My name is Dr Masanori Mori and I am currently working as a palliative care physician in a palliative care team at a tertiary regional hospital and serving as a Director of the Division of Palliative and Supportive Care at Seirei Mikatahara General Hospital, Japan. Usually, I work with the inpatient and outpatient palliative care teams.
Tell us more about your background. How did you get into Palliative Care and what made you stay?
Initially, I wanted to become a medical student to help patients who are suffering live, but I was not sure what kind of help I could offer during my years as a medical student. During my fourth year of medical school, I had an opportunity to go to Hobart. When I visited an inpatient hospice, I was allowed to enter the room of a patient with a terminal illness, and it was the first time I had met a patient as a medical student. The patient was jaundiced, he could not walk and he looked very depressed in this dark room. However, when the attending physician arrived, the patient’s face lit up as if someone shone a light into the room. At that moment, I was shocked and wondered what kind of magic it was. Following her on her morning rounds, I witnessed the same thing happen whenever she went inside the patient’s room. What impressed me the most was her communication skills with the patients, and it made an impact on me.
During my residency in Okinawa, most cancer patients did not receive their diagnosis and prognosis. I saw many patients suffering at the end of life (EOL) without knowing they had cancer and how long they have left. At that time, palliative care was still in its infancy in Japan and we did not get educated about palliative care as a student. Hence, we were not equipped with the skills to deal with patients at the EOL. I remember being asked by some patients to stay with them till the end and I did not know how to manage spiritual pain. Hence, I felt I needed to know how to manage total pain and learn communicate terminal nature of illness to patients with causing anxiety in patients.
When I went to Beth Israel Medical Center in New York where Russell Portenoy was running the palliative care service. I did the elective rotation in palliative care for two months. During the patient care rotation, I had the opportunity to see Dr Portenoy’s outpatient clinic and got to learn a lot from him in terms of patient care approach and I wanted to learn more. During my research rotation, Dr Portenoy introduced me a hospice in Manhattan. During that time, people in hospices could not receive advanced therapy so they tried to develop a programme where people could benefit from advanced care.
I learned that hospice and palliative care was not only about love and tender care but also requires a scientific approach and deserved good innovation for patient care.
You have been part of the APHN family for quite some years. What has been the highlight thus far of working with APHN?
I was introduced to APHN by Dr Tsuneto at one of the EAPC conferences and ended up joining the council hereafter. Learning that APHN was derived from Dr Shigeaki Hinohara’s initiatives, I had great respect for him and honoured this opportunity and was interested in hospice and palliative care in the Asia Pacific.
We attended a strategic meeting in Sydney some years back and during one of the sessions, I was seated next to Dr Rosalie Shaw and had a nice chat about the history of palliative care in the Asia Pacific, how she mentored clinicians, how she helped open palliative care services and more and I was really impressed with her dedication. That interaction with Dr Shaw was very special and a blessing to me. That day, I had also met with Joyce for the first time along with the other council members such as Dr Goh, Dr Ednin and I felt like I was part of the APHN family.
Another highlight for me was the APHC 2019 in Surabaya, as I enjoyed the rich culture of Indonesia as well as getting to work with the members of the Scientific Committee as it was my first-time being part of the Scientific Committee. The APHC 2020 was a good experience as well. It was not easy, but it was a good learning experience.
You are very involved in research, especially in cross-cultural studies! What drew you into the area of research?
The continuous experience with patient care was the driving force for my interest in research. Since the first year of residency, I saw a lot of patients suffering from breathlessness or severe pain at the EOL. Symptom management was an issue, and a number of patients continue to suffer at EOL, no matter how much advancement we have in modern medicine. Hence, how to manage the patient’s suffering was a target of research. Communication and end-of-life conversations were also of interest to me.
When I did my residency in Japan, clinicians did not always disclose bad news to the patient. Whereas in New York, the clinicians did have tough conversations with the patients as they felt that the patients should be in the driver’s seat instead of first speaking to their family members. I observed that was a gap between patient preferences and clinician practice. The similarities and differences in communication in different cultures allowed me to develop an interest in cross-cultural studies.
You have done many studies on Advanced Care Planning and end-of-life communication. Do you have any breakthroughs or discoveries on ACP to share from your research?[Laughs] I wish I could tell you there was some sort of breakthrough!
However, let me introduce you to two papers I was involved in. The first one is ‘What I did for my loved one was more important than whether we talked about death’. In that project, I was involved in a study that had over 900 bereaved family members of cancer patients who died at inpatient hospices in Japan. The specific questions were whether the family talked about death with the patient, whether they acted in preparation for death, did they regret the degree of talk/action with the patient. We also asked them about their level of depression and complicated grief. We found out that approximately only half of the families talked about death with the patient, about 80 % of families acted in preparation of death with the patient, there was a higher percentage of regret in terms of action (e.g., acting in preparation of death) rather than talking about death. The level of action in preparation of death was associated with the level of depression and complicated grief e.g., the more they acted in preparation of death, the less they were depressive or had complicated grief. Hence, the conclusion was that acting in preparation of death matters, whether they talked about death.
The other interesting study was ‘Communication and Behavior of Palliative Care Physicians of Patients With Cancer Near End of Life in Three East Asian Countries’. This study asked a proportion of patients who had explicit discussions about impending death with patients and family. There was a huge difference in the percentage of physicians discussing impending death with patients amongst the three countries.
From these two studies, I felt that there are certain ways of appropriate communication styles in each country. An individual approach would be the next step for ACP research.
As a palliative care physician in Japan, what are some of the challenges you face?
The challenges I face would be the difficulties in serving specific issues in patient care. There is also an issue with refractory symptoms. Even with state-of-the-art palliative care, we still have patients with refractory symptoms that are difficult to control and we do not have many tools to tackle these except palliative sedation.
Another difficulty would be engaging in open communication with patients, especially in the last weeks to days of life, as their function goes down, they are less aware of their prognosis. Hence, the gap between the actual and perceived prognosis gets wider. The challenge is how to have a person-centered approach with regard to engaging in open communication.
The last challenge is a lack of experience in palliative care for the non-cancer population. Unlike many other regions, in Japan, only cancer or HIV/AIDs patients can be admitted to inpatient hospices. For other illnesses, they do not get reimbursed if a palliative care physician were to see them. Hence, in Japan, we need to build expertise in this field.
How do you spend your free time?
When I have free time, I enjoy spending time with my family. The past couple of years amidst the pandemic have granted me more time to spend with my children. I also enjoy being surrounded by nature so I take walks to a nearby park.
I also write Haiku poetry. Over the last several years, I had more time to write so I enjoy doing that. Palliative care and poetry have some similarities as it is about nature, beauty and blessing. When I was a student, I was impressed by nature surrounding myself and I wanted to feel more immersed in nature. So, I started writing when I was struck by the beauty of nature while walking to university and by writing, I began to appreciate nature more. I joined a Haiku group when I was a 4th-year medical student, so it has been more than 20 years!
When I was in Houston, I remember seeing a 30-year-old EOL cancer patient. One day, he asked me what I would do in his shoes as someone who was diagnosed with terminal cancer and now must choose between going to the hospice or phase one trial. At that time, I took off my white coat to speak to him as myself and I told him “I enjoy Haiku poetry, spending time with children and nature. If I were you, I would consider what matters most at this very moment and I would appreciate time with family and nature.”. So, he asked me to write a Haiku for him and I did! He was surrounded by his parents who were dedicated in his care, and they were quietly watching me as he asked me this question.
A month later he passed away and I could not help feeling him when I was in nature, so I wrote a Haiku for the bereaved family. The family sent me a picture of a ceremonial place they made in their garden and a picture of my Haiku as part of the garden.
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Original article source: APHN