Treatment strategies of palliative care and psycho-oncology specialists for patients with both pain and delirium: a nationwide survey

Pain and delirium frequently coexist in patients with advanced cancer, creating substantial challenges in end-of-life care and complicating clinical decision-making regarding symptom prioritization. However, how physicians determine treatment strategies when these symptoms coexist in the terminal phase remains unclear. We conducted a nationwide cross-sectional postal survey of Japanese palliative care physicians and psychiatrists using a standardized clinical vignette describing a patient with advanced cancer experiencing irreversible terminal delirium and severe but ill-defined pain. Of 1617 eligible physicians, 555 provided complete responses. Psychiatrists were more likely than palliative care physicians to prioritize pain, favor opioid escalation, avoid simultaneous management of pain and terminal delirium, and show greater acceptance of continuous palliative sedation. Cluster analysis identified two practice patterns: a pain-prioritizing type and a dual-focus type emphasizing concurrent attention to both pain and terminal delirium across specialties. These findings suggest that although specialty background influences symptom prioritization, many physicians converge on a dual-focus approach in this ambiguous clinical context.