Palliative Care
Introduction
The Palliative Care Service of the National Cancer Center Hospital East (NCCHE) is composed of three divisions, the palliative care unit (PCU) for inpatients (25 beds), the clinic for out patients and the telephone consultation service. Many patients have visited the clinic up to the present, and clinical demand is rapidly increasing.
The Palliative Care Service has set up the following scheme consisting of six programs: inpatient care, home care, consultation, research, volunteer, education and training. The goal of the six programs is the highest possible quality of life for patients and family. Palliative care affirms life and regards dying as a normal process. Palliative care emphasizes relief of pain and other distressing symptoms, integrates the physical, psychological and spiritual aspects of patient care, offers a support system to help the patient live as actively as possible till death and a support system to help the family cope during the patient's illness and the bereavement period.
Routine Activities
Inpatient Care
A total of 300 patients (151 males, 149 females) have been admitted at the palliative care unit from January to December 1998. According to a survey of these patients, 179 (60%) were referred from the other clinical departments of NCCHE, 32 (11%) from the National Cancer Center Hospital, Tokyo, and 89 (29%) from medical institutions other than the above two. As with their primary illness, lung cancer was the most frequent (103 patients: 34%), followed by colorectal cancers (46 patients: 15%), breast cancers (46 patients: 15%) and pancreatic cancers (23 patients: 8%). The most common reason for patient admission was pain, and other reasons were fatigue, loss of appetite, dyspnea, nausea and vomiting. The number of deceased patients was 211 in 1998. Annual changes in the number of inpatients in the PCU in the past three years are shown in the first Table.
Outpatient Clinic
A patient who hopes to receive Palliative Care Service must first register and obtain an application from the outpatient clinic to confirm informed consent. Registration of 333 patients (192 males, 141 females) was completed at the palliative care clinic in 1998. Of the 333 patients, 152 (46%) had been previously treated with surgery, 161 (48%) with chemotherapy, and 128 (38%) with radiotherapy. In other words, 63 (19%) were untreated and the remaining 1 was unclear. Of the 333 patients, after the first consultation, 186 (62%) had been registered on the outpatient list, 114 (38%) had been put on the waiting list for admission. Their primary illness shown in the second Table. Most of the cases were in advanced stages, i.e. 6% were in Stage III, 74% in Stage IV and 15% were recurrent disease.
Telephone Consultation Service
A clinical psychologist is in charge of the telephone consultation service; telephone consultation by clinical psychologist accounts for 443 cases in 1998. The details vary widely and include consultation for information about the PCU, patient care and cancer treatment. Approximately 80% of the clients are members of patients' families seeking counseling to relieve the mental anguish of the family. We started another telephone consultation service by a specialist nurse in October in 1994. This service for patients at home has proved very effective for obtaining information on the patient's condition and providing advice to families. The objective of the telephone consultation service is to relieve patients and their families of anxiety and to support domiciliary care. A specialist nurse regularly calls a patient at home on Monday or Wednesday. In 1998, 92 patients used the service for 5 to 30 minutes once or twice a week. Consultation is concernd with the patient's condition, symptoms, anxiety, and other problems of daily life. The service is also used to make an appointment with a doctor when necessary, to decide appropriate timing of hospitalization, and to give psychological support to those who take care of the patient.
New Developments
In 1998, we undertook two clinical research projects for the treatment of PCU patients. One was a phase I/II study of octreotide for abating nausea and vomiting caused by an obstructive condition of the gastrointestinal tract. Up to the present, 15 patients entered into this study, which is ongoing. The other project was a study of intravenous hydration for terminal patients. Dehydration in terminally ill patients is a common condition and in an active oncology unit is often treated by intravenous hydration. On the other hand, palliative care physicians have often argued against this approch, and as a consequence, patients treated by palliative care professinals usually receive little parenteral fluids. Sixty-three patients were enrolled in this study, which is ongoing.
Two cooperative projects were started with the Division of Psycho-Oncology and the Division of Thoracic Oncology. The first one is a study on malaise and fatigue in cancer patients.One hundred twenty-four patients were registered in this study from October to December 1997. The second is a study on nebulized morphine for patients with dyspnea. Fifteen patients with dyspnea were given 20 mg of morphine dissolved in 5 ml of normal saline through an ultranebulizer.The subjective effects were evaluated using a Visual Analog Scale (VAS) immediately before and 60 minutes after inhalation. In 8 of 15 patients, subjective dyspnea was impaired with the result that VAS was decreased more than 10%. Our preliminary data confirmed the feasibility of nebulized morphine use in dyspnea patients and suggested its possible usefulness. A randomized controlled study is warranted to better evaluate the clinical benefits of nebulized morphine.
Statistics
| 1996 | 1997 | 1998 | |
| Hospitalized | 294 | 281 | 300 |
| Discharged | 235 | 263 | 267 |
| Dead | 184 | 199 | 211 |
| Alive | 51 | 64 | 56 |
| Diagnosis | No. of pts | % |
| Lung cancer | 122 | 37 |
| Colorectal cancer | 38 | 11 |
| Gastric cancer | 23 | 7 |
| Pancreatic cancer | 23 | 7 |
| Head and neck cancer | 23 | 7 |
| Breast cancer | 22 | 7 |
| Others | 82 | 24 |
(Y. Shima)
