厚生労働行政が推進する「がんと診断された時からの緩和ケア」のロジックモデル開発に関する研究

京都大学新制・課程博士博士(医学)甲第24285号医博第4901号新制||医||1061(附属図書館)京都大学大学院医学研究科医学専攻(主査)教授 髙折 晃史, 教授 小杉 眞司, 教授 佐藤 俊哉学位規則第4条第1項該当Doctor of Medical ScienceKyoto UniversityDFA

Prognosis Prediction Models and their Clinical Utility in Palliative Care

Prognosis prediction is a clinically relevant issue to facilitate optimal decision-making for both physicians and patients with cancer. Many previous studies revealed that prognosis prediction based on the physician’s intuition and/or clinical experience is inaccurate and often optimistic, which means that there is a tendency to overestimate patient survival in daily clinical practice. In recent decades, many efforts have been made to develop prognosis prediction models which aid physicians to make more accurate prognosis prediction. In this chapter, we review the representative prognosis prediction models in palliative care and related studies. In addition, we refer to several prognosis prediction models developed by unique methods (for instance, case-crossover design or machine learning). Finally, we focus on the possible clinical utility of prognosis prediction models. In fact, no previous studies have clearly demonstrated whether the application of such prognosis prediction models truly benefits patient care in daily clinical practice. Therefore, we will discuss how the application of prognosis prediction models could benefit patients under palliative care

Communication with Families in the Last Days of a Patient’s Life and Optimal Delivery of a Death Pronouncement

Communicating with family members is critically important when a severely ill patient is experiencing their last few days of life. However, healthcare professionals (HCPs) have limited opportunities to learn effective and respectful ways to perform this communication. In recent decades, significant effort has been put forth to identify the phenomena that indicate the last hours and days of life and the optimal methods to deliver a death pronouncement, which will potentially help HCPs communicate compassionately with family members throughout the dying process. In this chapter, we will review the literature regarding the phenomena that indicate the last hours and days of life and the death pronouncement. Furthermore, we will discuss clinical implications derived from those articles and future research perspectives

Difficulties Facing Junior Physicians and Solutions Toward Delivering End-of-Life Care for Patients with Cancer: A Nationwide Survey in Japan

Background: Junior physicians' perceived difficulty in end-of-life care of patients with cancer has not been structurally investigated; therefore, current challenges and solutions in this area remain unknown. Objectives: To identify some difficulties junior physicians face in delivering end-of-life care for patients with cancer and to clarify the support required to reduce these difficulties. Design: A nationwide survey was conducted in over 300 institutions selected randomly from 1037 clinical training hospitals in Japan. Participants: From each of these institutions, two resident physicians of postgraduate year (PGY) 1 or 2, two clinical fellows of PGY 3–5, and an attending physician were requested to respond to the survey. Measurements: The survey investigated issues regarding end-of-life care using the palliative care difficulties scale with two additional domains (“discussion about end-of-life care” and “death pronouncement”). Items related to potential solutions for alleviating the difficulties as well were investigated. Results: A total of 198 resident physicians, 134 clinical fellows, and 96 attending physicians responded to the survey (response rate: 33.0%, 22.3%, and 32.0%). The results revealed that junior physicians face difficulties within specific domains of end-of-life care. The most challenging domain comprised communication and end-of-life discussion with patients and family members, symptom alleviation, and death pronouncement. The most favored supportive measure for alleviating these difficulties was mentorship, rather than educational opportunities or resources regarding end-of-life care. Conclusion: The findings of this study reveal the need for further effort to enrich the mentorship and support systems for junior physicians delivering end-of-life care

A Need for Grounded Mental Health Interventions to Reduce Cancer Stigma

Nineteen million people were diagnosed with cancer, and almost ten million cancer deaths were recorded worldwide in 2020. The extent of cancer stigmatisation can be as prevalent as 80%. 24% of advanced cancer patients have been diagnosed with an anxiety or depressive disorder. The aim is to provide valuable plans of how it may be conceptually possible to form an intervention from a public health perspective. Preliminary observations identified a gap in research of a novel framework for cancer stigma. It is hoped this knowledge will build the foundations to develop an explanatory evidence-based theoretical model for improving the understanding, evaluation and planning of cancer stigma. Less than 6% of current studies are aimed at actually implementing interventions into practise. Using the Health Stigma and Discrimination Framework as an example, whilst drawing upon the independently existing theoretical work on stigma mechanisms and mental health intervention strategies, widening the field of exploration, through mixed method analysis concerning cancer stigma to address the barriers at person, provider, and societal levels, will expand upon the initial application of theories and suggest ways of countering the broader attitudes and beliefs. Guiding future evidence-based initiatives, designed to target and address the many levels at which, cancer stigma can derive. It holds the potential to map out public health directives and strategies, targeting such a multidimensional facet, intricately interwoven across a myriad of levels, being able to support a rationale as to the origins of stigma

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

Development of a novel COMPAssion focused online psyChoTherapy for bereaved informal caregivers: the COMPACT feasibility trial protocol

Introduction An easy-to-access and effective psychotherapy for bereaved informal caregivers has not been established. People with higher self-compassion status tend to have lower bereavement related grief, psychotherapy focused on self-compassion can be promising for this population. This study aimed to examine the feasibility of online self-compassion focused psychotherapy for bereaved informal caregivers.Method and analysis A total of 60 study participants will undergo an intervention programme comprising online sessions of 2 hours per week for five consecutive weeks and undertake postsession work. The intervention personnel will comprise psychologists who have received more than 10 hours of structured training. The primary endpoint will be assessed on the intervention completion rate, with secondary endpoints consisting of the Complicated Grief Questionnaire, Patient Health Questionnaire-9, Generalised Anxiety Disorder-7, Brief Resilience Scale and Self-Compassion Scale. Evaluations will be conducted preintervention, immediately after intervention, and 4 and 12 weeks after intervention.Ethics and dissemination This study has been reviewed and approved by the Ethics Committee of the Kyoto University Graduate School and Faculty of Medicine, Kyoto University Hospital, Japan (Approved ID: C1565). The results of this study will be disseminated through publication in a peer-reviewed journal and conference presentations.Trial registration number UMIN000048554

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