Work environmental factors associated with compassion satisfaction and end-of-life care quality among nurses in general wards, palliative care units, and home care settings: A cross-sectional survey.

BACKGROUND: Nurses providing end-of-life care experience not only burnout and compassion fatigue, but also positive effects such as compassion satisfaction. Nurses' compassion satisfaction was shown to be related to job satisfaction, work engagement, and nurse caring. Studies in emergency departments, intensive care units, oncology wards, and general wards have identified work environmental factors associated with nurses' compassion satisfaction, but no similar studies have been conducted in palliative care units or home care settings. It is also unknown whether work environmental factors associated with compassion satisfaction contribute to end-of-life care quality. OBJECTIVE: To explore work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality in three types of workplaces: general wards, palliative care units, and home care settings. DESIGN: A cross-sectional survey of nurses providing end-of-life care. SETTINGS: Sixteen general wards, 14 palliative care units, and 25 home-visit nursing agencies in Japan. PARTICIPANTS: There were 347 study participants: 95 nurses in general wards, 128 in palliative care units, and 124 in home care settings. METHODS: Compassion satisfaction was assessed using the Professional Quality of Life Scale, and end-of-life care quality was rated on a 4-point scale. Work environments were assessed using the Areas of Worklife Survey, which measures the fit between an individual and their work environment in six areas: workload, control, reward, community, fairness, and values. RESULTS: Compared to nurses in general wards and palliative care units, home care nurses scored statistically significantly higher on all work environmental factors except reward. Work environmental factors that were significantly positively associated with higher compassion satisfaction were values in general wards (ß = 0.335, P = 0.007), reward and workload in palliative care units (ß = 0.266, P = 0.009 and ß = 0.179, P = 0.035), and community and control in home care settings (ß = 0.325, P = 0.001 and ß = 0.261, P = 0.004). In addition, higher scores for workload in general wards (odds ratio = 5.321; 95 % confidence interval, 1.688-16.775) and for community in palliative units (odds ratio = 2.872; 95 % confidence interval, 1.161-7.102) were associated with higher end-of-life care quality. No associated work environmental factors were found in home care settings. CONCLUSIONS: Work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality varied between workplaces. These results may contribute to creating work environments that are appropriate for each workplace type to maintain both nurses' compassion satisfaction and end-of-life care quality. TWEETABLE ABSTRACT: Work environmental factors associated with nurses' compassion satisfaction and end-of-life care quality were identified in three workplaces.

Comparison of survival times of advanced cancer patients with palliative care at home and in hospital.

OBJECTIVES: One primary concern about receiving care at home is that survival might be shortened because the quality and quantity of treatment provided at home will be inferior to that given in the hospital. Although our previous study demonstrated a longer survival of those with home-based palliative care (PC), it lacked adjustment for some potential confounders including symptoms and treatments during the stay. We aimed to compare the survival times among advanced cancer patients receiving home-based and hospital-based PC with adjusting for symptoms and treatments. METHOD: We compared survival time of participants who enrolled two multicenter, prospective cohort studies of advanced cancer patients at 45-home-based PC services between July 2017 and December 2017, and at 23-hospital-based PC services between January 2017 and December 2017. We analyzed with stratification by the estimated survival of Days, Weeks, and Months, which were defined by modified Prognosis in Palliative care Study predictor models-A. We conducted a Cox regression analysis with adjusting for potential confounders including symptoms and treatments during the stay. RESULTS: A total of 2,998 patients were enrolled in both studies and 2,878 patients were analyzed; 988 patients receiving home-based PC and 1,890 receiving hospital-based PC. The survival time of patients receiving home-based PC was significantly longer than that of patients receiving hospital-based PC for the Days Prognosis (estimated median survival time: 10 days [95% CI 8.1-11.8] vs. 9 days [95% CI 8.3-10.4], p = 0.157), the Weeks prognosis (32 days [95% CI 28.9-35.4] vs. 22 days [95% CI 20.3-22.9], p < 0.001), and the Months Prognosis, (65 days [95% CI 58.2-73.2] vs. 32 days [95% CI 28.9-35.4], p < 0.001). CONCLUSION: In this cohort of advanced cancer patients with a Weeks or Months prognosis, those receiving home-based PC survived longer than those receiving hospital-based PC after adjusting for symptoms and treatments.

Rationale and design of a multicenter, double-blinded, randomized, placebo-controlled trial to investigate the effects of naldemedine on opioid-induced constipation for patients with cancer pain: A study protocol.

Background: It is unclear which laxatives are appropriate to prevent opioid-induced constipation (OIC). This study will evaluate whether prophylactic use of naldemedine prevents OIC in patients with cancer who start opioid administration. Methods: This study is a multicenter, double-blinded, randomized, placebo-controlled trial. Patients who meet the eligibility criteria and give consent will be randomly assigned to the naldemedine or placebo group. Both groups will take each drug once a day after breakfast for 14 days. Results: The primary endpoint is the proportion of patients with a Bowel Function Index of less than 28.8 on Day 14. The secondary endpoints include assessment scales of the impact of constipation on comprehensive quality of life. Conclusions: This is the first study proposed to assess the superiority of naldemedine over placebo in the prevention of OIC. If naldemedine is found to be effective in reducing OIC compared with the placebo, it will be regarded as a new standard for OIC prophylaxis at opioid initiation. Trial registration: jRCT identifier: jRCTs031200397. Registered March 5, 2021, https://rctportal.niph.go.jp/en/detail?trial_id=jRCTs031200397.

Changes in home visit utilization during the COVID-19 pandemic: a multicenter cross-sectional web-based survey.

OBJECTIVE: Home care is one of the essential community health care services; thus, identifying changes of home care utilization before and during the COVID-19 pandemic would be useful for researchers and policymaker to reconsider the home care system, the support needed for home care staff, and the collaborative system with hospitals in the COVID-19 era. We conducted a multicenter cross-sectional web-based anonymous survey of the directors of home visit facilities in Japan in August 2021. RESULTS: A total of 33 participants from 37 facilities responded to the survey. The number of patients dying at home and newly requested home visits increased during the COVID-19 pandemic (74.2%, 71.0%). One possible reason was the restricted visitation of inpatient facilities (93.5%). The underlying disease that the largest number of participants perceived as having increased compared with before the COVID-19 pandemic was cancer (51.6%). There were no significant differences in being in a rural area or the number of doctors in perceived changes in home visit utilization. Our study indicated that the director of home visit facilities thought the number of patients dying at home and newly requested home visits had increased compared with before the COVID-19 pandemic.

Association of a home-based nursing service during chemotherapy with the transfer to home care immediately after the last chemotherapy treatment in patients with advanced cancer.

BACKGROUND: The appropriate timing of introducing the home-based nursing service to patients with advanced cancer has not been clarified. This study conducted a retrospective cohort study to investigate the associations of the early utilization of the home-based nursing service during chemotherapy with the place of care immediately after the last chemotherapy treatment in patients with advanced cancer. METHODS: Among the patients referred to the palliative care team of the University of Tsukuba Hospital between January 2018 and December 2019, patients with advanced cancer undergoing chemotherapy or before the start of chemotherapy at referral were included. The study patients who utilized the home-based nursing service during chemotherapy were classified into the early utilization group. The primary endpoint was the place of care immediately after the last chemotherapy treatment. RESULTS: Of the 1154 patients referred to the palliative care team during the study period, 261 were eligible for this study. Of these patients, 15.3% of patients (n = 40) received the home-based nursing service during chemotherapy. The proportion of patients transferred to home care after the last chemotherapy treatment was 17.5% in the early utilization group and 7.2% in the control group. The multivariate analysis revealed that the early utilization of the home-based nursing service during chemotherapy was significantly associated with the transfer to home care (odds ratio = 3.077; 95% confidence interval, 1.113-8.502). CONCLUSION: The early utilization of the home-based nursing service during chemotherapy might be associated with the transfer to home care immediately after the last chemotherapy treatment.

Exploration of the impact of the COVID-19 pandemic on the mental health of home health care workers in Japan: a multicenter cross-sectional web-based survey.

BACKGROUND: The COVID-19 pandemic has caused home health care workers (home-HCWs) to experience anxiety. The mental health of home-HCWs and related factors during the COVID-19 pandemic have not been clarified; therefore, we aimed to investigate the status and associated factors of fear of COVID-19 infection, anxiety, and depression among home-HCWs in Japan. METHODS: We conducted a multicenter cross-sectional web-based anonymous survey of home-HCWs in August 2021, during the fifth wave of the pandemic in Japan. We surveyed members of facilities that provided home visit services during the COVID-19 pandemic. We measured the Japanese version of the Fear of COVID-19 scale (FCV-19S-J) and the Hospital Anxiety and Depression scale (HADS) as objective variables, and the Japanese version of the Assessment of Interprofessional Team Collaboration Scale-II (J-AITCS-II) as an explanatory variable. RESULTS: A total of 328 members of 37 facilities responded to the survey, and we ultimately analyzed 311 participants. The most frequent occupation was nurse (32.8%), followed by doctor (24.8%) and medical office staff (18.0%). The mean score of the FCV-19S-J was 16.5 ± 5.0 (7.0 - 31.0), and the prevalences of definitive anxiety and depression were 7.4% and 15.7%, respectively. Multivariate regression analysis revealed that the J-AITCS-II teamwork subscale was significantly negatively associated with FCV-19S-J, HADS-anxiety, and HADS-depression (ß = -0.171, p = 0.004; ß = -0.151, p = 0.012; ß = -0.225, p < 0.001, respectively). Medical office staff showed significant positive associations with FCV-19S-J and HADS-depression (ß = 0.219, p = 0.005; ß = 0.201, p = 0.009, respectively), and medical social workers with HADS-anxiety and HADS-depression (ß = -0.166, p = 0.011; ß = -0.214, p < 0.001, respectively) compared with doctors. The unmet support need for expert lectures on COVID-19 was significantly positively associated with FCV-19S-J (ß = 0.131, p = 0.048), and the unmet support need for support systems for psychological stress and emotional exhaustion was significantly positively associated with HADS-anxiety (ß = 0.141, p = 0.022). CONCLUSIONS: Fear of COVID-19 infection and depression of nurses, medical office staff, and other occupations was significantly higher than those of doctors. These findings suggest that non-physicians were more likely to be fearful and depressed during the COVID-19 pandemic; thus, it is necessary to tailor mental health support based on occupation in the home care setting.

Patient-perceived symptomatic benefits of olanzapine treatment for nausea and vomiting in patients with advanced cancer who received palliative care through consultation teams: a multicenter prospective observational study.

PURPOSE: To examine the safety, effectiveness, and patient-perceived benefit of treatment with olanzapine for nausea and vomiting (N/V) in patients with advanced cancer. METHODS: 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). RESULTS: 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<0.001). The proportion of patients who did not experience vomiting episodes in the last 24 h increased from 40-89%. Mean decrease in nausea NRS by patient-perceived treatment benefit were as follows: -0.8 for "none" (n=4, 5%); -2.8 for "slight" (n=17, 20%); -3.3 for "moderate" (n=14, 16%); -4.7 for "lots" (n=25, 29%); and -6.1 for "complete" (n=25, 29%; p-for-trend<0.001). The most prevalent AE was somnolence (n=15, 18%). CONCLUSION: Short-term and relatively low-dose olanzapine treatment was effective for multifactorial N/V. Confirmatory studies with longer observation periods are needed to clarify the duration of the effect and adverse events.

Effects of an Indomethacin Oral Spray on Pain Due to Oral Mucositis in Cancer Patients Treated With Radiotherapy and Chemotherapy: A Double-Blind, Randomized, Placebo-Controlled Trial (JORTC-PAL04).

CONTEXT: Oral mucositis (OM) pain due to anticancer chemo- and radiotherapy has a very negative impact on patient quality of life. However, no high-quality studies have been performed regarding the analgesic efficacy of indomethacin (IM) oral spray for OM pain. OBJECTIVES: This randomized, placebo-controlled, double-blind trial aimed to evaluate the analgesic efficacy of IM oral spray for OM pain due to anticancer chemo- and radiotherapy. METHODS: From July 2015 to December 2016, we enrolled adult cancer patients with OM pain that was due to anticancer chemo- or radiotherapy and was rated 4 or higher on Brief Pain Inventory (BPI) Item 5. Patients were randomly assigned in a 1:1 ratio to receive either IM oral spray or placebo. The primary endpoint was the change in the BPI Item 6 ("current pain") score from before to 30 minutes after treatment. Secondary endpoints were the areas under the curves of BPI Item 6 at 15, 60, 120, 180, and 240 minutes after treatment; five items related to meals and conversation from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire, Head and Neck Module 35; the Clinical Global Impressions-Improvement (CGI-I) scale; and adverse events. RESULTS: A total of 60 patients were assigned to receive IM oral spray (n = 33) or placebo spray (n = 27). The average change in the BPI item 6 score from before to 30 minutes after treatment was -1.85 (95% confidence interval: -2.37 to -1.32) in the IM spray group and -0.59 (-1.02 to -0.16) in the placebo group, indicating a significant difference (-1.26, -1.94 to -0.57, P < 0.01). The pain improvement persisted for 180 minutes. The intergroup differences in ability to drink liquids, ease in conversing, and CGI-I were all significant (P = 0.03, P = 0.02, and P < 0.01, respectively). No serious adverse events were reported. CONCLUSION: IM oral spray alleviated short-term OM pain due to anticancer chemo- and radiotherapy, and may reduce the difficulty in eating meals.

Prevalence of Extrapyramidal Symptoms in Cancer Patients Referred to Palliative Care: A Multicenter Observational Study (JORTC PAL12).

BACKGROUND: Neuroleptics are commonly used in palliative care settings. However, adverse events of neuroleptics, known as extrapyramidal symptoms (EPSs), might be overlooked in clinical practice. We conducted this study to explore the prevalence of EPSs in palliative care setting. METHODS: This multicenter, prospective, observational study included patients who 1) were referred to either a specialist palliative care team or a palliative care unit, 2) had a diagnosis of cancer, and 3) were ≥20 years of age. We investigated the prevalence of EPSs and medications used. The primary outcome was the overall Drug-Induced Extrapyramidal Symptom Scale (DIEPSS) score. RESULTS: Between November 2015 and October 2016, 149 patients from 5 centers in Japan were enrolled. The median age was 67 years (range: 21-88 years) and the study population included 81 men (54.4%). The cancer types included lung (55 patients, 36.9%), upper gastrointestinal tract (5, 3.3%), hepatobiliary (19, 12.8%); breast (12, 8.1%); head and neck (10, 6.7%), gynecologic (10, 6.7%), genitourinary (10, 6.7%), and others (28, 18.8%). The median Karnofsky performance status was 60 (20-100). Most patients (86.6%) did not experience delirium. Thirty-nine (26.2%) patients received one or more EPS-inducing medications. EPSs occurred in 4 (2.7%) patients with a cutoff score of 5 points for 5 parkinsonism items in DIEPSS. CONCLUSION: A lower frequency (<3%) of patients than expected in this population had EPSs. Therefore, we concluded that an interventional study is not feasible. However, medications that cause EPSs are often used in palliative care; therefore, a longitudinal study is warranted. TRIAL REGISTRATION: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) (UMIN000019810) on 16, November, 2015.

A combination of routine laboratory findings and vital signs can predict survival of advanced cancer patients without physician evaluation: a fractional polynomial model.

INTRODUCTION: There have been no reports about predicting survival of patients with advanced cancer constructed entirely with objective variables. We aimed to develop a prognostic model based on laboratory findings and vital signs using a fractional polynomial (FP) model. METHODS: A multicentre prospective cohort study was conducted at 58 specialist palliative care services in Japan from September 2012 to April 2014. Eligible patients were older than 20 years and had advanced cancer. We developed models for predicting 7-day, 14-day, 30-day, 56-day and 90-day survival by using the FP modelling method. RESULTS: Data from 1039 patients were analysed to develop each prognostic model (Objective Prognostic Index for advanced cancer [OPI-AC]). All models included the heart rate, urea and albumin, while some models included the respiratory rate, creatinine, C-reactive protein, lymphocyte count, neutrophil count, total bilirubin, lactate dehydrogenase and platelet/lymphocyte ratio. The area under the curve was 0.77, 0.81, 0.90, 0.90 and 0.92 for the 7-day, 14-day, 30-day, 56-day and 90-day model, respectively. The accuracy of the OPI-AC predicting 30-day, 56-day and 90-day survival was significantly higher than that of the Palliative Prognostic Score or the Prognosis in Palliative Care Study model, which are based on a combination of symptoms and physician estimation. CONCLUSION: We developed highly accurate prognostic indexes for predicting the survival of patients with advanced cancer from objective variables alone, which may be useful for end-of-life management. The FP modelling method could be promising for developing other prognostic models in future research.

[Hospital Formulations for Palliative Medicine].

　Palliative care had a role in maintaining and improving the patient's QOL. To optimize symptomatic management, that cannot be controlled using commercial formulations, in-house pharmaceutical preparations customized to meet an individual's clinical needs are sometimes administered. Despite a growing arsenal of oncology drugs, opioids, and other compounds, many elderly cancer patients have a wide spectrum of comorbid conditions that require the help of skilled pharmacists. Although drugs prepared in in-house pharmacies can be customized to the conditions of individual patients, their preparation is time- and resource-intensive, and their benefits sometimes do not outweigh the costs. In addition, it is often difficult to predict the required amount of a drug that will be dispensed to a very small number of patients via these custom formulations. However, we occasionally experience cases in which hospital formulations (HF) significantly alleviate symptoms and improve the QOL of patients with cancer. In fact, efforts to develop HF of palliative medications sometimes pave the way to new marketable products. In fact, collaborations between physicians and pharmacists have indeed produced new types of medications, which have been further developed into commercial painkillers by drug manufacturers. This article presents examples of HF used in clinical practice. It also discusses the future need for HF, taking note of the ongoing shift towards outpatient oncology care. Regarding the use of HF, we believe it is always important to ensure patient safety, to obtain informed consent, and to follow up.

Assessment of indomethacin oral spray for the treatment of oropharyngeal mucositis-induced pain during anticancer therapy.

PURPOSE: The efficacy and safety of indomethacin (IM) oral spray (OS) as a pain control therapy for oropharyngeal mucositis due to anticancer chemo- and radiotherapy were assessed in patients with head and neck carcinomas and haematological tumours. METHOD: We observed 35 patients (male/female, 20/15; 53 ± 17 years) with oropharyngeal mucositis who were treated with IM-OS preparation for pain relief at University of Tsukuba Hospital, Japan. Analgesic effects were assessed using the six-grade face scale for pain in 28 patients at the start of IM oral spray treatment. Systemic exposure was assessed by determining urinary excretions of IM in seven patients. RESULTS: Pain relief was achieved in 26 (93%) patients at 25 (5-60) min after applying the IM-OS preparation (15.6 ± 3.4 µg/kg) and analgesic effects were maintained for 120 (10-360) min. The pain was significantly decreased after using the spray (3.6 ± 0.7 vs. 2.4 ± 0.9, p < 0.01). Moreover, urinary IM excretion rates after applying the IM spray preparation were 1.8 ± 0.8% of the IM oral spray dose (130.5 ± 77.7 µg/kg/day), which was markedly lower than that following oral administration of IM (60%). No adverse events were observed following application of the spray. CONCLUSIONS: The present IM spray is an effective and safe preparation for pain relief and can be used as an alternative therapeutic option for oropharyngeal mucositis in cancer patients.

Clinical Implications of C-Reactive Protein as a Prognostic Marker in Advanced Cancer Patients in Palliative Care Settings.

CONTEXT: Plasma C-reactive protein (CRP) levels are elevated in patients with advanced cancer. OBJECTIVES: To investigate CRP as a prognostic marker in palliative settings. METHODS: This multicenter prospective cohort study comprised 2426 patients. Laboratory data were obtained at baseline, and all patients were followed until death or six months after their enrollment. A total of 1511 patients were eligible for the analyses. They were divided into four groups: low-CRP (CRP < 1 mg/dL), moderate-CRP (1 ≤ CRP <5 mg/dL), high-CRP (5 ≤ CRP <10 mg/dL), and very high-CRP (10 mg/dL ≤ CRP) groups. Survival was investigated by the Kaplan-Meier method with the log-rank test. The 30-, 60-, and 90-day mortality rates were tested by Chi-squared tests. Univariate- and multivariate-adjusted hazard ratios (HRs) and 95% CIs in each group were calculated using Cox proportional hazard models. RESULTS: Survival rate decreased and mortality rate increased with increasing CRP level. The differences in survival and 30-, 60-, and 90-day mortality rates among the groups were statistically significant (P < 0.001). Baseline CRP level was significantly associated with a higher risk of mortality after adjustment for age, gender, primary tumor site, metastasis, chemotherapy, Eastern Cooperative Oncology Group Performance Status, and setting of care (moderate-CRP: HR 1.47 [95% CI 1.24-1.73], high-CRP: HR 2.09 [95% CI 1.74-2.50], and very high-CRP: HR 2.55 [95% CI 2.13-3.05] vs. low-CRP). CONCLUSION: Clear dose-effect relationships between elevated CRP levels and prognoses indicate that CRP could be useful in predicting prognoses in patients with advanced cancer.

Effect of continuous deep sedation on survival in patients with advanced cancer (J-Proval): a propensity score-weighted analysis of a prospective cohort study.

BACKGROUND: Continuous deep sedation (CDS) before death is a form of palliative sedation therapy that has become a focus of strong debate, especially with respect to whether it shortens survival. We aimed to examine whether CDS shortens patient survival using the propensity score-weighting method, and to explore the effect of artificial hydration during CDS on survival. METHODS: This study was a secondary analysis of a large multicentre prospective cohort study that recruited and followed up patients between Sept 3, 2012, and April 30, 2014, from 58 palliative care institutions across Japan, including hospital palliative care settings, inpatient palliative care units, and home-based palliative care services. Adult patients (aged ≥ 20 years) with advanced cancer who received care through the participating palliative care services were eligible for this secondary analysis. Patients with missing data for outcome variables or who lived for more than 180 days were excluded. We compared survival after enrolment between patients who did and did not receive CDS. We used a propensity score-weighting method to control for patient characteristics, disease status, and symptom burden at enrolment. FINDINGS: Of 2426 enrolled patients with advanced cancer, we excluded 289 (12%) for living longer than 180 days and 310 (13%) with missing data, leaving an analysis population of 1827 patients. 269 (15%) of 1827 patients received CDS. Unweighted median survival was 27 days (95% CI 22-30) in the CDS group and 26 days (24-27) in the no CDS group (median difference -1 day [95% CI -5 to 4]; HR 0·92 [95% CI 0·81-1·05]; log-rank p=0·20). After propensity-score weighting, these values were 22 days (95% CI 21-24) and 26 days (24-27), respectively (median difference -1 day [95% CI -6 to 4]; HR 1·01 [95% CI 0·87-1·17]; log-rank p=0·91). Age (p(interaction)=0·67), sex (p(interaction)=0·26), performance status (p(interaction)=0·90), and volume of artificial hydration (p(interaction)=0·14) did not have an effect modification on the association between sedation and survival, although care setting did have a significant effect modification (p(interaction)=0·021). INTERPRETATION: CDS does not seem to be associated with a measurable shortening of life in patients with advanced cancer cared for by specialised palliative care services, and could be considered a viable option for palliative care in this setting. FUNDING: Japanese National Cancer Center Research and Development Fund.

Survival prediction for advanced cancer patients in the real world: A comparison of the Palliative Prognostic Score, Delirium-Palliative Prognostic Score, Palliative Prognostic Index and modified Prognosis in Palliative Care Study predictor model.

PURPOSE: The aim of this study was to investigate the feasibility and accuracy of the Palliative Prognostic Score (PaP score), Delirium-Palliative Prognostic Score (D-PaP score), Palliative Prognostic Index (PPI) and modified Prognosis in Palliative Care Study predictor model (PiPS model). PATIENTS AND METHODS: This multicentre prospective cohort study involved 58 palliative care services, including 19 hospital palliative care teams, 16 palliative care units and 23 home palliative care services, in Japan from September 2012 to April 2014. Analyses were performed involving four patient groups: those treated by palliative care teams, those in palliative care units, those at home and those receiving chemotherapy. RESULTS: We recruited 2426 participants, and 2361 patients were finally analysed. Risk groups based on these instruments successfully identified patients with different survival profiles in all groups. The feasibility of PPI and modified PiPS-A was more than 90% in all groups, followed by PaP and D-PaP scores; modified PiPS-B had the lowest feasibility. The accuracy of prognostic scores was ⩾69% in all groups and the difference was within 13%, while c-statistics were significantly lower with the PPI than PaP and D-PaP scores. CONCLUSION: The PaP score, D-PaP score, PPI and modified PiPS model provided distinct survival groups for patients in the three palliative care settings and those receiving chemotherapy. The PPI seems to be suitable for routine clinical use for situations where rough estimates of prognosis are sufficient and/or patients do not want invasive procedure. If clinicians can address more items, the modified PiPS-A would be a non-invasive alternative. In cases where blood samples are available or those requiring more accurate prediction, the PaP and D-PaP scores and modified PiPS-B would be more appropriate.

Surprise Questions for Survival Prediction in Patients With Advanced Cancer: A Multicenter Prospective Cohort Study.

BACKGROUND: Predicting the short-term survival in cancer patients is an important issue for patients, family, and oncologists. Although the prognostic accuracy of the surprise question has value in 1-year mortality for cancer patients, the prognostic value for short-term survival has not been formally assessed. The primary aim of the present study was to assess the prognostic value of the surprise question for 7-day and 30-day survival in patients with advanced cancer. PATIENTS AND METHODS: The present multicenter prospective cohort study was conducted in Japan from September 2012 through April 2014, involving 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services. RESULTS: We recruited 2,425 patients and included 2,361 for analysis: 912 from hospital-based palliative care teams, 895 from hospital palliative care units, and 554 from home-based palliative care services. The sensitivity, specificity, positive predictive value, and negative predictive value of the 7-day survival surprise question were 84.7% (95% confidence interval [CI], 80.7%-88.0%), 68.0% (95% CI, 67.3%-68.5%), 30.3% (95% CI, 28.9%-31.5%), and 96.4% (95% CI, 95.5%-97.2%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 30-day surprise question were 95.6% (95% CI, 94.4%-96.6%), 37.0% (95% CI, 35.9%-37.9%), 57.6% (95% CI, 56.8%-58.2%), and 90.4% (95% CI, 87.7%-92.6%), respectively. CONCLUSION: Surprise questions are useful for screening patients for short survival. However, the high false-positive rates do not allow clinicians to provide definitive prognosis prediction. IMPLICATIONS FOR PRACTICE: The findings of this study indicate that clinicians can screen patients for 7- or 30-day survival using surprise questions with 90% or more sensitivity. Clinicians cannot provide accurate prognosis estimation, and all patients will not always die within the defined periods. The screened patients can be regarded as the subjects to be prepared for approaching death, and proactive discussion would be useful for such patients.

Prospective clarification of the utility of the palliative prognostic index for patients with advanced cancer in the home care setting.

AIMS: This study aimed to prospectively clarify the accuracy of the Palliative Prognostic Index (PPI) for advanced cancer patients in home care settings. METHOD: The study included 66 advanced cancer patients who received home visiting services between April 2010 and June 2012, and who died at home or in the hospital. Using medical records from initial home visits, we prospectively calculated PPI scores along with sensitivity and specificity. RESULTS: For 3- and 6-week survival, prognostic prediction showed respective sensitivities of 60% and 70.6%, and specificities of 87.0% and 71.9%. CONCLUSION: The sensitivity of the PPI for advanced cancer patients in home care settings was lower than that reported for patients in palliative care units. Development of prognostic tools suitable for home care settings is needed.

Advance directives and do-not-resuscitate orders among patients with terminal cancer in palliative care units in Japan: a nationwide survey.

OBJECTIVE: To examine the current status of advance directives (ADs) and do-not-resuscitate (DNR) orders among patients with terminal cancer in palliative care units (PCUs) in Japan. METHODS: We conducted a retrospective chart review of the last 3 consecutive patients who died in 203 PCUs before November 30, 2010. RESULTS: The percentages of patients who had ADs during the final hospitalization for cardiopulmonary resuscitation, mechanical ventilation, intravenous fluid administration, tube feeding, antibiotic administration, and who had appointed a health care proxy were 47%, 46%, 42%, 19%, 18%, and 48%, respectively. Seventy-six percent of the patients had a DNR order. Of the patients with decision-making capacity, 68% were involved in the DNR decision. CONCLUSIONS: These findings may reflect positive changes in patients' attitudes toward ADs, in Japan.

Specialized palliative care services in Japan: a nationwide survey of resources and utilization by patients with cancer.

OBJECTIVE: The aim of this study was to investigate the availability and utilization of specialized palliative care services among patients with cancer in Japan. METHODS: We conducted a nationwide cross-sectional survey of 828 institutions predicted to provide specialized palliative care services. RESULTS: Responses were received from 751 institutions (response rate, 91%); of these, 541 had specialized palliative care services. Adding the census data of palliative care units, the total estimated number of institutions with specialized palliative care services was 659. Of all the patients with cancer who died in the period from April 2009 to May 2010 in Japan, the estimated proportion who utilized specialized palliative care services was 24%. CONCLUSIONS: Usage of specialized palliative care services in Japan have increased explosively in the past decade.