From the results of this study, we generated a potentially useful care strategy for terminal delirium: respect the patients' subjective world, treat patients as the same persons as before, explore unmet physiological needs behind delirium symptoms, consider ambivalent emotions when using psychotropics, coordinate care to achieve meaningful communication according to changes in consciousness levels during the day, facilitate preparations for the patients' death, alleviate the feelings of being a burden on others, relieve family's physical and psychological burden and information support.

Late referral to a specialized palliative care service hinders quality symptomatic management. The aim of this article is to describe the feasibility and clinical usefulness of screening for patient discomfort as the fifth vital sign using an electronic medical recording system to identify patients with undertreated physical symptoms. For the electronic medical recording system, all admitted patients received routine nurse assessment of discomfort (defined as any physical symptom) at every vital signs check using Item 2 of the Support Team Assessment Schedule Japanese version (STAS). All medically treated cancer patients admitted to seven oncology units were automatically screened at one-week intervals. Positive screening was defined as a STAS score of 2 or more at least two times during the previous week. For each patient identified by screening, a palliative care team reviewed the medical record and provided written recommendations when other treatments might improve the patient's physical symptoms. Of 629 patients screened, 87 (14%) initially met the positive screening criteria. Fifteen (17%) were false positive due to psychiatric symptoms without physical symptoms or due to misrecording. Of 72 cases with actual discomfort, 33 had already been referred to the palliative care team, 14 had received adequate palliative care as determined by the palliative care team, 14 had self-limiting transient discomfort, and one patient died before the screening day. In the remaining 10 cases (11% of symptomatic patients, 1.7% of all screened patients), the palliative care team recommended potentially useful interventions for symptom control; seven patients were referred to the palliative care team within one week. The time required for all screening processes was about 30 minutes per week. This experience demonstrates that screening for patient discomfort as the fifth vital sign using an electronic medical recording system can be successfully implemented and may be useful in facilitating early referral of distressing patients to the specialized palliative care service.

This screening system was feasible but the majority of screening-positive patients did not require additional palliative care interventions.

Changes in medical and nursing care were frequent, and the frequency of local healthcare providers' assessment of the changes may be insufficient. Providing general ward staff with data about changes in interventions occurring just after PCU admission might be effective for improving palliative care for terminal patients.

No abstract