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12097 Background: The integration of palliative care into standard cancer treatment during the early phase of the disease can improve cancer patients’ quality of life (QOL). The current study examined the effectiveness of a nurse-led, screening-triggered, early specialized palliative care intervention program for patients (pts) with advanced lung cancer. Methods: Pts with advanced lung cancer undergoing initial chemotherapy were randomized (1:1) to the intervention group (IG) or the usual care group (UG) between January 2017 and September 2019. The intervention, which was triggered using by a brief, self-administered screening tool, comprised comprehensive need assessments, counseling, and service coordination by advanced-leveled nurses. The primary endpoint was the change from baseline of the Functional Assessment of Cancer Therapy -Lung Trial Outcome Index (TOI) at week 12, and the secondary endpoints were TOI at week 20, depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and survival. Results: Pts were randomly allocated (102 for each group). The median age was 69 y (range, 27-91) and 77.5% were male. Seventy-two pts had extensive disease small-cell lung carcinoma and 132 Pts had stage IV non-small cell lung carcinoma. Because there was not a significant time-by-group interaction, we estimated main effects and the IG did not show a significant improvement in TOI from the baseline at week 12 and 20 compared to the UG (Mean group difference [the same applies hereafter] 2.13; 90% CI: -0.70, 4.95; P =.107, one-tailed). However, when we considered time-by-group interaction effects exploratorily, the IG did show significant improvement in TOI from baseline at week 20 compared to the UG (3.58; 90% CI: 0.15, 7.00; P = 0.043). There was no significant difference in change from baseline depression and anxiety between the two groups either at week 12 (depression −0.38; 95% CI: -1.81, 1.05; P = 0.60, anxiety -0.18; 95% CI: -1.45, 1.09; P = 0.78) or at week 20 (depression -1.27; 95% CI: -2.79, 0.25; P =.10, 1.26; 95% CI: -2.61, 0.09; P =.067). The 1-year survival rates were 49.5% (95% CI: 39.3, 58.9) in the IG and 43.4% (95% CI: 33.6, 52.8) in the UG. Conclusions: This trial failed to show statistical superiority of nurse-led, screening-triggered, early specialized palliative care intervention program over usual care, however, it’s possible delayed clinical benefits of improvement in QOL (TOI), depression and anxiety were suggested. The study design that some pts in the IG received later or no intervention, may dilute the difference of intervention between group differences. Further investigation, including the mixed method approach adopted in this study, is needed to uncover mediating factors for the effect of this low-cost, novel model of early palliative care. Clinical trial information: UMIN000025491.

Purpose To explore the associations between place of death and quality of death and dying and caregiver burden in terminally ill patients with cancer and their families. Methods Two bereavement surveys were conducted in October 2008 and October 2011. A total of 2,247 family caregivers of patients with cancer who were deceased responded to the mail surveys (response rate, 67%). Family members reported patient quality of death and dying and caregiver burden by using the Good Death Inventory and Caregiving Consequences Inventory. Results Patient quality of death and dying was significantly higher at home relative to other places of dying after adjustment for patient and/or family characteristics (adjusted means): 5.0 (95% CI, 4.9 to 5.2) for home, 4.6 (95% CI, 4.5 to 4.7) for palliative care units, and 4.3 (95% CI, 4.2 to 4.4) for hospitals. For all combinations, pairwise P < .001; the size of the difference between home and hospital was moderate (Hedges' g, 0.45). Home was superior to palliative care units or hospitals with respect to “dying in a favorite place,” “good relationships with medical staff,” “good relationships with family,” and “maintaining hope and pleasure” (P < .001 for all combinations of home v palliative care units and home v hospitals). Home death was significantly associated with a lower overall (P = .03) and financial caregiver burden (P = .004) relative to hospital death. Conclusion Dying at home may contribute to achieving good death in terminally ill patients with cancer without causing remarkably increased caregiver burden. Place of death should be regarded as an essential goal in end-of-life care.

96 Background: The integration of oncology and palliative care (IOP) is an emerging issue that has been encouraged by several agencies, including the American Society of Clinical Oncology. Despite such efforts, clinical implementation of IOP is evolving slowly. One key barrier to implementation is the lack of institutional support; however, recognition of IOP by the heads of hospitals has rarely been investigated. Methods: This was a secondary qualitative analysis of a nationwide survey, which was performed in November 2017 to clarify the current status of IOP in Japan. The questionnaires were distributed to all designated cancer hospitals (DCHs) (n = 399) and randomly sampled non-DCHs (n = 478). This survey included a free text query asking executives or directors of oncology departments at cancer hospitals to describe their opinions about encouragement of IOP in Japan (i.e., importance or challenges of IOP). In total, 174 hospitals (20.2%) responded to the free text query (106 DCHs and 68 non-DCHs). Contents analysis was performed using the free text data. Results: Three major categories emerged from the descriptive data: (1) perceptions and attitudes toward IOP, (2) perceived barriers to IOP, and (3) perceived facilitators of IOP, which possessed two, nine, and eight minor categories, respectively. Of these minor categories, there were both affirmative and contradictory opinions toward IOP. Reluctant attitudes of patients, caregivers, health care professionals, and hospital heads; limited clinical resources, process, and political support; and specific clinical circumstances in Japan were identified as perceived barriers. Education, improvement of clinical resources and process, and political initiatives were identified as perceived facilitators. Conclusions: Comprehensive perceptions, attitudes, challenges, and solutions regarding IOP were proposed. Such data may provide healthcare professionals and policymakers with greater understanding of how to encourage IOP in Japan.

Surveying bereaved family members could enhance the quality of end-of-life cancer care in inpatient palliative care units (PCUs). We systematically reviewed nationwide postbereavement studies of PCUs in Japan and attempts to develop measures for evaluating end-of-life care from the perspective of bereaved family members. The Care Evaluation Scale (CES) for evaluating the structures and processes of care, and the Good Death Inventory (GDI) for evaluating the outcomes of care were considered suitable methods. We applied a shortened version of the CES to three nationwide surveys from 2002 to 2007. We developed the CES as an instrument to measure the structures and processes of care and the GDI as an outcomes measure for end-of-life cancer care from the perspective of bereaved family members. We conducted three nationwide surveys in 1997, 2001, and 2007 (n = 850, 853, and 5,301, respectively). Although six of the 10 areas of the CES showed significant improvements between the two time points investigated, we identified considerable potential for further progress. Feedback from surveys of bereaved family members might help to improve the quality of end-of-life cancer care in inpatient PCUs. However, the effectiveness of feedback procedures remains to be confirmed. Furthermore, there is a need to extend the ongoing evaluation process to home care hospices and general hospitals, including cancer centers, identify the limitations of end-of-life care in all settings, and develop strategies to overcome them.

Purpose To clarify the bereaved family's perceptions about the appropriateness of timing when physicians first referred patients to palliative care units, and to identify the factors contributing to family-perceived late referrals. Subjects and Methods A multicenter questionnaire survey was conducted on 630 bereaved family members of cancer patents who were admitted to palliative care units in Japan. A total of 318 responses were analyzed (effective response rate, 62%). Results Half of the bereaved family members regarded the timing of referrals to palliative care units as late or very late, while less than 5% of families reported early referrals (very late [19%, n = 59], late [30%, n = 96], appropriate [48%, n = 151], early [1.6%, n = 5], and very early [2.2%, n = 7]). Multiple regression analyses revealed that the independent determinants of family-perceived late referrals were: family belief before admission that palliative care shortens the patient's life, insufficient in-advance discussion about preferred end-of-life care between patients/families and physicians, families' insufficient preparation for changes of patient conditions, and hospital admission before referrals. Conclusion In Japan, the timing of referrals to palliative care units was late or very late from the families' perspectives. The independent determinants of family-perceived late referrals were: family misconception about palliative care, inadequate communication with physicians, and families' insufficient preparation for deterioration of patients' conditions. Systematic strategies to overcome these barriers would contribute to providing appropriate palliative care at all stages of cancer.

PURPOSE: To clarify the frequency of practice of sedation therapy for terminally ill cancer patients and to identify physicians’ attitudes toward sedation. METHODS: Questionnaires were mailed to 1,436 Japanese oncologists and palliative care physicians with a request to report their practice of and attitudes toward palliative sedation therapy. RESULTS: A total of 697 physicians returned questionnaires (response rate, 49.6%). Use of mild, intermittent-deep, or continuous-deep sedation for physical and psychologic distress was reported by 89% and 64%, 70% and 46%, and 66% and 38%, respectively. In vignettes in which physicians were asked whether they would use sedation for a patient with refractory dyspnea or with existential distress, 14% and 15%, respectively, chose continuous-deep sedation as a strong possibility. Those physicians less confident with psychologic care and with higher levels of professional burnout were more likely to choose continuous-deep sedation. In vignettes in which they were asked whether they use sedation for a patient with depression or delirium, 39% and 31%, respectively, considered psychiatric treatment to be a strong possibility, and 42% and 50% regarded continuous-deep sedation as a potential treatment option. Physicians less involved in caring for the terminally ill and less specialized in palliative medicine were significantly less likely to choose psychiatric treatment. CONCLUSION: Sedation is frequently used for severe physical and psychologic distress of cancer patients. Physicians’ clinical experiences with the terminally ill and their levels of professional burnout influence the decisions. Training and education for physicians in regard to end-of-life care and valid clinical guidelines for palliative sedation therapy are necessary.

100 Background: Few studies have investigated the need for nutritional support in advanced cancer patients in palliative care settings.The aim of this survey is to examine the relationship between the need for nutritional support and cancer cachexia, specific needs, perceptions, and beliefs. Methods: We conducted a questionnaire in outpatient service/palliative care teams/palliative care units. Patients were classified into two groups: 1) Non-cachexia/Pre-cachexia and 2) Cachexia/Refractory cachexia. Results: A total of 117 out of 121 patients responded (96.7%). A significant difference was observed in the need for nutritional support between the groups: Non-cachexia/Pre-cachexia (32.7%) and Cachexia/Refractory cachexia (53.6%) (p = 0.031). The specific needs of patients requiring nutritional support were nutritional counseling (93.8%), ideas to improve food intake (87.5%), oral nutritional supplements (83.0%), parenteral nutrition and hydration (77.1%), and tube feeding (22.9%). The top perceptions regarding the best time to receive nutritional support and the best medical staff to provide nutritional support were “when anorexia, weight loss, and muscle weakness become apparent” (48.6%) and “nutritional support team” (67.3%), respectively. The top three beliefs of nutritional treatments were “I do not wish to receive tube feeding” (78.6%), “parenteral nutrition and hydration are essential” (60.7%), and “parenteral hydration is essential” (59.6%). Conclusions: Patients with cancer cachexia had a greater need for nutritional support. Advanced cancer patients wished to receive nutritional support from medical staff with specific knowledge when they become unable to take sufficient nourishment orally and the negative impact of cachexia becomes apparent. Additionally, most patients wished to receive parenteral nutrition and hydration.

e21511 Background: End-of-life discussion (EOLd) including information about incurability, prognosis, the site of death, and do-not-resuscitate (DNR) status is considered indispensable for advanced care planning (ACP). However, the preference for EOLd in cancer patients has not been elucidated. Objective: To clarify the preferences of EOLd in Japanese patients with newly diagnosed advanced or recurrent cancer. Methods: A multi-center questionnaire survey was conducted on Japanese adult patients with breast cancer, pancreatic cancer, or sarcoma, who were diagnosed as incurable within the past three months. We asked patients whether they would like to have EOLd with their physician at the time of survey. Factors related to preferences of EOLd were analyzed using chi-square or Mann-Whitney U-test. Results: For 1 year from August 2015, we distributed the questionnaire to 251 patients at five centers. Responses were obtained from 159 patients (45 males, 113 females) (response rate: 63%). The median age was 65 years (range: 29-86). 93 patients (59%) answered they would like to have EOLd, while 60 patients (38%) answered they would not. In univariate analyses, elderly patients (odds ratio [OR]: 1.03; p = 0.027), patients having worse performance status (OR: 1.988; p = 0.03), and with any physical symptoms (OR: 1.533; p = 0.044) preferred to have EOLd. On the other hand, patients who perceived “being able to sufficiently fight the disease” ( p = 0.021) and “living without being aware of the disease” ( p = 0.004) as important were reluctant to have EOLd. 114 patients (72%) answered they wanted to know their life-time prognosis. Employed patients preferred to know their prognosis (OR: 8.919; p = 0.004) while patients who had received chemotherapy did not (OR: 0.313; p = 0.009). Conclusions: Even just after the diagnosis as an incurable disease, more than half of patients with advanced cancer were willing to have EOLd with their treating physician. Patients’ preference of knowing about life-time prognosis was affected by their social and medical experience.

3 Background: End-of-life (EOL) discussions are important for providing appropriate care to patients with advanced cancer at the end of their life. To explore the relationship between EOL discussions and bereaved families’ mental health, as well as the quality of the patient’s death and quality of care at the end of life. Methods: This was a nationwide questionnaire survey of bereaved families of deceased cancer patients who died at 75 sites (20 inpatient palliative care teams in acute hospitals, 33 palliative care units/inpatient hospices, and 22 outpatient clinics that provide home palliative care service) in Japan. 13,711 bereaved family members of cancer patients who died before January 2014 in each of the participating institutions were potential participants. We evaluated the prevalence and details of EOL discussions which were defined as “a discussion with physicians about the preferred place of death or resuscitation”. We also evaluated the prevalence of depression (defined as the Patient Health Questionnaire-9 ≥ 10) and complicated grief (defined as the Brief Grief Questionnaire ≥ 8) in bereaved families. Results: 9123 questionnaires returned (response rate 67%). Of those, 80.6% had EOL discussions. After propensity score weighted adjustment, bereaved families with EOL discussion less frequently developed depression (17.3% and 21.6% ; P < 0.001) and complicated grief (13.7% and 15.9% ; P = 0.03) than without. There were significant differences in the trend test among families without and in those with EOL discussions < 1, 1–3, and > 3 months before the patient’s death, for the prevalence of depression (21.6%, 20.6%, 16.8%, and 15.5%, respectively; P trend < 0.001) and complicated grief (15.9%, 16.4%, 12.8%, and 12.9%, respectively; P trend < 0.001). Conclusions: EOL discussions may contribute to decrease depression and complicated grief in bereaved families. EOL discussions should be initiated with advanced cancer patients when physicians expect a patient’s prognosis is limited to several months.

10025Background: There are few reports about patient’s prognosis depending on primary sites of cancer in palliative care settings. Methods: This study was conducted as a secondary analysis for a la...

e20503 Background: Although having timely end-of-life discussions (EOLd) with advanced cancer patients is essential to provide optimal end-of-life (EOL) care consistent with patients’ preferences a...

e20717 Background: Prognosis disclosure could facilitate end-of-life discussions and advance care planning in advanced cancer patients. However, many Japanese and Japanese American patients do not wish to know of their own prognosis, and physicians infrequently disclose terminal prognosis in Japan. We aimed to investigate Japanese physicians’ practice and emotion regarding prognosis disclosure. Methods: We adopted a qualitative design based on semi-structured interviews and content analysis. Attending physicians in a local cancer center were eligible if they had disclosed terminal prognosis to their cancer patients and/or families more than three times in the past year. The sample size was justified by recruiting participants through consistent comparison analysis until data saturation occurred. Results: We conducted 11 face-to-face interviews and detected the following categories; [practice in disclosure], [reasons for/against disclosure], and [emotion regarding disclosure]. [Practice] indicated that some physicians have almost always disclosed prognosis to their patients, while others have almost never done so. It included various skills such as “having families/nurses attend the meeting,” “asking families how much prognostic information physicians should provide to patients,” “asking patients why they want to know,” and “answering with a range of estimation.” [Reasons for disclosure] included “to help patients deal with unfinished business” and “to support realistic hope.” [Reasons against disclosure] included “uncertain prognosis,” “physicians’ concern about hurting patients,” “lack of time and staff support for physicians,” and “insufficient training in communication skills.” Lastly, many physicians felt “sad,” “nervous,” and “difficult,” while few felt “fulfilled” when disclosing prognosis. Conclusions: Practice patterns, reasons and emotional experiences vary widely in prognosis disclosure among Japanese physicians. Team approach, physician training in communication skills, and understanding of families’ as well as patients’ preferences may contribute to better-quality individualized cancer care based on patients’ goals, not on physicians’ personal preferences.

e16523 Background: In Japan, total national opioid consumption is lower than in Western countries. Japanese physicians may be insufficiently knowledgeable about opioid treatment in cancer patients....

9577 Background: The Japan Hospice and Palliative Care Evaluation (J-HOPE) study was conducted in 2007 and 2008. The aim of the study was to evaluate the quality of end-of-life care at regional cancer centers (CCs), inpatient palliative care units (PCUs), and home hospices (HHs) in Japan from the perspective of bereaved family members. Methods: A nationwide cross-sectional mail survey was conducted in 2007 and 2008. The survey was sent to bereaved families 6–18 months after the death of a patient at 56 CCs, 100 PCUs, or 14 HHs. Outcome measures were the good death inventory, the care evaluation scale, and overall satisfaction with care. The protocol of this study was approved by the institutional review boards of each participating institution. Results: Of the 13,181 bereaved family members that received the survey, 8,163 (62%) participants returned their responses. Among bereaved family members, significantly fewer responded that patients were free from physical distress at CCs (50%) than PCUs (80%) and HHs (73%) (P No significant financial relationships to disclose.