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The first nationwide study on a patient referral system was conducted in Honduras. It covered all 25 public hospitals (six National, five Regional and 14 Area Hospitals) and 24 major health centres. Based on 46,739 reviews of patient records, 226 'received referral' and 1072 'sent referral' cases were analyzed by age and sex of the patient, diagnosis on referral, institution from or to which the case was referred, use of proper referral form, and reception of reply for referrals. At the same time, the study team supervised the function of the registry and management of patient records at each institution. The average referral rate by the level of health facility was 15.8% at National, 4.0% at Regional, 2.8% at Area Hospitals, and 0.8% at health centres. The referral rate was observed to be higher when institutional managers emphasized the importance of the referral system. Only 1.4% of referrals received a reply from upper level institutions. The most common cases for referral were neurological at National, obstetric at Regional and respiratory cases at Area Hospitals. The use rate of the standard referral form was 70 to 80% at hospitals and 60% at health centres. There was no norm to duplicate referral letters for record keeping. The patient referral system has not developed satisfactorily in Honduras. The main problems were: 1) low referral rate at all levels of institution, 2) evident by-pass phenomenon at intermediate hospitals, 3) inadequate health information system for patient referral, and 4) misunderstanding of the terminology of referral by health personnel. The following recommendations were made: guarantee of essential health services at peripheral institutions, development of an effective information system for patient referral, facilitation of frequent reply for referrals, elaboration of referral case discussion between institutions, patient education on proper use of health facilities, and restructuring the health service network in the two major cities.

In order to explore possible differences in the scope of end-of-life decisions and attitudes toward advance directives (AD) in palliative care, we conducted a survey of 159 patients in palliative care institutions and 93 health-care professionals experienced in palliative care in the United States, Germany, and Japan. Giving an AD in this clinical setting was considered important by patients and professionals. The prevalence of a formal written AD was 79% in the United States, 18% in Germany, and 9% in Japan. In Japan, there was a high prevalence of entrusting all decisions to the family (known as omakase). More than 80% of the patients had negative feelings toward their future decisions in the United States and Germany, in contrast to only 45% in Japan. Although favored by the professionals, there were no specific instruments for obtaining ADs. In Germany and Japan, some patients had given an informal AD. As a pilot content validity step, survey results were used to derive a checklist for content and procedural aspects in end-of-life decision-making. This checklist may provide the basis for developing an instrument to guide physicians, especially non-palliative care specialists, in communication with their patients and their families in this difficult clinical situation.

Background: Dementia is clinically noted to influence both reporting and experience of cancer pains. However, no systemic evaluation of this aspect has been reported. The aim of the present study was to retrospectively evaluate how dementia modified the cancer discovery process, frequency of cancer pain reports and analgesic-narcotic use at a large psychiatric hospital. Methods:We reviewed all the records of cancer patients with and without dementia treated at the surgical ward of Matsuzawa Hospital from 1993 to 2004. Psychiatric diseases other than dementia, brain metastasis and alcoholism, as well as leukaemia and skin cancer, were excluded. Patients' communicativeness as to pain was ascertained from nursing records. Results: A total of 134 cancer patients with and without dementia (50 demented and 84 non-demented) were included. Demented patients were accidentally discovered to have cancer (48%) or by an unexpected unfolding of clinical signs (44%), whereas most non-demented patients (63%) voluntarily sought medical evaluation (P = 0.000). Overall, 76% of non-demented patients had cancer pains (stages I and II, 64%; stages III and IV, 84%), whereas just 22% of demented patients had cancer pains (stages I and II, 16%; stages III and IV, 26%; P = 0.000). Non-demented patients showed stage-dependent requirements for both non-narcotic analgesics (stages I and II, 64%; stages III and IV, 84%) and narcotics (stages I and II, 0%; stages III and IV, 41%). Demented patients required much less analgesics (stages I and II, 11%; stages III and IV, 13%), with only one stage IV patient requiring narcotics (P = 0.000). Conclusion: Dementia greatly modifies the cancer discovery process, reduces prevalence of cancer pain and analgesic requirement.