Saran Yoshida

The Yale–Brown Obsessive Compulsive Scale Modified for Olfactory Reference Syndrome (ORS‐YBOCS) is a self‐rated measure for assessing the severity of current olfactory reference disorder (ORD) symptoms. This scale has been translated into multiple languages and used in previous studies. However, its psychometric properties have not been investigated. The present study aimed to develop a Japanese ORS‐YBOCS (newly named the ORD‐YBOCS) and conduct a preliminary examination of its reliability and validity. Our study included 104 individuals with self‐reported ORD symptoms. The Japanese ORD‐YBOCS had good internal consistency (α = .81) and partial validity ( r = .43 with Jikoshu‐kyofu symptoms, r = .20 with body image concerns, r = .56 with depression, and r = .27 with fear of negative evaluation). The minimum average partial correlation and the scree plot suggested a one‐factor model, but the confirmatory factor analysis results did not support this. This study is the first to examine the psychometric properties of the self‐reported ORS‐YBOCS. Our results suggest that the Japanese ORD‐YBOCS is a reliable tool to measure ORD symptom severity. Further examination is needed for its validity.

医療場面では，さまざまな治療や療養の選択が行われる。近年，患者と医療者が共に意思決定の過程を共有する，協働意思決定という考え方が重視されており，治療選択に対して患者自身が主体的に参加することを求められる場面が増えてきている。このことは患者の自立尊重という側面で重要である一方で，複雑な医学的な情報を処理しながら時として自身の生命に関わる重大な選択をしなければならず，患者にとっては負担の大きな作業でもある。このような意思決定の難しさを軽減するアプローチとして，行動経済学の活用が考えられている。治療選択場面を取り上げた研究としてはこれまで，シナリオを用いた質問紙による仮想実験を用いて，ナッジの効果を検証する研究が重ねられてきた。また最近では，実臨床場面での無作為化比較試験を用いた実証的な研究も増えつつある。こうした研究からは，多様なナッジの効果が検証されている。特にデフォルト設定を活用した研究が複数行われており，その有用性が示されている。同時に，医療における意思決定にナッジを用いた介入を行うことの倫理的な課題も抽出されている。例えば，「明らかに望ましい」選択肢が存在しないような意思決定課題において，患者の選択を一方に誘導することの倫理性や，ナッジを用いることそのものが患者に与える侵襲などについて，考慮することが必要である。本稿では，医療における治療選択場面に行動経済学の考えを応用した研究を示しながら，その効果と課題について解説する。

Objective: The Yale-Brown Obsessive Compulsive Scale Modified for Olfactory Reference Syndrome (ORS-YBOCS) is a self-rated measure for assessing the severity of current olfactory reference disorder (ORD) symptoms. This scale has been translated into multiple languages and used in previous studies. However, its psychometric properties have not been investigated. The present study aimed to develop a Japanese ORS-YBOCS (newly named the ORD-YBOCS) and examine its reliability and validity. Methods: A total of 104 individuals with self-reported ORD symptoms were included (mean age = 30.20 years, SD = 10.25). Internal consistency and factor structure were assessed by calculating Cronbach’s alpha and conducting confirmatory factor analysis (CFA) respectively. Convergent and divergent validity were examined via correlations with measures of Jikoshu-Kyofu symptoms, body image concerns, depression, and fear of negative evaluation. Results: The Japanese ORD-YBOCS had good internal consistency ( α = .81) and acceptable construct validity ( r = .43 with Jikoshu-Kyofu symptoms, r = .20 with body image concerns, r = .56 with depression, and r = .27 with fear of negative evaluation). The scree plot suggested a one-factor model, but the CFA results did not support this (CFI = 0.76, TLI = 0.70, RMSEA = 0.14, and SRMR = 0.10). Conclusion: This is the first study to examine the psychometric properties of the self-report ORS-YBOCS. The linguistically validated Japanese ORD-YBOCS showed good internal consistency and acceptable validity. These results suggest that the Japanese ORD-YBOCS is a valid and reliable tool to measure ORD symptom severity.

This study aimed to clarify the situation and evaluate the communication on anticancer treatment discontinuation from the viewpoint of a bereaved family, in reference to the concept of nudges. A multi-center questionnaire survey was conducted involving 350 bereaved families of patients with cancer admitted to palliative care units in Japan. The following explanations were rated as essential or very useful: (i) treatment would be a physical burden to the patient (42.9%), (ii) providing anticancer treatment was impossible (40.5%), (iii) specific disadvantages of receiving treatment (40.5%), (iv) not receiving treatment would be better for the patient (39.9%) and (v) specific advantages of not receiving treatment (39.6%). The factors associated with a high need for improvement of the physician’s explanation included lack of explanation on specific advantages of not receiving treatment (β = 0.228, P = 0.001), and lack of explanation of ‘If the patient’s condition improves, you may consider receiving the treatment again at that time.’ (β = 0.189, P = 0.008). Explaining the disadvantages of receiving treatment and the advantages of not receiving treatment, and presenting treatment discontinuation as the default option were effective in helping patients’ families in making the decision to discontinue treatment. In particular, explanation regarding specific advantages of not receiving treatment was considered useful, as they caused a lower need for improvement of the physicians’ explanation.

Background: It has been said that physicians should provide their patients with accurate evidence in terms of information on treatment options. However, in some cases, although the physician provides accurate and sufficient information, the patient still chooses the medically not-recommended treatment. The purpose of this research is to clarify how patients’ decisions differ when a physician changes the frame of an explanation when he/she provides information about cancer treatment. Methods: An online questionnaire survey was conducted in March 2017. Through the aid of a survey company, we emailed questionnaires to 1,360 cancer patients who received treatment within the last 2 years. We randomly assigned participants to 6 hypotheticals scenario of a terminal cancer patient, and presented hypothetical evidence in different ways. Subsequently, we asked survey participants whether they would choose to receive additional anti-cancer treatment. Results: Although there was no statistically significant difference between scenarios, the “social burden” groups showed a lower rate of patients who preferred to continue a medically ineffective anti-cancer treatment than the control group, at a 10% significance level. The scenario significantly affected the patients’ sense of abandonment [F_{(5, 1,354)}=5.680, P(5, 1,354)=3.920, P=0.002], and necessity of improvement [F_{(5, 1,354)}=2.783, P=0.017]. Conclusions: Nudges were not shown to be effective in situations where discontinuation of anticancer treatment was being considered. On the other hand, some nudges were found to be invasive and should be used with caution.

Purpose: Several studies have investigated good communication practices with adult patients receiving bad news about cancer. However, while communication preferences may differ between adults and adolescent and young adult (AYA) patients, these preferences have not been determined for AYA patients. The primary endpoint of this study was to describe the communication preferred by AYA patients with cancer. Methods: The study cohort consisted of 15 patients who received a cancer diagnosis at the age of 15–29 years. Patients were recruited at the National Cancer Center Hospital or through “STAND UP!!,” an association of AYA patients with cancer. Semistructured interviews were conducted, and content analysis was performed to analyze the data. Results: For the preferred communication of AYA patients, 80 categories were extracted in the following five domains: (1) “Supportive setting,” (2) “Method of disclosure of bad news,” (3) “Information given,” (4) “Emotional support,” and (5) “Support for the patient's decision making.” Although more than half of the categories extracted were identical to the preferred communication of adult patients, some categories specific to AYA patients were identified that physicians should consider. Preferences specific to AYA patients included mentioning generation-specific social factors, not showing excessive empathy, and communicating in a manner considering their age and cognitive development that supports their decision making. Conclusion: Although physicians should be mindful of the specific preferences of AYA patients, the basic attitude and communication preferences are similar to those of patients of other generations.

Purpose: This study aimed to clarify the situation and evaluate the communication on anticancer treatment discontinuation from the viewpoint of a bereaved family, in reference to the concept of nudges. Methods: A multi-center questionnaire survey was conducted involving 350 bereaved families of patients with cancer admitted to palliative care units in Japan. Results: The following explanations were rated as essential or very helpful: 1) anticancer treatment would be a physical burden for the patient (43.1%), 2) providing anticancer treatment was impossible (40.6%), 3) the disadvantages of undergoing treatment (40.6%), 4) not having the treatment would be better for the patient (40.6%), and 5) the advantages of not having the treatment (40.3%). The factors associated with a high need for improvement of the physician’s explanation included older age of the participant (β = 0.221, p = 0.010); lack of explanation that anticancer treatment cannot be given (β = 0.219, p = 0.001); and lack of explanation on the specific benefits of not having treatment (β = 0.251, p = 0.001). Conclusion: Explaining the disadvantages of continuing anticancer treatment and the advantages of discontinuing treatment and presenting treatment discontinuation as the default option were effective in helping patients’ families in making the decision to discontinue treatment. In particular, explanation regarding the benefits of treatment discontinuation and show the discontinuation of anticancer treatment as the default option was considered important, as the lack of them caused a higher need for improvement.

Purpose: Several studies have investigated good communication practices with adult patients receiving bad news about cancer. However, communication preferences differ between adult and adolescent and young adult (AYA) patients. These preferences have not been determined for AYA patients. The primary endpoint of this study was to describe the communication preferred by AYA patients with cancer.Methods: The study cohort consisted of 15 patients who received a cancer diagnosis at the age of 15–29 years. Semistructured interviews were conducted, and content analysis was performed to analyze the data.Results: For the preferred communication of AYA patients, 80 attributes were extracted in the following five domains: 1) “Supportive setting,” 2) “Method of disclosure of bad news,” 3) “Information given,” 4) “Emotional support,” and 5) “Support for the patient’s decision-making.” Although more than half of the attributes extracted were identical to the preferred communication of adult patients, some attributes specific to AYA patients were identified that physicians should consider. Preferences specific to AYA patients included mentioning generation-specific social factors, not showing excessive empathy, and communicating in a manner considering their age and cognitive development that supports their decision-making.Conclusion: Although physicians should be mindful of the specific preferences of AYA patients, the basic attitude and communication preferences are similar to those of patients of other generations.

Objective: Research on the association between circumstances of death in advanced cancer patients and depression in their bereaved caregivers is limited.Methods: A longitudinal study was performed on patients admitted to 21 inpatient hospices/palliative care units (PCUs) in Japan. Patient symptoms were assessed at admission and in the last 3 days of life. Data on distressing events (unexpected death, bleeding) and received treatments (morphine prescriptions, continuous deep sedation, cardiopulmonary resuscitation) were also obtained. Bereaved caregiver depression was assessed 6 months or more after patient death via mail survey using the Patient Health Questionnaire‐9 (PHQ‐9). A multivariable logistic regression analysis was used to explore variables predicting bereaved caregiver depression.Results: Of 1324 deceased patient–bereaved caregiver dyads, data were finally analyzed for 711 dyads. The proportion of probable depression (PHQ‐9 scores ≥10) in bereaved caregivers was 13.6% (91/671; 95% confidence interval: 11.0–16.2). The multivariable logistic regression analysis showed that patient hyperactive delirium at PCU admission was significantly associated with the development of bereaved caregiver depression (odds ratio: 2.2, 95% CI: 1.2–3.8). Bereaved caregiver perceived low social support (OR: 4.7, 95% CI: 2.2–10.0) and low preparedness for death (OR: 4.5, 95% CI: 2.6–7.8) were also significantly associated with the development of depression. Other patient and bereaved caregiver variables had no association with depression.Conclusions: Hyperactive delirium in terminally ill cancer patients was associated with bereaved caregiver depression. The development of effective strategies to reduce delirium‐related agitation and to provide educational interventions for caregivers may be needed.

End-of-life discussions (EOLd) including the option of forgoing anticancer treatment infrequently occur until treatment options have been exhausted for advanced cancer patients. We aimed to identify oncologist-related factors contributing to the timing of discussing the option of forgoing anticancer treatment. In this nationwide survey of 864 medical oncologists, we asked about physicians' attitudes toward the timing of discussing the option of forgoing anticancer treatment for a simulated patient with newly diagnosed metastatic cancer, physicians' experience of EOLd, perceptions of a good death, and beliefs. Multivariate analyses identified determinants of early discussions. Among 490 physicians (response rate = 57%), 167 (35%) would discuss the option of forgoing anticancer treatment "now (at the diagnosis)." Physicians' attitudes toward discussing the option "now" were significantly correlated with a greater physician-perceived importance of life completion (odds ratio (OR) = 1.30, 95%CI = 1.00-1.69, p = 0.048) and dying in a preferred place (OR = 1.29, 95%CI = 1.01-1.65, p = 0.045) for a good death, and not perceiving EOLd as being severely distressing for patients/families (OR = 0.70, 95%CI = 0.54-0.95, p = 0.021). In multivariate analyses, independent determinants of the attitude toward discussing the option now included a greater physician-perceived importance of life completion for a good death (OR = 1.38, 95%CI = 1.05-1.81, p = 0.019), and not perceiving EOLd as being severely distressing for patients/families (OR = 0.70, 95%CI = 0.52-0.94, p = 0.017). Reflection by oncologists on their own perception regarding a good death and beliefs about EOLd may help oncologists individualize the timing of discussing the option of forgoing anticancer treatment.