Evaluation of care for leukemia and lymphoma patients during their last hospitalization from the perspective of the bereaved family.

We aimed to evaluate care for leukemia and lymphoma patients during their last hospitalization from the perspective of the bereaved family. Questionnaires were sent to the bereaved family members of adult leukemia and lymphoma patients. We used the Care Evaluation Scale (CES) and asked the bereaved family members about care satisfaction and "good death" factors during the patient's last week of life or last admission period. We distributed 177 questionnaires and were able to analyze 103 (58.2%) responses. Compared with the results of a previous study of palliative care units in Japan, the CES scores were significantly lower in 9 out of 10 domains. Assessment of the "good death" components revealed that only 33% of respondents agreed that the patient had been relieved as far as possible of pain and physical distress during the last week of life. Only 21.4% of respondents agreed that the patient had been relieved as far as possible of psychological distress, and 57% of caregivers were not satisfied with the level of care. During the last hospitalizations of leukemia or lymphoma patients, their care was insufficient and a good death was not often achieved. Improvement of end-of-life care for leukemia and lymphoma patients is needed.

Nurse education program on meaninglessness in terminally ill cancer patients: a randomized controlled study of a novel two-day workshop.

BACKGROUND: Fostering patients' sense of meaning is an essential task for palliative care clinicians. Few studies have reported the effects on nurses of a short-term training program aimed at improving skills to relieve feelings of meaninglessness in terminally ill cancer patients. OBJECTIVE: The primary aim of this study was to determine the impact on nurses of a novel two-day education program focusing on care that addresses patients' feelings of meaninglessness. Measured were impacts on nurses' confidence, self-reported practice, attitudes toward caring for such patients, burnout, meaning of life, and knowledge. METHODS: This study was a randomized controlled trial using the waiting list control. Intervention consisted of a two-day interactive education program. A total of 76 nurses randomly allocated to two groups completed the study. Outcome measures included confidence scale; self-reported practice scale; scales of nursing attitudes toward caring for patients who experience feelings of meaningless (willingness to help, positive appraisal, helplessness, nurse-perceived value of being, and nurse-perceived value of patients' inner power); Maslach burnout scale, Functional Assessment of Chronic Illness Therapy-Spiritual, and knowledge scale. RESULTS: There were significant intervention effects in nurse-reported confidence and nurse-perceived value of patients' inner power. Nurse-reported helplessness showed marginally significant improvement after intervention (p=0.067). No significant intervention effects were observed in the self-reported practice scale; attitudes toward caring for patients (willingness to help, positive appraisal, and nurse-perceived value of being); burnout scale, meaning of life; and knowledge score. The percentages of nurses who evaluated this program as useful or very useful were 95% (understanding the conceptual framework) and 85% (helping to learn how to provide care for patients feeling meaninglessness in clinical practice). CONCLUSION: This short-term educational intervention had a significant beneficial effect on nurses' confidence and modest effects on attitudes.

Multiple evaluation of a hospital-based palliative care consultation team in a university hospital: activities, patient outcome, and referring staff's view.

OBJECTIVE: Although the number of hospital-based palliative care consultation teams (PCCTs) is rapidly increasing in Japan, there is limited information available concerning the activities and usefulness of PCCT in the country. The aim of this study is to clarify the activities, patient outcome, and referring staff's view of an established PCCT in Japan. METHOD: This was a prospective study to follow patients referred to a PCCT for 28 days over a 1-year period. Patients were assessed by the Support Team Assessment Schedule-Japanese version (STAS-J) and EORTC QLQ C-30 at the time of referral and on days 7, 14, and 28. A staff survey was implemented using a questionnaire after each observation period. RESULTS: Of 180 patients referred, 53 patients were eligible for the study. Although the median of the number of the reasons for referral was 1, the PCCT provided several kinds of support: pain management, 94%; emotional support for the patient, 49%; and emotional support for the family, 36%. On day 7 after referral, of the items of STAS-J and the EORTC QLQ C-30 subscales, only insomnia improved significant whereas "other physical symptoms" and constipation were significantly exacerbated. In the staff survey, of the 98 respondents, more than 90% considered the effect of the PCCT as "excellent" or "good" and were satisfied with the support provided. SIGNIFICANCE OF RESULTS: This study showed that the PCCT performed comprehensive assessments on referred patients and provided extra support. No patient's QOL 1 week after referral was improved with the exception of insomnia. Referring staff highly evaluated the activities of the PCCT. In the evaluation of PCCTs, further research about the variation of clinical activities of PCCTs, their applicability, and benefit is needed.

Validity and reliability of the Japanese version of the Caregiver Reaction Assessment Scale (CRA-J) for community-dwelling cancer patients.

BACKGROUND: The aim of this study was to validate the Caregiver Reaction Assessment (CRA) among caregivers of community-dwelling advanced cancer patients in Japan. METHODS: A cross-sectional questionnaire was administered to advanced cancer patients and their caregivers who were cared for at day hospices and home palliative care services. We translated the CRA into Japanese, and then verified factor validity, reliability, construct validity, concurrent validity, and known groups' validity. To address construct and concurrent validity, we calculated Pearson's correlation coefficient between the Japanese version of the CRA and the Burden Index of Caregivers (BIC). To address known groups' validity, we used the t test or analysis of variance (ANOVA). RESULTS: A total of 57 caregivers participated in the study. Five factors were extracted (''impact on schedule,'' ''caregiver's self-esteem,'' ''lack of family support,'' ''impact on health,'' and ''impact on finances'') and reliability was good. Construct and concurrent validity among the subscales of the BIC were good. Regarding known groups validity, the subscale score of ''impact on schedule'' for the groups that cared 6 hours or more per day was higher than the other group (P = .04). CONCLUSION: The CRA-J is valid and reliable. This scale is useful for caregivers of cancer patients in Japan.

Prospective evaluation of transition to specialized home palliative care in Japan.

The aim of this study was to clarify patients' characteristics and the level of symptom management in the transition to specialized home palliative care, and to examine prospectively real-time evaluation of both terminal cancer patients and their families. This study was conducted at one of the largest institutions offering specialized home palliative care in Japan. We asked both the patient's and the family's health status at the initial assessment and 2 weeks later. One hundred sets of patients and their families were included in this study. Regarding patient characteristics at the time of referral to the specialized home palliative care service, patients referred from outpatient settings had more severe physical symptoms than patients referred from inpatient settings. The specialized home palliative care service could contribute to patients' symptom and families' psychosocial status.

Discharge from a palliative care unit: prevalence and related factors from a retrospective study in Japan.

PURPOSE: Selecting a place for end-of-life care is an important issue for patients with cancer. In this study we conducted a retrospective analysis on the prevalence of discharge from a palliative care unit (PCU) and explored factors related to discharge based on individual-level data from 5 years of experience at the Tokyo Metropolitan Toshima Hospital PCU. METHODS: We retrospectively collected information on patients and families from the admission database of the PCU. We calculated the prevalence of patients discharged from the PCU and explored the factors related to discharge using bivariate and multivariate analysis. RESULTS: The subjects were 498 terminal patients with cancer. The overall discharge rate was 33%. For subjects who were admitted for symptom control, the discharge rate was 54%. The duration of the period from referral to death (odds ratio [OR] = 4.98, p < 0.001), Eastern Cooperative Oncology Group Performance States [ECOG PS]_OR = 0.51, p = 0.003), problems with oral intake (OR = 0.41, p = 0048), presence of nausea (OR = 0.41, p = 0.046), experience of radiation therapy (OR = 0.27, p = 0.003), and patient's anxiety for family (OR = 0.35, p = 0.029) were independent related factors for discharge from the PCU, according to logistic regression. CONCLUSION: Early referral to the PCU and development of alleviation methods for symptoms such as nausea and anxiety and depression are important for promoting discharge and would contribute to the patient's quality of life at the end of life.

Quality of life, day hospice needs, and satisfaction of community-dwelling patients with advanced cancer and their caregivers in Japan.

BACKGROUND: The aims of this study were to clarify (1) the quality of life (QOL) of community-dwelling patients with advanced cancer and their caregivers in home palliative care and day hospice settings, (2) the need for day hospice of home palliative care patients and caregivers, and (3) the satisfaction with day hospice by day hospice patients and caregivers. METHODS: A cross-sectional questionnaire was administered to patients with advanced cancer and their caregivers who were cared for at day hospice and home palliative care. We measured the health-related quality of life using the SF-8, the need for day hospice of home palliative care patients and caregivers, and the satisfaction with day hospice by day hospice patients and caregivers. RESULTS: A total of 57 pairs of patients and caregivers participated in the study (day hospice, n = 23; home palliative care, n = 34). The physical and mental aspects of the patient QOL were significantly lower than national standard value. However, although physical aspect of caregivers QOL was significantly lower than national standard value, mental aspect of caregiver's QOL was not lower than national standard value. Forty-four percent of home palliative care patients and 67% of home palliative care caregivers preferred day hospice. The needs of patients and caregivers were wide ranging including medical treatment, distraction, information provision, and respite. Overall, the Japanese day hospice was evaluated highly. CONCLUSION: This is the first study of day hospice in Japan. Although there are several day hospices in Japan, the initiation of day hospice would probably be successful. The dissemination of day hospice is an important issue for patients with advanced cancer and their caregivers in Japan.

Perceptions of specialized inpatient palliative care: a population-based survey in Japan.

This study aimed to clarify and compare the awareness and perceptions of the specialized inpatient palliative care service. A cross-sectional questionnaire survey was performed on the general population selected by stratified two-stage random sampling (n=2,548) and bereaved families who actually received specialized inpatient palliative care at 12 palliative care units (PCUs) in Japan (n=513). The respondents reported their awareness and perceptions of PCUs. Thirty-eight percent of the general population answered that they had "considerable" or "moderate" knowledge of PCUs, but 24% answered that they had "no" knowledge. Bereaved families who received PCU care (PCU-bereaved families) were likely to have better perceptions of PCUs than the general population: "alleviates pain" (68% of the general population and 87% of PCU-bereaved families agreed), "provides care for families" (67% and 86%, respectively), and "provides compassionate care" (67% and 87%, respectively). Both groups, however, expressed concerns about PCUs: "a place where people only wait to die" (30% and 40%, respectively) and "shortens the patient's life" (8% and 17%, respectively). These perceptions were associated with overall satisfaction with received care, and differed among the 12 PCUs. In conclusion, public awareness of PCUs was insufficient in Japan. Although PCU-bereaved families were generally likely to have better perceptions of PCUs than the general population, both groups shared concerns that a PCU was a place where people only wait to die. To facilitate appropriate use of specialized palliative care services, more efforts to inform the general population about the actual palliative care system are needed. In addition, the role of PCUs might be reconsidered in terms of the continuum of cancer care.

Family caregiver's experiences in caring for a patient with terminal cancer at home in Japan.

OBJECTIVES: The aim of the study was to clarify the care experience of primary caregivers when caring for a terminal cancer patient in the home with the assistance of a home palliative care service. Participants were asked to provide background data and to evaluate their experience of caregiving and of the patient's response throughout the period of home palliative care, up to the time of death. METHODS: One hundred twelve primary family caregivers were a mailed self-report questionnaire, and 74 valid questionnaires were returned (response rate 66%). RESULTS: Ninety percent felt that the patient's condition of mind and body was reasonably stable, and 75% felt that the death was peaceful. About 90% reported a deepening of their bond with the patient and that the bond of other family members deepened also. Sixty percent reported that the burden of caregiving was not too great or not felt at all. Approximately 90% judged that the patient retained his or her own personal qualities to the end. Ninety percent also felt that they had done their best in their caregiving and judged that home care had been beneficial for the deceased, for the primary caregiver him/herself, and for other family members. These primary caregivers' evaluations of caring for a terminally ill patient at home in conjunction with a home palliative care service were both high and positive. SIGNIFICANCE OF RESULTS: Our findings suggest that it is important to maintain the patient's personal qualities up to the time of death through appropriate symptom management, to respect the family bond of the household, and to provide professional support in order to reduce the load on the family. If appropriate care is provided, peaceful home death will be possible, resulting in significant benefits for patients and their families in Japan.

Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients.

The aim of this study was to clarify the relationship of nursing autonomy and other factors related to attitudes toward caring for dying patients. A cross-sectional survey of nurses was conducted in November 2003 using a self-administered questionnaire. We collected demographic data from 178 (75%) participants and used the Frommelt Attitude Toward Care of the Dying scale, Form B, Japanese version (FATCOD-Form B-J), the Pankratz Nursing Questionnaire (PNQ), and the Death Attitude Inventory (DAI). FATCOD-Form B-J measures nurse's attitude toward caring for dying patients. It includes two subscales: positive attitude toward caring for the dying patient and perception of patient- and family-centered care. The PNQ measures nursing autonomy of individual nurses and has three subscales: nursing autonomy and advocacy, patients' rights, and rejection of traditional role limitations. The DAI measures attitudes toward death in context of Japanese cultural characteristics. It includes seven subscales: afterlife beliefs, death anxiety, death relief, death avoidance, life purpose, death concern, and supernatural beliefs. We investigated the factors associated with the FATCOD-Form B-J. Support of a mentor regarding end-of-life issues (beta = .19, P = .001), death avoidance domain of the DAI (beta = -.14, P = 0.03), life purpose domain of the DAI (beta = .23, P = .001), and rejection of traditional role limitations domain of the PNQ (beta = .51, P = .001) were selected as significant independent variables by multivariate analysis to evaluate nurses' positive attitudes toward caring for dying patients. Death anxiety domain of the DAI (beta = -.17, P = .02), patients' rights domain of the PNQ (beta =.46, P = .001), and rejection of traditional role limitations domain of the PNQ (beta = .34, P = .001) were selected as significant independent variables by multivariate analysis to evaluate the nurses' perception of patient-and family-centered care. In conclusion, nursing autonomy plays an important role in the attitudes of Japanese nurses who care for dying patients. Educational and administrative efforts to strengthen nursing autonomy are necessary.

Factors relating to terminally ill cancer patients' willingness to continue living at home during the early phase of home care after discharge from clinical cancer centers in Japan.

OBJECTIVE: To assess the willingness of Japanese terminally ill cancer patients to continue living at home during the early phase of home care after discharge from a Clinical Cancer Center (CCC) in Japan, and to identify factors relating to their willingness to continue living at home. METHODS: A cross-sectional questionnaire survey of a convenient sample of both Japanese terminally ill cancer patients and their caregivers (PFCs) was conducted (n = 294, effective response rate 25.0%). Questionnaires were mailed and medical records were accessed for 73 pairs of respondents, comprising one terminally ill cancer patient and one PFC. RESULTS: At about 10 days after discharge, 64 patients (88%) wished to continue living at home. A hierarchical logistic regression analysis was performed on the data. It was found that the fewer the medical treatments undergone (OR = 0.20, 95% CI: 0.05-0.72), the higher the patients' perception that their condition was consistent with care at home (OR = 2.77, 95% CI: 1.08-8.62) and with their functional well-being (OR = 1.45, 95% CI: 1.08-2.17). In addition, the higher the caregivers' satisfaction with life (OR = 2.37, 95% CI: 1.15-5.77), the more willing patients tended to be to continue living at home. SIGNIFICANT OF RESULTS: The willingness of Japanese terminally ill cancer patients to continue living at home appears to be affected by caregiver status. This indicates a need for discharging facilities to monitor the state of home assistance and to investigate the nature of assistance required for continuing home care.

The current status of palliative care teams in Japanese university hospitals: a nationwide questionnaire survey.

GOAL: Although the importance of the palliative care team (PCT) to university hospitals is widely accepted, the issues of palliative care at the national level have not been clarified. We conducted a nationwide survey of the current status of PCTs in all (123) Japanese university hospitals. MATERIALS AND METHODS: In 2003, 2004 and 2005, the authors conducted a self-reporting cross-sectional survey. Questionnaires were mailed to nursing directors and selected PCT members of all Japanese university hospitals. RESULTS: Of 123 hospitals in 2005, 99 (80%) returned the questionnaire; 33% used PCTs, and 11% used certified PCTs. Our findings include: annual number of patients treated by PCTs (83/70 +/- 64, mean/median +/- SD), daily number of patients treated by PCTs (12/11 +/- 14), and days of PCT care per patient (30/30 +/- 22). Certified PCTs treated more patients per year (p = 0.004) and more patients per day (p < 0.001) compared to noncertified PCTs. Over the 3-year period, the number of hospitals utilizing PCTs only slightly increased (2003: 27%, 2004: 29%, 2005: 33%), as did those using certified PCTs (2003: 3%, 2004: 9%, 2005: 11%). In 2005, the reasons for noncertification of PCTs included "lack of physicians who specialize in palliative care (82%)" and "lack of nurses who specialize in palliative care (56%)." CONCLUSIONS: The entire system of palliative care in Japanese university hospitals is currently insufficient. The lack of physicians and nurses who specialize in palliative care is a significant barrier, and therefore, the initiation of a formal training system for these health care professionals is a high priority issue.

Attitudes toward disease and prognosis disclosure and decision making for terminally ill patients in Japan, based on a nationwide random sampling survey of the general population and medical practitioners.

OBJECTIVE: Employing a nationwide cross-sectional survey, we investigated the Japanese general population's attitudes toward disease and prognosis disclosure and related factors. Furthermore, we investigated Japanese medical practitioners' attitudes toward disease and prognosis disclosure for patients and decision making. METHODS: A nationwide anonymous questionnaire survey was conducted. A total of 5000 individuals were randomly sampled from the general population and 3104 physicians and 6059 nurses were randomly sampled in Japan. RESULTS: Finally, 2422 people from the general population (response rate, 48%), 1577 physicians (51%), and 3361 nurses (56%) returned questionnaires. Among the general population, 73% of participants answered that they "want to know" about their disease and prognosis when in an incurable disease state. Ninety percent desired direct disclosure and 8% disclosure through their family. However, few medical practitioners answered "patient himself" (physician 3%, nurses 4%) as the person whom they would primarily notify about the disease and prognosis when in charge of a patient with an incurable disease. On the other hand, physicians answered "family" most frequently (59%), whereas nurses most commonly responded, "depends on patient's condition" (63%). SIGNIFICANCE OF RESEARCH: Several detailed analyses of factors associated with prognosis disclosure were conducted. Japanese physicians need to carefully communicate with the patients individually about whether direct disclosure or disclosure primarily to the family is preferred.

Nurses' perception of adequacy of care for leukemia patients with distress during the incurable phase and related factors.

Leukemia patients experience distress during the incurable phase of illness. Adequacy of care (i.e., extent to which care relieves the patients' suffering) was described from the nurses' viewpoint, and institutional factors related to adequacy of care were explored. A self-administered questionnaire was completed by 425 nurses working in 26 hematology wards. Nurses tended to rate the care as inadequate. In particular, care for social distress needs to be improved. Our findings suggest that communication among health professionals, utilization of hospital resources, and palliative care education for staff were important in palliative care for leukemia patients during the incurable phase.

Pain management and related factors in advanced cancer patients who initiated opioid therapy in an outpatient setting.

OBJECTIVE: The aim of this study was to clarify the state of pain management in Japanese patients with advanced cancer who initiated opioid therapy in an outpatient setting. METHODS: Interview surveys using questionnaires were conducted and medical records were reviewed. Pain relief was defined as >33% decrease in worst pain intensity score, and significance of early pain relief was investigated in terms of changing self-efficacy for activities of daily living (ADL). Factors related to early pain relief were also investigated. RESULTS: The study was conducted between June and December 2003, on 20 patients (13 women, 7 men; mean age, 59 years). Compared to score at initiation of opioid administration (Numerical Rating Scale, 8.3 +/- 1.3), pain relief was generally insufficient at 2 weeks (early pain relief ratio was only 42%). Patients with sufficient pain relief at 2 weeks displayed significant improvements in numerous ADL functions and symptom-coping efficacy (p = 0.037), confirming the importance of early pain relief. Early pain relief was associated with high frequency of hospital visits before opioid administration and absence of sudden excavation within the first 2 weeks. SIGNIFICANCE OF RESULTS: Result of this study indicated insufficient pain relief at an outpatients setting with advanced cancer patients. In the meantime, patients had who their pain decrease after 2 weeks also had improved ADL and self-efficacy at the same time. These findings suggest that to achieve early pain relief in an outpatient setting, clinical staff must assess pain earlier and inform patients of possible breakthrough pain following opioid administration and available treatments for such occurrences.

Factors associated with difficulties encountered by nurses in the care of terminally ill cancer patients in hospitals in Japan.

OBJECTIVE: To identify the factors associated with difficulties encountered by nurses working in general wards in hospitals in Japan. METHODS: Questionnaires including items regarding difficulties in providing care to terminally ill cancer patients, the existence of a mentor regarding end-of-life issues, awareness of end-of-life issues, and demographic factors were administered to 375 staff nurses working in general in-patient wards. Multivariate regression analyses were employed to investigate correlations between factors. RESULTS: Multivariate regression analysis revealed that the existence of a mentor for end-of-life issues was associated with fewer difficulties in all areas other than "Knowledge and skill of nurses." Clinical experience was inversely related to difficulties in "Communication with patients and families" and "Personal issues." Greater awareness of end-of-life issues was related to higher difficulties in most areas. SIGNIFICANCE OF RESULTS: The existence of a mentor was correlated with fewer difficulties in most areas. Support by a palliative care team might be effective in reducing difficulties experienced by nurses and in improving care for terminally ill cancer patients. Basic communication training undertaken sooner after registration might be also useful.

Existential concerns of terminally ill cancer patients receiving specialized palliative care in Japan.

BACKGROUND: Although alleviation of existential distress is important for terminally ill cancer patients, the concept of existential distress has not been fully understood. The aim of this study was to categorize existential concerns of Japanese terminally ill cancer patients and explore care strategies based on the categorizations. METHODS: A multicenter cross-sectional study in 88 terminally ill cancer patients receiving specialized inpatient palliative care was performed. The nurses explored patient existential concerns by asking several key questions, and recorded the answers that they considered typically described the patients' concerns. All statements recorded by the nurses were analyzed using content analysis methods. RESULTS: A total of 89 statements were subjected to analysis. The categories and their prevalence were: relationship-related concerns (22%; isolation, concerns about family preparation, conflicts in relationship), loss of control (16%; physical control, cognitive control, control over future), burden on others (4.5%), loss of continuity (10%; loss of role, loss of enjoyable activity, loss of being oneself), uncompleted life task (6.8%), hope/hopelessness (17%), and acceptance/preparation (25%). CONCLUSIONS: Existential concerns of Japanese terminally ill cancer patients were categorized as relationship-related concerns, loss of control, burden on others, loss of continuity, uncompleted life task, hope/hopelessness, and acceptance/preparation. These themes seemed to encompass universal human suffering beyond cultural differences, and this conceptualization may contribute to the development of effective therapeutic interventions to alleviate existential distress.

Reliability and validity of the Japanese version of the Support Team Assessment Schedule (STAS-J).

OBJECTIVE: The aim of this project was to develop an appropriate and valid instrument for assessment by medical professionals in Japanese palliative care settings. METHODS: We developed a Japanese version of the Support Team Assessment Schedule (STAS-J), using a back translation method, and tested its reliability and validity. In the reliability study, 16 nurses and a physician who work in a palliative care unit evaluated 10 hypothetical cases twice at 3-month intervals. For the validity study, external researchers interviewed 50 patients with matignancy and their families and compared the results with ratings by the nurses in the palliative care unit. RESULTS: Our results with hypothetical cases were: interrater reliability weighted kappa = 0.53-0.77 and intrarater reliability weighted kappa = 0.64-0.85. In the validity study comparing nurse evaluations and the results of interviews with patients and families, complete agreement was 36-70%, and close agreement (+/-1) was 74-100%. As a whole, weighted kappa were low: between -0.07 and 0.51. Our results were similar to those in the United Kingdom and Canada. SIGNIFICANCE OF RESULTS: Although this research was conducted under methodologically limited conditions, we concluded that the STAS-J is a reliable tool and its validity is acceptable. The STAS-J should become a valuable tool, not only for daily clinical use, but also for research.

Difficulties encountered by nurses in the care of terminally ill cancer patients in general hospitals in Japan.

The aim of this study was to investigate the difficulties encountered by nurses who have cared for terminally ill cancer patients at general hospitals. To collect data, a survey by questionnaire was self-administered. The respondents were 375 nurses and the response rate was 70.2%. Factor analysis was conducted on 80 items related to the difficulties encountered by nurses who have cared for terminally ill cancer patients to allow reasonable item reduction and to explore better domains. Two items were excluded and the results revealed eight underlying domains: 'Communication with patients and families', 'Knowledge and skill of nurses', 'Treatment and informed consent (IC)', 'Personal issues', 'Collaboration as a team including patients and families', 'Environment and system', 'Collaboration among nurses', and 'Near-death issues'. Cronbach's alpha coefficients for each domain ranged from 0.77 to 0.93. The results showed that nurses working at general hospitals have experienced a high degree of difficulty overall while caring for the dying, particularly with communication with patients and families. It was concluded that this study was useful in determining the specific areas where nursing education and research should be focused.

Distress of inpatients with terminal cancer in Japanese palliative care units: from the viewpoint of spirituality.

A qualitative study was conducted in an attempt to improve our understanding of the spiritual distress of terminally ill cancer patients in Japan. The subjects were inpatients at four approved palliative care units in Japan. The patients were interviewed and they expressed their own experiences in which spirituality was considered to be identifiable. Literal records of the interviews were analyzed using constant comparative analyses as proposed in relation to the grounded theory approach. The analysis included 11 inpatients and a variety of expressions of distress were obtained. After the conditions of the subjects were evaluated in order to search for common factors related to distress, consciousness of the gap between the patient's aspirations and the present situation were found to cause gap-induced distress. Distress was classified into three categories: distress due to the gap between the present situation and how the individual wanted to live, how the individual wished to die, and the individual's wish to maintain relations with others. The aspirations causing the gap were then interpreted from the viewpoint of spirituality as "anchors in life" for Japanese patients with terminal cancer. It was also revealed that in patients who possessed pictures of how they wished to die as their "anchors in life" and who were in a severe physical condition, distress increased and they became confused after their physical symptoms were relieved following admission to PCU.