Incidence and associated factors of sudden unexpected death in advanced cancer patients: A multicenter prospective cohort study

[Purpose] A sudden unexpected death has significant negative impacts on patients, family caregivers, and medical staff in hospice/palliative care. This study aimed to clarify the incidence and associated factors of sudden unexpected death according to four definitions in advanced cancer patients. [Methods] We performed a prospective cohort study in 23 inpatient hospices/palliative care units in Japan. Advanced cancer patients aged ≥18 years who were admitted to inpatient hospices/palliative care units were included. The incidence and associated factors of sudden unexpected death were evaluated in all enrolled patients according to four definitions: (a) rapid decline death, defined as a sudden death preceded by functional decline over 1–2 days; (b) surprise death, defined if the primary responsible palliative care physician answered “yes” to the question, “Were you surprised by the timing of the death?”; (c) unexpected death, defined as a death that occurred earlier than the physicians had anticipated; and (d) performance status (PS)-defined sudden death, defined as a death that occurred within 1 week of functional status assessment with an Australia-modified Karnofsky PS ≥50. [Results] Among 1896 patients, the incidence of rapid decline death was the highest (30-day cumulative incidence: 16.8%, 95% CI: 14.8–19.0%), followed by surprise death (9.6%, 8.1–11.4%), unexpected death (9.0%, 7.5–10.8%), and PS-defined sudden death (6.4%, 5.2–8.0%). Male sex, liver metastasis, dyspnea, malignant skin lesion, and fluid retention were significantly associated with the occurrence of sudden unexpected death. [Conclusion] Sudden unexpected death is not uncommon even in inpatient hospices/palliative care units, with range of 6.4–16.8% according to the different definitions

TESS OF THE D\u27URBERVILLES TESS ノ シンタイ イシキ ノ ヘンセン ト ヒユテキ シカク ビョウシャ オカダ アキコ キョウジュ タイニン キネンゴウ

Tess of the d\u27Urbervilles is undoubtedly the most famous novel of Thomas Hardy\u27s numerous works. The novel\u27s shocking representations of woman\u27s sexuality made it controversial in Victorian society, which, in turn, made the author more well-known. Through its fierce representations of sexuality, however, the novel revealed problems in Victorian culture surrounding morality, sexuality and marriage. In Victorian culture, women were confined by strict codes of etiquette regarding proper manners, clothing and behavior. Those concerned with sexuality, especially, were most serious. Women were thought of as faithful and asexual beings like pure angels. In the novel, Hardy challenged this view of woman by attempting to depict the truth. In the strictness of Victorian society, however, strict censorship in publishing world made it quite difficult to honestly represent women\u27s sexuality. Hardy, therefore, chose to use metaphorical representations to depict it indirectly. Tess of the d\u27Urbervilles is filled with metaphorical representations. Representations of light and darkness, particularly, which surround the body of the main character, hold the most important function in the novel. Employing chiaroscuro Hardy visually emphasizes the bodily presence of characters. Meanwhile, he also uses the technique to depicts their emotions about corporeal problems. Through such characteristic expressions, the complex consciousness on the body and sexuality is revealed to readers. The novel\u27s narrative lies in revealing the life of Tess, the history of her love affairs, and growing awareness of her sexuality. She was a woman loved by two very different men, Alec D\u27Urberville and Angel Clare. Her relationships with the two men awaken her to both the sexuality within her body, something she had never known before, and awareness of the guilt surrounding that awakening. The light and darkness is often used to express her suffering and conflict connected with sexuality. Alec is portrayed as Tess\u27s seducer. He holds strong sexual desire for her physically, and through his strong lust, tries to dominate her. As ways of showing his desire, Alec stimulates her physically using means such as continually touching her body as well as teaching her to whistle. With such curious practices and experiences, her sexual sense of pleasure is awakened, visually emphasized with shining light. Tess is perplexed regarding such unknown bodily enjoyment. Feeling such pleasure, she suffers, bound by a moral consciousness of having violated the something inviolable. Conflicted, she also anxiously desires to be dominated by such pleasure Alec offers. Inevitably this anxiety brings her consciousness to a crisis. To defend her soul from the crisis Alec has brought, she sinks her soul into an abyss of darkness, secluding her consciousness from her body. In this way, she attempts to resist Alec\u27s lust. Whenever he expresses his desire for her, by forcing her awareness away from her from body, she strives to protect the peace within herself. Such movement of consciousness is represented quite visually, especially in the scene where Alec forces himself upon her. Dramatic scenes such as this, which surround her, are darkened, when her soul is separated from her body. The darkness acts to express the absence of her soul in her body, and her will to resist against Alec\u27s domination. Through her experience of life with Alec, she comes to know the forbidden pleasure of her sexual self and an awareness of guilt surrounding such feelings. She suffers through this conflict on sexuality. After the parting from Alec, she meets Angel Clare, a man of very different qualities compared to Alec. Angel is intellectual and philosophical, and Tess gradually becomes more fascinated with him. Her soul feels sympathy for his soul. But Angel also attempts to dominate her, not by bodily lust but by his ideas of womanhood. Though he is welleducated man, his mind is confined by a quite conservative view of women. In this the Victorian view, he idealizes Tess as a pure angelic woman. His desire for her reflects to the scenery of the place where they rendezvous. She is surrounded by misty twilight, the somber space making her appear like a goddess. For Tess, who now has experienced the corporeal pleasure and its sins, this was quite unacceptable. She, therefore, refuses to be the divine female. Her refusal is also represented visually. When she denies Angel\u27s idealized image of herself, her bodily presence is emphasized by light representing her refusal. But she cannot help being attracted to Angel. Aware of her guilt, she feels lust for him. The sexual urge, which Alec awakened in her, pushes her on. She secretly longs for bodily contacts with Angel. Like Tess, Angel is also gradually fascinated by her corporeal beauty. Through such bodily desires they become attracted to each other. As with Alec, the lust between Tess and Angel is also represented by shining light. Light emphasizes the presence of their bodies and their beauty, implying the secret pleasure between them. For both Tess, however, who experienced both love and violation with Alec, and Angel, with his conservative view of women, the pleasure they share inevitably makes them conscious of guilty and suffering. After Tess confesses her secret past, the conflict and suffering over sexuality become decisive. For Angel, Tess\u27s body, which experienced such raw sexuality with Alec, becomes an object of fear. Her sexuality, overwhelming his mind, is expressed by visually by light. Ironically, Tess\u27s experience with Alec becomes the cause of Angel\u27s mental anguish. After this incident, Tess is filled with a growing desire to take responsibility by destroying her sexual self to make Angel suffer. She unconsciously longs for death, but cannot kill herself because she also knows how much she enjoys sexual pleasure. The pleasure prevent her from leaving the body easily, filling her with ambivalent emotions about her sexual body. As a way of resolving this crisis within, Tess idealizes the darkness as a place of rest. The darkness diminishes her bodily senses to a minimum, bringing her an experience of pseudodeath, a temporal rest of mind. The darkness becomes a symbolic expression of her rest and liberation from the body. The last scene expresses this well, where Stonehenge is shrouded in darkness as Angel and Tess meet for their last rendezvous. The darkness symbolizes her rest and liberation, but is quite transient. As time passes, light inevitably intrudes into the darkened space, making her body visible and aware of its presence. Even in the last scene, the light flows into the darkness. Her rest is inevitably broken, indicating the cruel fact that as long as she lives, she cannot escape from the presence of her sexual body. Throughout the history of her love affairs with the two men, the use of chiaroscuro indicates Tess\u27s conflict of mind and emotion over her sexuality. Her sexual sense or desire is metaphorically represented with light. The light strengthens the presence of her sexual body and reveals her hidden sexual desire for men. But feeling such pleasure, Tess suffers a guilty conscience. She feels ambivalent emotions concerning her body. To liberate herself from such suffering, she seeks to destroy her body believing it to be the cause of her distress. As a way to destroy her physical self, she longs for darkness. The darkness temporarily makes her body invisible and diminishes her bodily senses, allowing her to briefly experience bodily liberation and oblivion. Consequently, this becomes a metaphor for her mental rest. Through his expression of visible light and darkness, Hardy expresses visually for reader the suffering that women endured under the strict moral code of the Victorian era. His novel also spotlights the absurdity and double standard of Victorian oppression of sexuality on women

THE WOODLANDERS メイアン ヨクボウ シセン

The Woodlanders was published in 1887. The novel is one of Thomas Hardy\u27s famous works along with Tess of the D\u27urbervilles and Jude the Obscure. The main theme of the novel concerns the tragedy of men and women in rural Wessex. All Hardy\u27s novels contain many detailed expressions ; not only detailed representations of men and women but also detailed descriptions of those characters in their natural setting; especially, the first appearance of characters is closely linked with the description of nature where characters metaphorically disclose their hidden emotions within the natural scene. Among the descriptions of nature in the novel, the most impressive is chiaroscuro, the contrast between light and dark, particularly, noteworthy. In all his works, the light and dark reflects the emotion of his characters. For instance, whenever the characters are depressed, the darkness is inserted around the characters. Conversely, whenever the characters are in high spirits, a light imagery is used. This contrast is one of important keys for understanding his novels. One of the conspicuous examples in The Woodlanders is the expression of the psychological contrast between two women: Marty South and Grace Melbury. This paper chiefly considers the interrelation of the chiaroscuro of the two women. Through the light and the dark, their consciousness and unconsciousness against men are represented. For Marty South, the light means man\u27s desire for her body. This is well represented when the merchant Percomb, who wants to buy her hair for a wig, looks at her in her cottage. The light emphasizes her physical beauty, especially her hair. But it also implies his focused gaze on her hair. The light shows his desire to get the beautiful hair for his own commercial purposes. However, she does not want to sell it, because she knew that the hair would be used for Mrs. Charmond\u27s wig to draw man\u27s attention to her. Marty is disgusted to be an object of man\u27s desire. (But the reason why she kept her hair is very paradoxical. In fact, Marty kept it for Giles Winterborne whom she loved, so subconsciously she wanted to be the object of man\u27s desire albeit one man in particular. However, after she cut off her hair, the hair served to attract men\u27s eye as a possible wig for Mrs. Charmond. Marty inevitably attracts men\u27s desire.) However, through cutting her hair herself she undergoes a form of metaphorical castration, which reveals her attempt to get away from being a commercial or sex object. After this incident, Marty avoids to be thrown by the light, since, to her, all light is a metaphorical representation of men\u27s eyes, not only Percomb\u27s. As a result, she hides herself in the darkness. The darkness shutters her off from men; in the last scene, when she stands before the grave of Giles, her appearance is hidden in mist and darkness. The darkness here symbolizes her rejection of being an object of men\u27s desire. For Grace, the chiaroscuro is very different from Marty. She was born in Hintock, but following her father\u27s will was educated in the urban culture. She is close to being an outsider as far as regional culture is concerned. In addition, her personality is very passive toward men (her father and husband). Therefore, her attitude toward light and dark is different from that of Marty. For instance, when she returns to her home, she meets her father Melbury in the light, which implies his joy to see his daughter as a refined lady. The light also represents his desire for her to be such a refined lady. Grace is also aware of his eye and desire. She does not reject the desire of men that the light represents : rather, she bends to it rather than rejecting. For example, she dresses herself to attract men surrounded by the illumination of candles. Her illuminated appearance also symbolizes a womanhood that men desire. Grace subconsciously tends to become the type of woman that men want. She is not disgusted to be the object of men\u27s desire as Marty is. And for Grace, the light frequently appears as a representation of male superiority. For instance, in the night when she came back to her native countryside from the school, she sees at a mystic light, which is revealed from Fitzpiers\u27s house. By this light Grace imagines his superior knowledge and power, which enhances her interest in him. As a result they eventually marry. And, when she has a fever, Fitzpiers helps her with medicine. The bottle of medicine reveals an image of light with opaline hue. The light has become a symbolic phenomenon that represents superiority over her. Grace accepts his superiority and she adjusts herself to a world that is not friendly toward women. The light represents men\u27s desire and her obedience. Thus light and darkness represent two ways of woman\u27s life in a men\u27s world. Marty rejects men\u27s desire. Conversely, Grace passively accepts their desire and vigilance. But neither succeeds to obtain a happy marriage. Marty cannot unite with Giles, because she feels that Giles should marry Grace according to the promise of Grace\u27s father, and has spoiled her beauty by cutting her hair. Grace marries Fitzpiers following the will of her father. However, Fitzpiers is not capable of being the superior man that she expected. Consequently she also fails to achieve a happy marriage. The unfortunate marriage is one of the important themes in Hardy\u27s works. Hardy seemed to portray freedoms even within an oppressive society. Through the impressive visual representation of woman\u27s misfortune, he accuses contemporary society where men\u27s one-sided oppression dominates women as defective and evil. Through the achievement of this novel, he appears to continue to investigate the problem till the achievement of Tess of D\u27urbervilles in which he represents fiercely oppressed women and the sexual tyranny of men

Development and validation of questionnaires for eating‐related distress among advanced cancer patients and families

Background: Eating‐related distress (ERD) is one type of psychosocial distress among advanced cancer patients and family caregivers. Its alleviation is a key issue in palliative care; however, there is no validated tool for measuring ERD. Methods: The purpose of this study was to validate tools for evaluating ERD among patients and family caregivers. The study consisted of a development and validation/retest phase. In the development phase, we made preliminary questionnaires for patients and family caregivers. After face validity and content validity, we performed an exploratory factor analysis and discussed the final adoption of items. In the validation/retest phase, we examined factor validity with an exploratory factor analysis. We calculated Pearson's correlation coefficients between the questionnaire for patients, the Functional Assessment of Anorexia/Cachexia Therapy Anorexia Cachexia Subscale (FAACT ACS) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire‐Cachexia 24 (EORTC QLQ‐CAX24) and Pearson's correlation coefficients between the questionnaire for family caregivers and the Caregiver Quality of Life Index‐Cancer (CQOLC) for concurrent validity. We calculated Cronbach's alpha coefficients (Cronbach's alpha) and intraclass correlation coefficients (ICCs) for internal consistency and test–retest reliability. We performed the Mann–Whitney U test between the questionnaires and cancer cachexia based on criteria from the international consensus for known‐group validity. Results: In the development phase, 162 pairs of patients and family caregivers were asked to participate, and 144 patients and 106 family caregivers responded. In the validation/retest phase, 333 pairs of patients and family caregivers were asked to participate, and 234 patients and 152 family caregivers responded. Overall, 183 patients and 112 family caregivers did the retest. Seven conceptual groups were extracted for the ERD among patients and family caregivers, respectively. Patient factors 1–7 correlated with FAACT ACS (r = −0.63, −0.43, −0.55, −0.40, −0.38, −0.54, −0.38, respectively) and EORTC QLQ‐CAX24 (r = 0.58, 0.40, 0.60, 0.49, 0.38, 0.59, 0.42, respectively). Family factors 1–7 correlated with CQOLC (r = −0.34, −0.30, −0.37, −0.37, −0.46, −0.42, −0.40, respectively). The values of Cronbach's alpha and ICC of each factor and all factors of patients ranged from 0.84 to 0.96 and 0.67 to 0.83, respectively. Those of each factor and all factors of family caregivers ranged from 0.84 to 0.96 and 0.63 to 0.84, respectively. The cachexia group of patients had significantly higher scores than the non‐cachexia group for each factor and all factors. Conclusions: Newly developed tools for measuring ERD experienced by advanced cancer patients and family caregivers have been validated