morphine for terminal dyspnea.

The benefits of parenteral nutrition and hydration (PNH) in patients with advanced cancer remain unknown. Therefore, we conducted a prospective multicenter cohort study to assess the effects of PNH on survival in patients with malignant bowel obstruction (MBO). The present study was a secondary analysis. Data on primary nutritional administration routes during the first week of admission to palliative care units, i.e., parenteral nutrition and parenteral hydration, were obtained. Data on the averaged calorie sufficiency rate/total calorie intake (75% ≤ or 750 kcal/day ≤ , 50–75% or 500–750 kcal/day, 25–50% or 250–500 kcal/day, and

To examine the safety, effectiveness, and patient-perceived benefit of treatment with olanzapine for nausea and vomiting (N/V) in patients with advanced cancer. We conducted a multicenter prospective observational study in a tertiary care setting (Trial registration number: UMIN000020493, date of registration: 2016/1/12). We measured the following: average nausea in the last 24 h using a Numeric Rating Scale (NRS: range 0–10) at baseline and day 2, patient-perceived treatment benefit (based on a 5-point verbal scale), and adverse events (AEs; using the Common Terminology Criteria for Adverse Events version 4). The 85 participants (45% men) had a mean age of 58.7±15.8 years. Major causes of N/V were opioids (44%) and chemotherapy (34%). All patients received a daily dose of olanzapine of 5 mg or less as first-line treatment (N=35) or second- or later-line treatment (N=50). Nausea NRS decreased from 6.1±2.2 to 1.8±2.0 (differences: −4.3, 95% CI −3.7 to −4.9, p

ObjectivesThe goal of palliative and supportive care is to improve patients’ quality of life (QoL). Patient-reported outcome measures (PROMs) are the gold standard for the assessment of QoL and symptoms; however, when self-reporting is complicated, PROMs are often substituted with proxy-reported outcome measures, such as clinician-reported outcome measures. The objective of this study was to assess the validity and reliability of the Japanese version of the Integrated Palliative care Outcome Scale (IPOS) for staff (IPOS-Staff).MethodsThis multicenter, cross-sectional observational study was conducted concurrently with the validation of the IPOS for patients (IPOS-Patient). Japanese adult patients with cancer and their staff were recruited. We assessed the characteristics of the patients and staff members, missing values, prevalence, and total IPOS scores. For the analysis of criterion validity, intra-rater, and inter-rater reliability, we calculated intraclass correlations (ICCs).ResultsOne hundred and forty-three patients completed the IPOS-Patient, and 79 medical staff members completed the IPOS-Staff. The most common missing values from IPOS-Staff were Family Anxiety (3.5%) and Sharing Feelings (3.5%). Over half of the patients scored themselves moderate or worse for Poor Mobility, Anxiety, and Family Anxiety, while staff members scored patients moderate or worse for Weakness, Anxiety, and Family Anxiety. For criterion validity (patient–staff agreement) as well as intra-rater and inter-rater reliability, ICCs ranged from 0.114 (Sharing Feelings) to 0.826 (Nausea), 0.720 (Anxiety) to 0.933 (Nausea), and −0.038 (Practical Problems) to 0.830 (Nausea), respectively.Significance of resultsThe IPOS-Staff is easy to respond to; it has fair validity and reliability for physical items but poor for psycho-social items. By defining the context and objectives of its use and interpretation, the IPOS-Staff can be a useful tool for measuring outcomes in adult patients with cancer who cannot complete self-evaluations.

Background: Continuous deep sedation is ethically controversial with respect to whether it shortens a patient’s life. Aim: To examine whether continuous deep sedation shortens patient survival from the day of Palliative Performance Scale decline to 20 (PPS20). Design: A part of a multicenter prospective cohort study (EASED study). Setting/participants: We recruited consecutive adult patients with advanced cancer admitted to 23 participating palliative care units in 2017 in Japan. We compared survival from PPS20 between those who did and did not receive continuous deep sedation. Continuous deep sedation was defined as the continuous administration of sedative medication with the intention to keep a patient continuously unconscious to alleviate otherwise uncontrollable symptoms, but the dose of sedatives was adjusted to achieve adequate symptom relief for each patient. The propensity score-weighting method was used to control for potential confounders, and five sensitivity analyses were performed. Results: A total of 1926 patients were enrolled. Patients discharged alive were excluded, and we analyzed 1625 patients of whom 156 (9.6%) received continuous deep sedation. Median survival from PPS20 of 1625 patients was 81 h (95% CI: 77–88). The RASS scores decreased to ⩽−4 was 66% at 24 h. Continuous deep sedation was not associated with a significant survival risk (adjusted hazard ratio: 1.06, 95% CI: 0.85–1.33). All sensitivity analyses, including continuous deep sedation defined as the RASS score was ⩽−4 achieved the essentially the same results. Conclusions: Continuous deep sedation with careful dose adjustment was not associated with shorter survival in the last days of life in patients with advanced cancer.

The perspective toward hypoactive delirium in the last days of life could be different among physicians.To clarify the attitudes, beliefs, and opinions of palliative care physicians and liaison psychiatrists toward hypoactive delirium in the last days of life and to explore the association among these factors.A nationwide cross-sectional questionnaire survey was conducted among 1667 physicians who were either certified palliative care specialists or liaison psychiatrists. Physicians' agreement with the appropriateness of pharmacological management (e.g., antipsychotics) (one item), their beliefs (11 items), and their opinions (four items) were measured.787 (47%) physicians responded. 481 (62%) agreed to use of medications for hypoactive delirium in the last days of life, whereas 296 (38.1%) disagreed. More than 95% agreed with "hypoactive delirium at the end of life can be considered as a part of natural dying process." Multivariate analysis identified two belief subscales of "hypoactive delirium at the end of life is a natural dying process" and "antipsychotics are futile and harmful in managing hypoactive delirium" had a significant negative correlation with the use of medications. On the other hand, one belief subscale of "hypoactive delirium can be distressing even if patients' consciousness is impaired" had significant positive correlations with the use of medications.Pharmacological management of hypoactive delirium in the last days of life differs depending on physicians' beliefs. Future research is needed to clarify the efficacy and safety of pharmacological management of hypoactive delirium.

Context: Some patients require continuous deep sedation (CDS) for refractory symptoms despite intensive palliative care. The principle of proportionality is proposed on the basis of clinical decisions, but no validated tools to assist such decision making are available. Aim: To develop a scoring system to determine whether CDS is proportionally appropriate. Subjects and Methods: A secondary analysis of a nationwide questionnaire survey of Japanese palliative care specialists was performed. Physicians were asked to rate the degree that they believed CDS to be appropriate in a total of 27 scenarios based on a combination of 3 factors with 3 levels: (1) the estimated survival (days, weeks, and months), (2) the patient's wish (clear and consistent, somewhat unclear and/or inconsistent, and unclear or inconsistent), and (3) confidence in refractoriness of the symptom (definite, probable, and unsure). Based on logistic regression analyses, a scoring system with two formulas (the proportionality score to determine that continuous deep sedation is appropriate [ProScoreCDS-appropriate] and proportionality score to determine that continuous deep sedation is inappropriate [ProScoreCDS-inappropriate]) to predict specialists' decision that CDS is appropriate or inappropriate was developed. The accuracy of the formulas was investigated. Results: Among 695 palliative care specialists, 469 returned the questionnaire (response rate, 69%) and 440 were analyzed. Logistic regression analyses identified that all three factors were significantly associated with physicians' decisions about the appropriateness of performing CDS. Using weighted value, the total score ranged from 3 to 67 for ProScoreCDS-appropriate, and 3 to 27 for ProScoreCDS-inappropriate. The area under the curve (AUC) values of ProScoreCDS-appropriate and ProScoreCDS-inappropriate were 0.88 (95% confidence interval [CI], 0.87-0.89) and 0.81 (95% CI, 0.81-0.82), respectively. Using cutoff points of 41 and 14, sensitivity and specificity were 68.6% and 88.9% for ProScoreCDS-appropriate and 67.7% and 76.0% for ProScoreCDS-inappropriate, respectively. Conclusion: A scoring system to determine whether CDS is proportionally appropriate can be constructed, and a further study to develop a clinical tool is promising.

Context: Poor understanding regarding the safe use, secure storage, and adequate disposal of unused opioids may contribute to the opioid epidemic. It is unclear what happens to unused opioids in the households of deceased cancer patients. Objectives: Our aim was to investigate the patterns of use, storage, and disposal of unused opioids among families of deceased cancer patients. Methods: A questionnaire was administered to families of deceased cancer patients. Questions were related to the use, storage, and disposal of opioids prescribed to their deceased family member. Results: Completed questionnaires were received from the families of 240 patients. Of these, 129 (53.8%) and 99 (41.3%) participants were aware of the danger of diversion and need for safe disposal, respectively. One (0.4%) participant reported diversion. In total, 177 participants (73.8%) stored opioids securely, 6 (2.5%) had unused opioids at home, and 142 (59.2%) returned unused opioids to medical health providers. Knowledge of safe opioid disposal increased the rate of returning opioids to medical health providers (84.8% vs. 53.2%; p

ObjectivesThe present study aims were (1) to identify the proportion of terminally ill cancer patients with desire for hastened death (DHD) receiving specialized palliative care, (2) to identify the reasons for DHD, and (3) to classify patients with DHD into some interpretable subgroups.MethodsAdvanced cancer patients admitted to 23 inpatients hospices/palliative care units in 2017 were enrolled. Data were prospectively obtained by the primarily responsible physicians. The presence/absence of DHD and reasons for DHD were recorded. A cluster analysis was performed to identify patterns of subgroups in patients with DHD.ResultsData from 971 patients, whose Richmond Agitation–Sedation Scale score at admission was zero and who died in palliative care units, were analyzed. The average age was 72 years, common primary cancer sites were the gastrointestinal tract (31%) and the liver/biliary ducts/pancreas (19%). A total of 174 patients (18%: 95% confidence interval, 16–20) expressed DHD. Common reasons for DHD were dependency (45%), burden to others (28%), meaninglessness (24%), and inability to engage in pleasant activities (24%). We identified five clusters of patients with DHD: cluster 1 (35%, 61/173): “physical distress,” cluster 2 (21%, 37/173): “dependent and burdensome,” cluster 3 (19%, 33/173): “hopelessness,” cluster 4 (17%, 30/173): “profound fatigue,” and cluster 5 (7%, 12/173): “extensive existential suffering.”ConclusionsA considerable number of patients expressed DHD and could be categorized into five subgroups. These findings may contribute to the development of therapeutic strategies.

Purpose To investigate the efficacy of two types of palliative sedation: proportional and deep sedation, defined by sedation protocols. Methods From a multicenter prospective observational study, we analyzed the data of those patients who received the continuous infusion of midazolam according to the sedation protocol. The primary endpoint was goal achievement at 4 hours: in proportional sedation, symptom relief (Integrated Palliative care Outcome Scale: IPOS ≤ 1) and absence of agitation (modified Richmond Agitation-Sedation Scale: RASS ≤ 0); in deep sedation, the achievement of deep sedation (RASS ≤ -4). Secondary endpoints included deep sedation as a result of proportional sedation, communication capacity (Communication Capacity Scale item 4 ≤ 2), IPOS and RASS scores, and adverse events. Results A total of 81 patients from 14 palliative care units were analyzed: proportional sedation (n = 64) and deep sedation (n = 17). At 4 hours, the goal was achieved in 77% (n = 49; 95% confidence interval: 66-87) with proportional sedation; and 88% (n = 15; 71-100) with deep sedation. Deep sedation was necessary in 45% of those who received proportional sedation. Communication capacity was maintained in 34% with proportional sedation and 10% with deep sedation. IPOS decreased from 3.5 to 0.9 with proportional sedation, and 3.5 to 0.4 with deep sedation; RASS decreased from +0.3 to -2.6, and +0.4 to -4.2, respectively. Fatal events related to the treatment occurred in 2% (n = 1) with proportional and none with deep sedation. Conclusion Proportional sedation achieved satisfactory symptom relief while maintaining some patients’ consciousness, and deep sedation achieved good symptom relief while the majority of patients lost consciousness.

The benefits of parenteral nutrition and hydration (PNH) in patients with advanced cancer remain unknown. Therefore, we conducted a prospective multicenter cohort study to assess the effects of PNH on survival in patients with malignant bowel obstruction (MBO).The present study was a secondary analysis. Data on primary nutritional administration routes during the first week of admission to palliative care units, i.e., parenteral nutrition and parenteral hydration, were obtained. Data on the averaged calorie sufficiency rate/total calorie intake (75% ≤ or 750 kcal/day ≤ , 50-75% or 500-750 kcal/day, 25-50% or 250-500 kcal/day, and 25% or 250 kcal/day) were also obtained. Participants with MBO were included and divided into two groups: PNH-high (25% ≤ or 250 kcal/day ≤) and PNH-low ( 25% or 250 kcal/day). We performed time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses.Patients were divided into the PNH-high (n = 68) and PNH-low (n = 76) groups. A significant difference was observed in survival rates between the two groups (log-rank P 0.001). Median survival times were 35.5 (95% CI 27-44) and 17.5 (95% CI 13-21) days, respectively. In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the PNH-high group (HR 0.55 (95% CI 0.36-0.83), P = 0.005) than in the PNH-low group.The present results indicated the beneficial effects of PNH for prolonging survival in advanced cancer patients with MBO in palliative care units.

The benefits of artificial nutrition and hydration in patients with advanced cancer remain unknown. Therefore, we conducted a prospective study to evaluate effects of enteral nutrition (EN) and parenteral nutrition and hydration (PNH) on survival in palliative care units.This study involved a secondary analysis of a multicenter cohort study. Data of primary nutritional administration routes during the first week after admission (oral intake, enteral tube feeding, parenteral nutrition, parenteral hydration, poor oral intake) were obtained. Data of averaged calorie sufficiency rate/total calorie intake [high (75% ≤ or 750 kcal/day ≤), moderate (50-75% or 500-750 kcal/day), low (25-50% or 250-500 kcal/day), very low (25% or250 kcal/day)] were also obtained. After investigating the implementation of artificial nutrition and hydration, participants were divided into three groups according to the nutritional administration route and calorie sufficiency rate/total calorie intake: EN, PNH, and control. We conducted time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses.Patients were divided into the EN group (n = 730), PNH group (n = 190), and control group (n = 533). Differences in survival rates among the three groups were significant (Log-rank P 0.001). Median survival times were 43.0 (95% CI 40-46), 33.0 (95% CI 29-37), and 15.0 (95% CI 14-16) days, respectively (P 0.001). In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the EN group and PNH groups (HR 0.43 [95% CI 0.37-0.49], P 0.001; and HR 0.52 [95% CI 0.44-0.62], P 0.001, respectively) than in the control group.This study indicated the clinical benefits of EN and PNH for patients with advanced cancer. Nevertheless, managing symptoms to improve oral intake is essential before initiation of PNH, because EN was superior to PNH.

Background: Continuous deep sedation (CDS) is ethically controversial with respect to whether it shortens a patient’s life. Previous studies reported no significant difference in survival from admission or enrolment into a palliative care program to death between patients treated with and without CDS. However, these baselines are too distant from the initiation of CDS to detect the effect of CDS on survival. We aimed to examine whether CDS shortens patient survival from the day of Palliative Performance Scale decline to 20 (PPS20). Methods: This study was a part of a multicenter prospective cohort study that recruited patients between Jan. and Dec. 2017 in Japan (EASED study). Consecutive Adult patients with advanced cancer admitted to 23 participating inpatient palliative care units were eligible for this analysis. We compared survival from PPS20 between those who did and did not receive CDS. We used the inverse probability of treatment weighting method to control for potential confounders of patient characteristics, complications and laboratory data at admission, and symptoms at PPS20. Findings: A total of 1926 patients were enrolled. Of these, patients discharged alive were excluded, and finally we analyzed 1625 patients of whom 156 (9.6%) received CDS. Median survival from PPS20 of 1625 patients was 3.4 days (95% CI: 3.2-3.7). CDS was not associated with a significant survival risk from PPS20 (adjusted hazard ratio: 1.06, 95% CI:0.85–1.33; p = 0.595). In exploratory subgroup analyses, a significant survival risk was not observed in any subgroup except for those with primary lung cancer and agitated delirium. Interpretation: CDS was not associated with shorter survival in the last days of life in patients with advanced cancer, and CDS had no measurable effects on survival. Our findings may relieve the concern of patients, families, and physicians that CDS might shorten survival. Funding Statement: This work was supported by Grant-in-Aid from the Japanese Hospice Palliative Care Foundation and in part by JSPS KAKENHI Grant number JP19H03869. Declaration of Interests: No relevant conflict of interest to declare. Ethics Approval Statement: This study was conducted in accordance with the ethical standards of the Helsinki Declaration and the ethical guidelines for epidemiologic research of the Ministry of Health, Labour and Welfare of Japan. The local institutional review boards of all participating institutions approved this study. Japanese law does not require individual informed consent from participants in a non-invasive observational trial such as this. Therefore, we used an opt-out method rather than acquiring written or oral informed consent.

Purpose To investigate the usefulness of screening for patient symptoms as the fifth vital sign using an electronic medical recording system. Patients and methods In the electronic medical recording system, all admitted patients received routine nurse-based assessment of discomfort (defined as any physical symptom) at every vital sign check regarding item 2 of the Support Team Assessment Schedule Japanese version (STAS-J). All cancer patients admitted to oncology units were screened at 1-week intervals. Screening-positive was defined when patients had a STAS-J score of 2 or more at least two times in a week. For all screening-positive patients, the palliative care team reviewed each patient's medical records, and provided written recommendations as needed. The primary outcomes were the proportion of screening-positive patient, and the proportion of patients deemed to need additional palliative treatment in the screening-positive patients. Results Of 2427 patients screened, 223 (9.1%; 95% confidence interval, 8-10%) met the screening-positive criterion. A total of 12 (5.4%; 95% confidence interval, 3-9%) of them were deemed to need additional palliative care, including six patients referred to the PCT within 1 week. In the remaining 211 screening-positive patients, 100 had received adequate palliative care, 68 had already been referred to the palliative care team and 43 had self-limiting transient discomfort. Conclusion This screening system was feasible but the majority of screening-positive patients did not require additional palliative care interventions.

Background The purpose of this study was to investigate the current status of distress screening implementation in Japanese designated cancer hospitals. Subjects and methods This was a cross-sectional observational study. Palliative care team representatives in all designated cancer hospitals in Japan completed an ad hoc questionnaire. Demographic data in 2014 were obtained from the Ministry of Health, Labour and Welfare in Japan. Results Of 422 institutions, 389 responded (92%) and data were obtained from 379 (90%). Approximately 90% of institutions had implemented a distress screening program at some level, and approximately 60% had just started screening. Among those institutions that screened, 77% provided individualized triage to specialized services within the institutions, whereas 60% did not routinely follow-up with patients who had positive screening results. The estimated median percentage of screened patients referred to palliative care teams was 0.4% in outpatient settings and 6.3% in inpatient settings. Although 68% of respondents perceived that screening was useful overall, they also reported difficulties when conducting screening with patients, reporting "no established effective treatment for problems screened" (66%), "patients complain it is difficult to express their distress using scales" (58%), and that it was "difficult to manage screened problems because of lack of time" (49%). Eight perceived barriers to implementing distress screening programs in hospitals were identified; a lack of human resources ranked highest. Conclusions Implementation of distress screening in designated cancer hospitals in Japan has just begun. Policymakers should acknowledge that screening can be beneficial for patients when it is implemented with appropriate resources and established methods.

Although the death of a loved one is a devastating family event, little is known about which behaviors positively affect families' perceptions on death pronouncements.The objective of this study was to evaluate the effect of a compassionate death pronouncement on participant-perceived physician compassion, trust in physicians, and emotions.In this randomized, video-vignette study, 92 people (≥50 years) in Tokyo metropolitan area viewed two videos of death pronouncements by an on-call physician with or without compassion-enhanced behaviors, including five components: waiting until the families calm themselves down, explaining that the physician has received a sign-out about information of the patient's condition, performing examination respectfully, ascertaining the time of death with a wristwatch (vs. smartphone), and reassuring the families that the patient did not experience pain. Main outcomes were physician compassion score, trust in physician, and emotions.After viewing the video with compassion-enhanced behaviors compared with the video without them, participants assigned significantly lower compassion scores (reflecting higher physician compassion) (mean 26.2 vs. 36.4, F = 33.1, P 0.001); higher trust in physician (5.10 vs. 3.00, F = 39.7, P 0.001); and lower scores for anger (2.49 vs. 3.78, F = 18.0, P 0.001), sadness (3.42 vs. 3.85, F = 11.8, P = 0.001), fear (1.93 vs. 2.55, F = 15.8, P 0.001), and disgust (2.45 vs. 3.71, F = 19.4, P 0.001).To convey compassion on death pronouncement, we recommend that physicians initiate prompt examination, explain that the physician has received a sign-out, perform examination respectfully, ascertain the time of death with a wristwatch, and reassure the families that the patient did not experience pain.

This study investigated the effect of two types of palliative sedation defined using intervention protocols: proportional and deep sedation. We retrospectively analyzed prospectively recorded data of consecutive cancer patients who received the continuous infusion of midazolam in a palliative care unit. Attending physicians chose the sedation protocol based on each patient’s wish, symptom severity, prognosis, and refractoriness of suffering. The primary endpoint was a treatment goal achievement at 4 h: in proportional sedation, the achievement of symptom relief (Support Team Assessment Schedule (STAS) ≤ 1) and absence of agitation (modified Richmond Agitation-Sedation Scale (RASS) ≤ 0) and in deep sedation, the achievement of deep sedation (RASS ≤ − 4). Secondary endpoints included mean scores of STAS and RASS, deep sedation as a result, and adverse events. Among 398 patients who died during the period, 32 received proportional and 18 received deep sedation. The treatment goal achievement rate was 68.8% (22/32, 95% confidence interval 52.7–84.9) in the proportional sedation group vs. 83.3% (15/18, 66.1–100) in the deep sedation group. STAS decreased from 3.8 to 0.8 with proportional sedation at 4 h vs. 3.7 to 0.3 with deep sedation; RASS decreased from + 1.2 to − 1.7 vs. + 1.4 to − 3.7, respectively. Deep sedation was needed as a result in 31.3% (10/32) of the proportional sedation group. No fatal events that were considered as probably or definitely related to the intervention occurred. The two types of intervention protocol well reflected the treatment intention and expected outcomes. Further, large-scale cohort studies are promising.

Objectives Primary aim was to clarify the prevalence and factors associated with the occurrence of deathbed visions, explore associations among deathbed visions, a good death, and family depression. Additional aim was to explore the emotional reaction, perception, and preferred clinical practice regarding deathbed visions from the view of bereaved family members. Methods A nationwide questionnaire survey was conducted involving 3964 family members of cancer patients who died at hospitals, palliative care units, and home. Results A total of 2827 responses (71%) were obtained, and finally 2221 responses were analyzed. Deathbed visions were reported in 21% (95% CIs, 19–23; n = 463). Deathbed visions were significantly more likely to be observed in older patients, female patients, female family members, family members other than spouses, more religious families, and families who believed that the soul survives the body after death. Good death scores for the patients were not significantly different between the families who reported that the patients had experienced deathbed visions and those who did not, whereas depression was more frequently observed in the former than latter, with marginal significance (20 vs. 16%, respectively, adjusted P = 0.068). Although 35% of the respondents agreed that deathbed visions were hallucinations, 38% agreed that such visions were a natural and transpersonal phenomenon in the dying process; 81% regarded it as necessary or very necessary for clinicians to share the phenomenon neutrally, not automatically labeling them as medically abnormal. Conclusions Deathbed vision is not an uncommon phenomenon. Clinicians should not automatically regard such visions as an abnormal phenomenon to be medically treated and rather provide an individualized approach.