Winter Summit in Palliative Medicine – Heart and Spirit in Palliative Care

Dr Piotr Sobanski, Chair of the European Association for Palliative Care Task Force on Palliative Care for People with Heart Disease, reports on a recent conference held in Poland that could be the first step for a joint programme of care for people with heart disease.

Provision of palliative care for people with heart disease demands cooperation and dialogue between the specialities involved in the care. Nurses and physicians representing palliative care and cardiology, as well as representatives of non-medical professions such as ethicists, spiritual care specialists and physiotherapists, met recently in Bydgoszcz, Poland, at a workshop and conference: Winter Summit in Palliative Medicine.

Lecturers and conference participants at the Winter Summit in Palliative Medicine.

The leading topics were palliative care for people with heart failure and spiritual care in palliative care. The event was organised under the auspices of the European Association for Palliative Care (EAPC), the Heart Failure Association of the Polish Cardiac Society, the Polish Association for Spiritual Care in Medicine, and three Polish medical universities: Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Medical University in Gdansk, and Collegium Medicum of Jagiellonian University in Krakow.

During the first day, Professor Christina Puchalski from George Washington University, Washington, DC, US, delivered a workshop to a group of Polish teachers of spirituality for students in medical universities. The second part of the day was dedicated to palliative care for people with heart failure. The members of the EAPC Task Force on Palliative Care for People with Heart Failure present at the conference – Prof. Sarah Goodlin (US), Prof. Malgorzata Krajnik (Poland), Prof. Philip Larkin (Ireland), Prof. Manuel Martinez-Selles (Spain) and Dr Piotr Sobanski (Switzerland) – analysed the progress of current work and discussed upcoming activities of the task force. They strengthened the interprofessional and interdisciplinary group of experts participating in the workshop, working both in cardiology (representing the most prominent Polish heart failure centres) and palliative care. During this workshop, the needs for palliative care provision, possible structures of care and the conditions needed to organise the requisite care were discussed.

Declaration calls for improved access to palliative care for people with heart failure

At the end of the meeting, participants signed a declaration stressing the urgent need for the improvement of access to palliative care for people with heart failure. The declaration received the endorsement of Prof. Philip Larkin, the President of the EAPC, the Heart Failure Association of the Polish Cardiac Society, the Polish Society for Palliative Medicine, the Polish Association for Spiritual Care in Medicine, and the Polish Society of Internal Medicine. The process to seek EAPC endorsement for this declaration is now under way. The broad endorsement received by the declaration shows how strongly medical societies in Poland appreciate the urgent need to improve the provision of palliative care for people with heart failure.

During the summit, invited lecturers shared with conference participants their expertise in the field of spirituality, palliative care and cardiology. The lively discussions on the presented topics, and the interest the participants expressed in similar future congresses gathering together the palliative and cardiology communities, shows the importance of the dialogue between the disciplines to facilitate cooperation.

We are convinced that the conference has been the very first step in a new future for a joint programme of care for people with heart disease.

Links and resources

Posted in EAPC Taskforces/special projects, NATIONAL & INTERNATIONAL REPORTS | Tagged | 2 Comments

What’s to like in palliative care: Our most-viewed posts on the EAPC Blog in 2017

The European Association for Palliative Care (EAPC) Social Media Team are delighted to announce the most-viewed posts published on the EAPC Blog in the first half of 2017. 

Last year, we were delighted to welcome yet more great contributions to enrich the quality and diversity of the EAPC Blog. Our authors came from far and wide: from 26 countries across every continent. Thanks to them the EAPC Blog is highly regarded and valued as a tool to disseminate research findings, journal articles and personal perspectives on palliative and hospice care in Europe and beyond.

Our readers have helped us once again by indicating what they liked best in 2017. So, based on the viewing statistics for the first six months of 2017, we are delighted to announce below the winners of the Top Ten most-viewed posts. Viewing statistics are cumulative throughout the year; thus, to ensure that posts published in the last part of the year are not unfairly disadvantaged, we will publish the Top Ten most-viewed posts from July to December 2017 later this year.

Contributors to our most-viewed posts in 2017.  Top row, left to right: Richard Sawatzky, Suresh Kumar and Robin Cohen.
Bottom row, left to right: Shane Sinclair, Gerhild Becker and Eduardo Bruera.

Top Ten posts for the first half of 2017 – just click on the title to read the full post

After more than 20 years, the McGill Quality of Life Questionnaire is revised
Robin Cohen, Professor, McGill Departments of Oncology and Medicine and Staff Investigator, Lady Davis Research Institute, Montreal, and Richard Sawatzky, Canada Research Chair in Patient-Reported Outcomes and Associate Professor, School of Nursing, Trinity Western University, Canada.

Sympathy, empathy and compassion: Patients can tell the difference – Can you?
Shane Sinclair PhD, Associate Professor, Cancer Care Research Professorship, Faculty of Nursing, University of Calgary, Canada.

Caring for patients’ rooms and souls: How cleaning staff communicate and cope with seriously ill and dying patients
Professor Gerhild Becker, Chair of the Department of Palliative Care, University Medical Center Freiburg, Germany.

Have you prepared for your death?
Dr Suresh Kumar, Director of the WHO Collaborating Center for Community Participation in Palliative Care and Long Term Care & Technical Advisor, Institute of Palliative Medicine, Calicut, Kerala, India.

Impacto del mundo hispano hablante en cuidados paliativos: Una entrevista con Eduardo Bruera Impact of the Spanish-speaking World on Palliative Care: An interview with Eduardo Bruera
Eduardo Bruera, Professor and FT McGraw Chair in the Treatment of Cancer, The University of Texas MD Anderson Cancer Centre, USA.

 

Claudia Bausewein, Steffen Simon, Raymond Voltz and Miguel Julião.

Germany has developed National Guideline on Palliative Care for Patients with Incurable Cancer
Professor Claudia Bausewein Director of the Department of Palliative Medicine, Munich University Hospital, Dr. Steffen Simon, Consultant in Palliative Medicine and Internal Medicine, the Center of Palliative Medicine and Clinical Trials Unit, University Hospital Cologne, and Professor Raymond Voltz, Director of the Center of Palliative Medicine, the University Hospital Cologne, Germany.

Dignity and other lessons from Portuguese clinical research – An interview with Dr Miguel Julião winner of the EAPC Clinical Impact Award.
Dr Miguel Julião is a visiting professor to the School of Medicine, University of Minho, Braga, Portugal.

 

Scott A Murray, Sébastien Moine, Jordi Amblàs-Novellas and Kirsty Boyd.

Palliative care from diagnosis to death
Scott A Murray, Sébastien Moine, Jordi Amblàs-Novellas and Kirsty Boyd, members of the EAPC Primary Care Reference Group.

Rethinking care toward the end of life: Outcomes from a Salzburg Global Seminar
Julie Ling, CEO of the European Association for Palliative Care, and Sheila Payne, Emeritus Professor, International Observatory on End of Life Care, Lancaster University, UK.

Is dying well as important as living
Dr Jonathan Koffman, Reader in Palliative Care and MSc Course Director, Cicely Saunders Institute, King’s College London, UK.

Left to right: Julie Ling, Jonathan Koffman and Sheila Payne.

Publisher of European Journal of Palliative Care will award a prize to the winner
We are delighted to announce that Hayward Medical Communications, publisher of the European Journal of Palliative Care, has kindly offered a prize of a one-year online personal subscription to the overall winner of the most-viewed post in 2017. The overall winner will be announced in July.

Who reads the EAPC Blog?
We’re proud to have a truly global audience. Viewing statistics show a consistent geographical spread reinforcing that the EAPC’s role is recognised globally. In 2017, our followers came from a total of 184 countries: 53 per cent of views came from Europe; 21 per cent from North America; 10 per cent from Asia; eight per cent from Latin America; six per cent from Oceania, and two per cent from Africa.  

Who contributes to the EAPC Blog?
Our contributors are part of a huge band of talented bloggers: academics, health and social care professionals, healthcare economists, students, creative therapists, advocacy consultants and more. Last year, we published 118 blog posts  – 73 per cent came from Europe and 27 per cent from Africa, Asia, North America, Latin America, Australia and New Zealand.

Congratulations and thanks to the authors of the above posts, and to all those who have contributed to our blog during the past six years. Whether you have written a post, commented on it, ‘liked’ or shared, you have all played an important part in our story. Your involvement and support enable the EAPC to disseminate high-quality information and research and to play its part in the global hospice and palliative care community.

We really want, and value, your involvement – if you’d like to contribute in any way please follow the links below. 

Links

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Seven songs for a long life

Dr Erna Haraldsdottir, Director of Education and Research/Senior Lecturer at St Columba’s Hospice/Queen Margaret University, Edinburgh, Scotland, UK, describes a collaborative project between patients, staff and a documentary film-maker that is energising and meaningful for patients and teaches us about life and death. Erna’s post is the background to her longer article published in the November/December issue of the European Journal of Palliative Care.

Dr Erna Haraldsdottir

The film Seven Songs for a Long Life is a documentary film made in a hospice and a joint venture between Strathcarron Hospice in South West Scotland and The Scottish Documentary Institute in Edinburgh. The idea arose from my conversation with a documentary film-maker, Amy Hardie, as we discovered our shared interest in using creative methods to challenge the fear of death and dying and negative perceptions of hospices.

For myself, I was inspired by Cicely Saunders’ principle of facing death as it is embedded in her philosophy of palliative care.1 I agree strongly with her notion that facing death offers the possibility for human growth through heightening our senses of our own being. However, as a palliative care nurse I have also come across the challenge that is inherent in this open approach towards death due to fear of death. The philosophical perspective of Heidegger shows how death and dying becomes integrated into our existence as we learn how to go about being in the world and the fear becomes part of human condition.2 Based on the tension between fearing death and the possibility of positive outcomes in facing it, I wanted to explore if creative art could add an extra dimension to how we approach the stark reality of dying.

The poster for Seven Songs for a Long Life

With full participation from patients and staff in the hospice, Amy Hardie worked for about three years with us making the film. The project was first funded by Creative Scotland and later with additional funding from the BBC. Patients in the hospice were keen to participate and were excited by the prospect of making a documentary film that would tell their individual story. They were also motivated to challenge the perception of hospices as sad places and patients in a hospice being weak and vulnerable people because they were seriously ill and facing imminent death.

Through a collaborative approach between patients, staff and the film-maker we decided to tell a story of patients’ own lives and the life within the hospice in a semi-musical format. The whole experience was an overall positive one for patients, their families and those that worked at the hospice. Challenges were solved through good communication and shared decision-making. For some of the staff it was ‘mind-blowing’ to think that a documentary film could be made in a hospice with patients as key ‘actors’. However, as the filming progressed it became evident that using creative engagement was, in fact, energizing and meaningful for patients.

Through the act of both making the film and also in watching it the project has demonstrated how death and dying can be faced through the process. We were able to create a documentary film in a hospice which is informative, moving, life- affirming and also teaches us about life and death.

References and links

  1. Saunders C. (1965) The Last Stage of Life American Journal of Nursing, 65,3,70-75
  2. Heidegger M. (1962) Being and Time, Oxford, Blackwell.

Read the full article in the European Journal of Palliative Care

This post relates to Enhancing death and dying through documentary film-making in a hospice’ by Erna Haraldsdottir, published in the November/December 2017 edition of the European Journal of Palliative Care (EJPC) (vol. 24 (6).

If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog.

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Trauma, dying and somatic experiencing

Post-traumatic stress disorder (PTSD) is more common in the dying, their families and the bereaved than you might think. Dr Louis Heyse-Moore, a retired consultant in palliative medicine, counsellor and writer, explains how recent advances in the treatment of PTSD may be relevant to improving support for the dying.

Dr Louis Heyse-Moore

He was an old, white-haired, stocky, Polish man dying of cancer. He lapsed into an agitated confusion. He was back in his Second World War concentration camp. The other patients were his fellow inmates and we hospice staff were the guards. He saw a woman who had recently died. No surprise; it happened all the time in the camp. This was my first encounter as a young doctor with post-traumatic stress disorder (PTSD) and I had no idea what to do.

 

THREAT: Henri Rousseau – Surprised! (detail). National Gallery, London.

Years later, I trained in Somatic Experiencing (SE), a trauma therapy. It was a queue of Aha! moments. Our mammalian body holds the key. Our life feels threatened; our physiology reacts − adrenaline, a racing heart, muscles primed to fight or flee. If we can’t, our nervous system freezes.

DISSOCIATION: Noda Tetsuya – Diary Jul. 1st ’69. British Museum.

The stage is set for PTSD with its unholy mix of hyperarousal (flashbacks and nightmares) and hypoarousal (dissociation, depression and avoidant behaviour). How does this apply to palliative care?

In several ways:

  • The immediate Traumatic Stress (TS) of a terminal illness − gnawing pain or incurability. PTSD from previous medical input − a diagnosis of cancer, a big operation, time in the Intensive Care Unit or toxic chemotherapy.
  • Reactivation of past PTSD − war veterans (as above) or developmental trauma from child abuse (violence, neglect, rape).

I thought back over my time in palliative medicine. I recalled many patients. It was hidden in plain sight: PTSD. There was Barbara with her nightmare of a demon staring at her and her terror every time I mentioned cancer or dying. And Vivian, her colon cancer successfully resected, who couldn’t understand her depression until childhood memories of violence and sexual abuse surfaced. There were many more.

My colleagues said PTSD was rare in palliative care. In a study of clients referred to me by a hospice for counselling because of bereavement issues, I found 33 per cent had PTSD. (1) Alici et al (2) found 17 per cent of veterans had PTSD-related symptoms in their last month of life.

Why is this important? Because new understandings in neurophysiology have enabled PTSD therapy to leap forwards in recent years. Hospice patients could benefit from this. How? Tune into the body. Listen to its language: sensations, symptoms, emotions. PTSD affects the emotional and reptilian parts of our triune brain. Talking cognitively isn’t enough.

GROUNDING. The Buddha in earth touching posture (detail). Thailand. 15-16th C. British Museum.

I’d like to tell you more about SE: about Xanthe, troubled by memories of a sexual attack, whom I watched in awe as she discharged her frozen trauma energy by gently shaking and trembling and left the session with a ton weight lifted from her shoulders; about grounding, bringing a person out of a traumatic terror trance; about carefully titrating the amount of suffering worked with to prevent overwhelm; about resourcing to help stabilisation; about unfreezing and restoring body defences. I’d like to tell you more, but there isn’t space. So maybe try the resources below …

Oh, and by the way, Somatic Experiencing works, as a recent study from Israel shows. (3)

 

References

  1. Heyse-Moore, LH. ‘Is Psychological Trauma in Palliative Care Underdiagnosed and Undertreated?’ Abstract. 1st European Conference on Somatic Experiencing, Denmark. 2015.
  2. Alici, Y, Smith, MS, Hien, L et al. ‘Families’ Perceptions of Veterans’ Distress Due to Post-Traumatic Stress Disorder-Related Symptoms at the End of Life.’ Journal of Pain and Symptom Management. 2010: 39(3): 507-514.
  3. Brom, D, Stokar, Y, Lawi, C, et al. ‘Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study.’ Journal of Traumatic Stress. 2017; 30(3): 304-312.

Notes: Patient details have been anonymised.
All photos were taken by Louis Heyse-Moore.

Links and Resources

 

 

 

 

Posted in PSYCHO-SOCIAL ISSUES | Tagged | 4 Comments

Together We Can: Free resources to help you set up a volunteering support service for families of sick children

Lizzie Chambers, Development Director, Together for Short Lives, UK, rolled up her sleeves to volunteer in the home of a family caring for a child with a life-limiting condition. Lizzie explains how her organisation has developed the Family Support Volunteering project and the free tools you can access to help you set up your own service.

Lizzie Chambers

As professionals working in children’s palliative care, we all know the enormous stress that parents are under, not only in providing 24-hour complex care to their sick child, but also in keeping up with normal everyday chores – housework, ironing, gardening, shopping, supporting siblings with homework or play activities. And that’s without even contemplating the emotional strain and loneliness that often comes with having a very sick child. In this post, I will explain how we went about developing a special kind of volunteering to support families and how you can make use of our free online resources.

Over the past two years I have had the privilege of making a real connection with some of these families caring for a child with a life-limiting condition, by volunteering with them in their own home. It’s been an experience that has helped to deepen my understanding of the obstacles faced by families caring for a seriously ill child – even the minor, everyday ones – and hopefully my support has helped them overcome some of them.

This model of volunteering, called Family Support Volunteering (FSV), has been piloted and championed by the organisation I am a part of – Together for Short Lives, the UK charity for children’s palliative care.

Pilot sites included a children’s hospice, a social care charity for children with life-limiting illness and three community children’s palliative care teams. Through these diverse sites we were really looking to test how the FSV model could be embedded and potentially replicated within a range of different settings.

And it worked! The pilot organisations told us that using volunteers in this way to help families directly had enabled them to extend the range of support they could offer and had increased their organisational capacity. They felt that volunteers had enriched their organisations and brought new ideas and impetus to their cause.

Just as importantly, families themselves told us that they had benefited greatly from having volunteers support them in their home. One family told us:

“It has meant we can concentrate on what’s important to us as a family and have family time instead of doing chores or stressing about the amount we have to do.”

For my own part, I was visiting a family to help them with housework every week. It may not sound like much, but the mum told me that I was doing jobs that she’d just not been able to get to and how much peace of mind it gave her to know that her rooms were getting cleared out from top to bottom. With so much weighing on her mind already, I was delighted to be able to ease the load in any way I could, and for her clear cupboards and clean rooms were the key!

Our early evaluation of the pilot shows that there is huge merit in the family support volunteering approach, for families, volunteers and for organisations alike.

Together, we truly can make a difference for children and families – we’ve developed a comprehensive set of online resources, Together We Can, to provide everything that an organisation might need to set up their own Family Support Volunteering Service, including a comprehensive set of training modules for volunteers.

Available to download, free of charge, from Together for Short Lives’ website.

Links and resources

Posted in CHILDREN'S PALLIATIVE CARE, VOLUNTEERING IN PALLIATIVE CARE | Tagged , | Leave a comment

Psychological ideas in palliative care: Changing behaviour

Dr Jenny Strachan is a clinical psychologist at Marie Curie Hospice, Edinburgh, United Kingdom. Throughout the past year, Jenny has contributed a special series of articles to the European Journal of Palliative Care that aims to summarise some of the ‘big ideas’ in psychology and translate them into practical advice for those providing palliative care, and has also contributed to this blog. Here, she explains the background to her latest article in the November/December issue of the journal.

Dr Jenny Strachan

Recently, while I was writing the article about behaviour and behaviour change, which is now published in the European Journal of Palliative Care, I talked it through with a non-psychologist friend. ‘Isn’t that a bit grim?’ they asked. Intrigued, I asked them to explain. I discovered that they found the ideas of behaviourism ‘soulless’, and felt it ‘reduced’ human beings to ‘lab rats pushing buttons’.

I was somewhat taken aback that ideas that are the basis of my work attempting to understand and support people might be seen as in some way diminishing them.  Since I suspect that many readers may share this initial response, I would like to use this platform to make a counter-argument. In doing so, I’m going to draw heavily on a thought experiment proposed by one of my undergraduate lecturers. I regret that I have long since forgotten his name, but his analogy has stayed with me.

Imagine a very simple stimulus-response device: a light sensor attached to a beeper. If there is enough light to activate the sensor, it beeps. If there is not enough light, it doesn’t. If you place the device in a dark room, and you control the only light source, it’s very easy for you to predict whether the device will beep or not (this is the lab rat paradigm).

But what if you place the device on a window sill? Now whether it beeps or not depends on what time of day it is, and what the weather is like: a little harder to predict. Now imagine that you place the device on a television set, which is showing a news channel. Whether it beeps or not depends on what is happening in current affairs. It’s even harder now to predict whether this ‘very simple’ device will beep or not. Now imagine that the device is capable of taking in not one ‘bit’ of information at a time, but thousands. That it can spot patterns in the information. That it has preferences and can choose to give differing weight to different bits of information …

To think of human behaviour in terms of learned responses to stimuli is to ‘limit people’ only in as much as their exposure to different stimuli is limited. And if thinking in this way helps us to recognise that some people and groups are unfairly limited, so much the better.

Loss and suffering are a part of every life, never more so than when we, or those we love, approach death. Suffering, and being cared for are immensely powerful stimuli. Though vastly more complex than the light sensor, ours is still a learned response which depends on our past encounters with suffering and care. If the people who ‘cared for’ us in the past were good to us, our response to being cared for now is likely to be one of appreciation and co-operation. If they were abusive, shaming or neglectful our response is likely to be quite different. When we meet someone who responds to our ‘care’ with aggression, ridicule, dismissal, we must ask – what happened to them that they learned to do this? We must also recall that in different circumstances, with different experiences, they may have made different choices. So might we.

In that capacity to recognise our shared humanity, and resist judgement, are the roots of compassion. And that is the very opposite of grim.

Read the full article in the European Journey of Palliative Care
This post relates to Psychology series: Changing behaviour’ that is published in the November/December 2017 edition of the European Journal of Palliative Care (EJPC) (vol. 24 (6). (If necessary, click the ‘Browse the archive’ and choose 2017/November/December to read this article).

If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

Links

  • Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog.
Posted in EAPC-LINKED JOURNALS, European Journal of Palliative Care, PSYCHO-SOCIAL ISSUES | Tagged | 2 Comments

What are the main challenges facing palliative/end-of-life care today in relation to Japan’s ageing society

Mariko Masujima, Principal Investigator, and Zaiya Takahashi, Core Promoter, the Center of Excellence for End-of-Life Care at Chiba University, describe the present situation, policy and cultures about end-of-life care in Japan.

Mariko Masujima

Zaiya Takahashi

Japan is on the precipice of a demographic crisis. One person out of three will be more than 65 years old by 2030, entering a super-ageing society and high mortality era. The goal is to develop a coordinated research strategy that ensures all older Japanese people live out their final years in a comfortable and dignified manner with their wishes and aims fulfilled. In this post, we describe the main challenges facing nursing contributions to palliative and end-of-life care in Japan.

Current status of palliative care in Japan

Ninety-seven point eight (97.8) per cent of palliative care units (PCUs) are incorporated into hospitals; a typical PCU has approximately 20 beds with an average length of stay of 33.4 days. 1 PCUs are used not only for terminal care but for symptom control too, enabling some patients to return home. The number of PCUs in Japan increased after medical insurance started to reimburse 70-90 per cent of the expense in 1990, (394 PCUs and 8,068 beds in 2017 against 127 million of the current population). 2

The most common cause of death is cancer at 28.5 per cent, while other causes in total account for 32.4 per cent. 3 However, as PCUs have mostly accepted AIDS and cancer patients, only 3.1 per cent of the entire number of deaths occurs in PCUs.1 Therefore, palliative care for patients who have symptoms other than cancer is needed in inpatient PCUs.

Let’s talk about death and dying in Japanese culture

It is essential to promote talk about death and dying. Japanese people don’t commonly talk about it with each other. Miyashita et al.4 investigated consciousness about ‘good death’ among Japanese citizens and showed that they tended to avoid thinking about death, rather than deciding on their own wishes, and that they value the opinions of others/families rather than their own. It is necessary not only to push for self-determination but also to make a supportive network where we can think and talk about the end of life. We have just started attempting to promote these conversations among communities.

We retain a culture where we honour those who have passed away. It’s called ‘Obon’, which is a religious event held in the middle of August to commemorate the souls of ancestors. In this period, we often come back to our hometown, offer food to the Buddhist altar in the house, visit graves and feel somewhat intimate with our deceased family. Our culture could be regarded as a potential resource for promoting conversation about end of life.

It is a challenge for us to develop and implement systematic programmes to promote advance care planning for older Japanese people. Most of them wish to spend their end of life in relative comfort and without any symptoms. We have a responsibility to ease the blow of a top-heavy demographic by fostering cooperation between the public and the professionals who assist older people.

References

  1. Miyashita et al., The current state of palliative care in Japan as seen by data. Hospice, palliative care White Paper 2016. Seikaisha Ltd. 67-89. [Available from: https://www.hospat.org/assets/templates/hospat/pdf/hakusyo_2016/2016-all.pdf].
  2. Hospice Palliative Care Japan. [Available from: https://www.hpcj.org/what/pcu_sii.html].
  3. Ministry of Health, Labor, and Welfare. [Available from: http://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei16/index.html]
  4. Miyashita et al., Good death in cancer care: a nationwide quantitative study, Annals of Oncology 18: 1090–1097, 2007.

More about the authors

Mariko Masujima is an associate professor in Oncology Nursing, Graduate School of Nursing, Chiba University and Principal Investigator of the Center of Excellence for End of Life Care at Chiba University in Japan. Contact Mariko Masujima by email.
Zaiya Takahashi is a lecturer in the Interprofessional Education Research Center, Graduate School of Nursing, Chiba University, and Core Promoter of the Center of Excellence for End of Life Care at Chiba University in Japan. Contact Zaiya Takahashi by email.

Links

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