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NCCN Guidelines Index
Palliative Care TOCDiscussion
NCCN.org
Continue
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) ®
Palliative Care
Version 1.2012
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NCCN Guidelines Index
Palliative Care TOCDiscussion
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NCCN Guidelines Panel Disclosures
NCCN Guidelines Version 1.2012 Panel MembersPalliative Care
Michael H. Levy, MD, PhD/Chair
Fox Chase Cancer Center
Michael D. Adolph, MD, MPH, MBA, FACSThe Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute
Anthony Back, MDFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance
Susan Block, MDDana-Farber/Brigham and Women’s Cancer Center
Shirley N. Codada, MDH. Lee Moffitt Cancer Center &
Research Institute
Shalini Dalal, MDThe University of TexasMD Anderson Cancer Center
Teresa L. Deshields, PhDSiteman Cancer Center at Barnes-Jewish Hospital and Washington
University School of Medicine
Elisabeth Dexter, MDRoswell Park Cancer Institute
† £
† £
£
£ Þ
£
Sydney M. Dy, MD
The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins
Sara J. Knight, PhDUCSF Helen Diller FamilyComprehensive Cancer Center
Sumathi Misra, MD Vanderbilt-Ingram Cancer Center
Christine S. Ritchie, MD, MSPHUniversity of Alabama at BirminghamComprehensive Cancer Center
Todd M. Sauer, MDUNMC Eppley Cancer Center atThe Nebraska Medical Center
Thomas Smith, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins
David Spiegel, MDStanford Cancer Institute
Linda Sutton, MD
Duke Cancer Institute
Robert M. Taylor, MDThe Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute
£
Þ £
£
£
† £
£
₪
₪
Jennifer Temel, MD
Jay Thomas, MD, PhDCity of Hope Comprehensive Cancer Center
Roma Tickoo, MD, MPHMemorial Sloan-Kettering Cancer Center
Susan G. Urba, MDUniversity of MichiganComprehensive Cancer Center
Jamie H. Von Roenn, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University
Joseph L. Weems, MD
Sharon M. Weinstein, MD, FAAHPMHuntsman Cancer Instituteat the University of Utah
St. Jude Children`s Research Hospital/University of Tennessee Cancer Institute
† £
Þ £
† £
† £
£
Massachusetts General HospitalCancer Center
‡ Hematology/hematology oncology
† Medical oncology
Þ Internal medicine
£ Supportive care including palliativeand pain management
Psychiatry and psychology, includinghealth behavior
Neurology/neuro-oncology
Anesthesiology
* Writing committee member
₪ Geriatric medicine
*
NCCNDeborah Freedman-Cass, PhD
Mary Anne Bergman
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Uncontrolled symptoms
Moderate-to-severe distress related to cancer
diagnosis and/or cancer therapy
Serious comorbid physical, psychiatric, and
psychosocial conditions
Life expectancy 6 moIndicators include:
Poor performance status
ECOG 3 or KPS 50HypercalcemiaBrain or cerebrospinal fluid metastasisDelirium
Superior vena cava syndromeSpinal cord compressionCachexiaMalignant effusions
Bilirubin 2.5 m
Creatinine 3 mor
Patient/family concerns about course of disease
and decision-makingor
Patient/family requests for palliative care
or
or
Many stage IV cancers
g/dL
g/dL
or
Present
Not present
Rescreen at next visit
See PAL-4
SCREENINGc,d ASSESSMENT BY ONCOLOGY TEAM
PAL-3
Benefits/risks of
anticancer therapy
Symptoms
Psychosocial distress
See PAL-5
See PAL-6
Personal goals/expectations
Educational and informational
needs
Cultural factors affecting care
Criteria for early
consultation with a
palliative care specialist
Inform the patient and family of the role and benefits of palliative care services
Discuss anticipation and prevention of symptoms and advance
care planning
c
d
Management of any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, social workers and other mentalhealth professionals, chaplains, nurse practitioners, physician assistants, and dietitians.
Oncologists should integrate palliative care into general oncology care. Early consultation/collaboration with a palliative care specialist/hospice team should be
considered to improve quality of life and survival.
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Natural history of specific tumor
Potential for response to further treatment
Potential for treatment-related toxicities
Meaning of anticancer therapy to patientand family
Impairment of vital organs
Performance status
Serious comorbid conditions
ASSESSMENT BY ONCOLOGY TEAM
Anticancer therapyinterventions (See PAL-8)
PAL-4
Benefits/risks of
anticancer therapy
Psychosocial distress
Psychosocial/psychiatric
Depression/anxietyIllness-related distress
Social support problems
Resources problems
Spiritual or existential crisis
HomeFamilyCommunity
Financial
Symptoms
Pain
Dyspnea
Anorexia/cachexia
Nausea/vomiting (NV)
Constipation
Malignant bowel obstruction
Fatigue/weakness/astheniaInsomnia/s
Delirium
edation
Pain I (See PAL-9)nterventions
See NCCN Distress Management Guidelines
Delirium I (See PAL-20)nterventions
Anorexia/Cachexia Interventions (See PAL-12)
See NCCN Cancer-Related Fatigue Guidelines
Constipation I (See PAL-16)nterventions
Nausea/Vomiting I (See PAL-14)nterventions
Malignant Bowel Obstruction (See PAL-17)
Dyspnea I (See PAL-10)nterventions
Social Support/Resource Management(See PAL-22)
Insomnia/Sedation I (See PAL-19)nterventions
Consider Consultation with Palliative Care
Specialist (See PAL-6)
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
PAL-5
Palliative Care Tableof Contents
Patient goals and expectationsAdvance care planning
Family goals and expectations
Priorities for palliative careGoals and meaning of anticancer therapyQuality of life
Eligibility for hospice, with needs that might bemet by hospice
Patient/family values and preferences aboutinformation and communication
Patient/family perceptions of disease status
Personal goals/
expectations
Educational and
informational needs
Cultural factors affectingcare
Interventions (See PAL-24)Advance Care Planning(See PAL-26)
Interventions (See PAL-24)
(See PAL-6)
Criteria for early
consultation with palliativecare specialist
PALLIATIVE CARE ASSESSMENT
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Consult with palliative care
specialist/teamCollaborate with other health careprofessionals treating the patient
Refer to appropriate health careprofessionals
Mental health and social servicesHealth care interpretersOthers
Mobilize community supportReligiousSchoolCommunity agencies
Expedite referral to hospiceservices when appropriate
c,d
REASSESSMENT
Unacceptable
Ongoing reevaluation and
communication betweenthe patient and health
care team
Acceptable
Adequate pain and symptom control
Reduction of patient/family distress
Acceptable sense of controlRelief of caregiver burden
Strengthened relationships
Optimized quality of life
Personal growth and enhanced
meaning
Advance care planning in progress
:
Patient satisfied with response to
anticancer therapy
PAL-7
Ongoing
reassessment
ONCOLOGY TEAM INTERVENTIONS
Intensify palliative care efforts to
communicate palliative care options
Consult with a mental healthprofessional to evaluate and treatundiagnosed psychiatric disorders,substance abuse, and inadequatecoping methods
See NCCN Distress Management
Guidelines
c
d
Management of any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, social workers and other mentalhealth professionals,chaplains, nurse practitioners, physician assistants, and dietitians.
Oncologists should integrate palliative care into general oncology care. Early consultation/collaboration with a palliative care specialist/hospice team should beconsidered to improve quality of life and survival.
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NCCN Guidelines Index
Palliative Care TOCDiscussion
NCCN Guidelines Version 1.2012Palliative Care
Years
to
months
Months
to
weeks
Weeks to
days(Dying
patient)
Provide appropriate prevention and managementof symptoms caused by anticancer therapy
Discuss intent, goals, benefits, and risks of
anticancer therapy, including possible effects on
quality of life
Provide appropriate anticancer therapy as
outlined in
Provide appropriate palliative care
Prepare patient psychologically for possible
disease progression
NCCN disease-specific guidelines
See above interventions
Redirect goals and hopes to those that areachievable
Provide guidance regarding anticipated courseof disease
Consider potential discontinuation of anticancer treatment
Offer best supportive care, including referral topalliative care or hospice
Provide guidance regarding anticipated dyingprocess
Focus on symptom control and comfort
Foster patient participation in preparing lovedones
Refer to palliative care/hospice team
Encourage discontinuation of anticancer therapy
Intensify palliative care in preparation for death
Continueanticancer therapy
and palliative care
BENEFITS/RISKS OF ANTICANCER THERAPYESTIMATED
LIFEEXPECTANCY
INTERVENTIONS
REASSESSMENT
PAL-8
Years
Acceptable:
Adequate pain and
symptom control
Reduction of
patient/family distress
Acceptable sense of control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
Personal growth and
enhanced meaning
Ongoing
reassessment
Change or
discontinue
anticancer therapy
Review patient
hopes about and
meaning of
anticancer therapy
Intensify palliativecare efforts
Review advance
care planning
Consult or refer to
specialized
palliative care
services or hospice
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Unacceptable
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Years to
months
Monthsto weeks
Weeks to
days(Dying
patient)
Treat according to NCCNAdult Cancer Pain Guidelines
In addition:
and hyperalgesia
Treat according to
Do not reduce dose of opioid solely for
decreased blood pressure, respiration rate, or
level of consciousness
Maintain analgesic therapy; titrate to optimal
comfortRecognize and treat opioid-induced neurotoxicity,
including myoclonus
If opioid reduction is indicated, reduce by 50%
per 24 h to avoid acute opioid withdrawal or pain
crisis. Do not administer opioid antagonist
Balance analgesia against reduced level of
consciousness based on patient preference
Modify routes of administration as needed (PO,IV, PR, subcutaneous, sublingual, transmucosal,
and transdermal) applying equianalgesic dose
conversions
Consider sedation for refractory pain
( )
Consult with a pain management/palliative carespecialist
NCCN Adult Cancer Pain
Guidelines
See PAL-30
Continue to treataccording to
Monitor symptoms andquality of life todetermine
whether additional end-of-life measuresare required
NCCNCancer PainGuidelines
Adult
INTERVENTIONS REASSESSMENT
PAL-9
Ongoing
reassessment
Years
Acceptable:
Adequate pain and
symptom controlReduction of
patient/family distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationshipsOptimized quality of
life
Personal growth and
enhanced meaning
PAIN
Continue to
treat according
to
Consider aconsultationwith a painmanagement/palliative carespecialist
NCCN
Cancer PainGuidelines
Adult
ESTIMATED
LIFEEXPECTANCY
Unacceptable
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Years to
months
Assess symptom intensity
Treat underlying causes/comorbidconditions:
Radiation/chemotherapyTherapeutic procedure for cardiac,
pleural, or abdominal fluidBronchoscopic therapy
Bronchodilators, diuretics, steroids,antibiotics, or transfusions
Relieve symptoms
Educational, psychosocial, and emotional
support for the patient and family
Nonpharmacologic therapies, including
fans, cooler temperatures, stress
management, relaxation therapy, andphysical comfort measuresIf opioid naive, morphine, 2.5-10 mg PO q
4 hr prn, 1-3 mg IV q 1 hr prnBenzodiazepines (if benzodiazepine
naive, starting dose lorazepam, 0.5-1 mg
PO q 4 hr prn)
f
Oxygen therapy for hypoxia
Temporary ventilatory (CPAP, BiPAP)
support if clinically indicated for severe
reversible condition
INTERVENTIONS REASSESSMENT
Weeks to
days(Dying
patient)
See Interventions (PAL-11)
Months
to weeks
DYSPNEA
Ongoing
reassessment
Years
Acceptable:
Adequate dyspnea and
symptom control
Reduction of
patient/family distressAcceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
Personal growth andenhanced meaning
Continue to treat andmonitor symptoms
and quality of life to
determine whether
status warrants
change in strategies
PAL-10
Intensify palliative care
efforts
Consult or refer to
specialized palliative
care services or hospice
ESTIMATED
LIFE
EXPECTANCY
f For acute progressive dyspnea, more aggressive titration may be required.
Unacceptable
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Assess symptom intensity
Nonpharmacologic therapies; educational,
psychosocial, and emotional support
If opioid naive, morphine, 2.5-10 mg PO q 4 hr
prn, 1-3 mg IV q 1 hr prnBenzodiazepines (if benzodiazepine naive,
starting dose lorazepam, 0.5-1 mg PO q 1 hr prn)
Reduce excessive secretions withscopolamine, 0.4 mg SC q 4 hr prn; 1.5 mg
patches, 1-6 patches q 3 d; atropine 1%
ophthalmic solution 1-2 drops SL q 4 h pr; or
glycopyrrolate 0.2-0.4 mg IV or SQ q 4 hr prn
Provide anticipatory guidance for patient/familyregarding dying of respiratory failureProvide emotional and spiritual support
Use physical signs of distress as potentialdyspnea in noncommunicative patients
Focus on comfortContinue to treat underlying condition asappropriate
Relieve symptoms
Withhold/withdraw/initiate time-limited trial of mechanical ventilation as indicated
Address patient and family preferences,prognosis, and reversibility
Provide sedation as neededDiscontinue fluid support/consider low-dosediuretics if fluid overload may be a contributingfactor
f
g
4
FansOxygen if hypoxic and/or subjective relief is
reported
( )See PAL-10
Continue to
treat and
monitor
symptoms and
quality of lifeto determine
whether status
warrants
change in
strategies
INTERVENTIONS REASSESSMENT
DYSPNEA
Acceptable:dyspnea
Adequateand symptom controlReduction of
patient/family distressAcceptable sense of
controlRelief of caregiver
burdenStrengthened
relationshipsOptimized quality of
lifePersonal growth and
enhanced meaning
PAL-11
Months toweeks
Years to
months
Weeks to days(Dying patient)
SeeInterventions(PAL-10)
Years
Ongoing
reassessment
Intensify palliative
care interventions
and consider a
consultation with a
palliative care
specialistConsider sedationfor intractablesymptoms( )See PAL-30
ESTIMATED
LIFEEXPECTANCY
Unacceptable
f For acute progressive dyspnea, more aggressive titration may be required.gHughes A et al. Audit of three antimuscarinic drugs for managing retained secretions. Palliative Medicine. 2000; 14:221-222.
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Evaluate rate/severity of weight loss
Treat readily reversible cause of anorexia:Early satiety
MetoclopramideSymptoms that interfere with intake
Dysgeusia
DyspneaDepression/Anorexia
(Mirtazapine 7.5-30 mg hs)ConstipationPain
Review/modify medications that interfere with
intake
Evaluate for endocrine abnormalities:HypogonadismThyroid dysfunctionMetabolic abnormalities (eg, increased calcium)
Consider appetite stimulant (eg, megestrol acetate,
400-800 mg/d; prednisone 10-20 mg BID)Consider an exercise program
Assess social and economic factors
Consider nutrition consult
Consider nutrition support,
Xerostomia
Oral-pharyngeal candidiasisMucositisNausea and/or Vomiting
Eating disorders/body image
enteral and parenteral
feeding (as appropriate)
h
i
Fatigue
Months to
weeks
Years
to
months
Weeks to
days(Dying
patient)
Continue to
treat and
monitor
symptoms and
quality of life to
determinewhether status
warrants
change in
strategies
ANOREXIA/CACHEXIA
INTERVENTIONS REASSESSMENT
Ongoing
reassessment
Years
Acceptable:
Weight stabilization or
gain
Improvement in
symptoms that
interfere with intake
Improved energy
Resolution of
metabolic or endocrine
abnormalities
See Interventions (PAL-13)
PAL-12
Intensify palliative
care interventions
Provide dietary
consultation
Consider clinical trial
ESTIMATED
LIFEEXPECTANCY
Unacceptable
hDy S, Lorenz K, et al. Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea. 2008 J Clin Oncol. 26:3886-3895.
i August DA, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapyduring adult anticancer treatment and in hematopoietic cell transplantation.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-500.
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NCCN Guidelines Index
Palliative Care TOCDiscussion
NCCN Guidelines Version 1.2012Palliative Care
Assess importance of symptoms of anorexia and cachexiato patient and family
If important, consider short course of
Provide education and support to patient and familyregarding emotional aspects of withdrawal of nutritionalsupport.
Inform patient and family of natural historyof disease, including the following points:
Absence of hunger and thirst is normal in the dyingpatientNutritional support may not be metabolized in patientswith advanced cancer There are risks associated with artificial nutritionand hydration, including fluid overload, infection, andhastened deathIV hydration may increase excretion of drugmetabolites providing benefit to the patientSymptoms like dry mouth should be treated with localmeasures, eg, mouthcare, small amounts of liquidsWithholding or withdrawal of enteral or parenteral nutritionis ethically permissible in this setting. It will not causeexacerbation of symptoms and may improve somesymptoms
prednisone 10-20 mg BID
Focus on patient goals and preferences
Provide family with alternate ways of caring for the patient
Provide emotional support
Treat for depression, if appropriate (Mirtazapine7.5-30 mg hs)
Continue to
treat and
monitor
symptoms and
quality of life to
determine
whether status
warrantschange in
strategies
INTERVENTIONS REASSESSMENT
Ongoing
reassessment
Acceptable:
Adequate a
c symptom
control
Reduction of
patient/family distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of
life
Personal growth and
enhanced meaning
norexia/
achexia
PAL-13
Months
to weeks
Years to
months
Weeks to
days(Dying
patient)
Years See Interventions (PAL-12)
ANOREXIA/CACHEXIA
Intensify palliative
care efforts
Consult or refer to
specialized
palliative care
services or hospice
ESTIMATED
LIFE
EXPECTANCY
Unacceptable
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
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Version 1.2012, 04/02/12 © National Comprehensive Cancer Network, Inc. 2012,All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .® ®
NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Add a 5-HT3 antagonist (eg, ondansetron)
± anticholinergic agent (eg, scopolamine)± antihistamine (eg, meclizine)± cannabinoid.If NV persists:
Add a corticosteroid(eg, dexamethasone).If NV persists:
Consider using a continuous IV/SCinfusion of antiemetics; consider an opioid rotation if patient is onopioids.
If NV persists:
Consider adding alternative therapies(eg, acupuncture, hypnosis, cognitivebehavioral therapy)
INTERVENTIONS
PAL-15
Acceptable:
Adequate NV symptom
control
Reduction of patient/family distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
REASSESSMENT
Continue to treatand monitor
symptoms and
quality of life to
determine
whether status
warrants change
in strategies
OngoingreassessmentSee Interventions(PAL-14)
PERSISTENT NAUSEA AND VOMITING
Intensify palliative care
efforts
Consult or refer to
specialized palliative
care services or hospice
Consider palliative
sedation ( )See PAL-30
Titrate dopamine receptor antagonist
(eg, prochlorperazine, haloperidol, )
to maximum benefit and tolerance
metoclopramide
Unacceptable
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
PAL-17
Weeks to
days(Dying
patient)n
Months
to weeks
Years tomonths
MALIGNANT BOWEL OBSTRUCTIONm
ASSESSMENT
Years
Screen for and treat underlying benign reversible
causesAdhesionsRadiation-induced stricturesInternal hernias
Assess for malignant causesTumor massCarcinomatosis
Assess the goals of treatment for the patient, which
can help guide the intervention (eg, decrease NV,
allow patient to eat, decrease pain, allow patient to
go home/to hospice)
n
Consider only if other measures fail to reduce
vomiting Endoscopic management
Pharmacologic management
Intravenous or subcutaneous fluids
Enteral tube drainage
Consider medical management
rather than surgical
management
Assess the goals of treatment
for the patient, which can help
guide the interventionn
(eg, decrease NV, allow patientto eat, decrease pain, allow
patient to go home/to hospice)
Provide education and support
to patient and family
SeeInterventions(PAL-18)
SeeReassessment(PAL-18)
m
n
Plain film radiography evaluation is usually enough to establish the diagnosis of bowel obstruction. Consider a computed tomography scan if surgical intervention iscontemplated, as it is more sensitive and helps identify the cause of obstruction.
Most malignant bowel obstructions are partial, allowing time to discuss appropriate intervention with the patient and family.
ESTIMATED
LIFEEXPECTANCY
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NCCN Guidelines IndexNCCN G id li V i 1 2012
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Assess for delirium(eg, DSM-IV criteria)Screen for and treat
underlying reversible
causesMetabolic causesHypoxiaBowel obstruction/obstipationInfectionCNS eventsBladder outlet
obstructionMedication or
substance effect or
withdrawal (eg,
benzodiazepines,
opioids,
anticholinergics)Assess, screen for,
and maximize
nonpharmacologic
interventions (eg,
reorientation,cognitive stimulation,
sleep hygiene)
Severe
delirium(agitation)
Avoid benzodiazepines unless
patient has refractory delirium
on antipsychoticsAdminister haloperidol
0.5-10 mg IV q 1-4 h prnAdminister alternative agents:
olanzapine, 2.5-7.5 mg/d PO/IV
q 2-4 h prn (maximum = 30
mg/d); chlorpromazine, 25-100
mg PO/PR/IV q 4 h prn for bed-
bound patients
Titrate starting dose to optimal
effectConsider opioid dose
reduction or rotation
If agitation is refractory to high
doses of neuroleptics,
consider adding lorazepam,
0.5-2 mg SQ/IV q 4 h
Support caregivers
Administer haloperidol
0.5-2 mg PO BID/TID
Administer alternative agents:
risperidone, 0.5-1 mg PO BID;olanzapine, 5-20 mg PO daily;or quetiapine fumarate,25-200 mg PO/SL BIDTitrate starting dose tooptimal effectOrient patient with familypresence
Weeks to
days(Dying
patient)
Months
to weeks
Years to
months
Continue to
treat and
monitor symptoms and
quality of life to
determine
whether status
warrants
change in
strategies
See Interventions(PAL-21)
DELIRIUM
INTERVENTIONS REASSESSMENT
Ongoingreassessment
Years
Acceptable:delirium
Adequate
symptom controlReduction of
patient/family
distress
Acceptable senseof controlRelief of caregiver
burdenStrengthened
relationshipsOptimized quality of
lifePersonal growth
and enhanced
meaning
PAL-20
Intensify palliative
care interventions
Consider consultation with a
palliative care
specialist or
psychiatrist
Mild/
moderatedelirium
ESTIMATED
LIFE
EXPECTANCY
Unacceptable
NCCN Guidelines IndexNCCN Guidelines Version 1 2012
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PAL-21
Evaluate
for
iatrogenic
causes
Disease
progression
Consider that agitation may bemistaken for pain resulting inhigher doses of opioids, whichmay exacerbate delirium
Rotate opioids
Focus on symptom control
Focus on family support andcoping mechanism
Provide appropriate upward dosetitration of haloperidol,risperidone, olanzapine, or quetiapine fumarate
Consider rectal or intravenoushaloperidol or administration of chlorpromazine ± lorazepam
Remove unnecessarymedications, tubes, etc.
Educate family and caregiver(s)
Provide appropriate upward dosetitration of lorazepam
Decrease doses of medicationsdependent upon hepatic or renalfunction
for patientswith refractory agitation despitehigh doses of neuroleptics
IatrogenicTreat cause if possible and
provide symptomatic relief
Weeks
to days(Dying
patient)
Months
to weeks
Years to
months
Continue totreat and
monitor
symptoms and
quality of life
to determine
whether status
warrants
change instrategies
Unacceptable
See Interventions(PAL-20)
INTERVENTIONS REASSESSMENT
Ongoing
reassessment
Years
Acceptable:
Adequate delirium
symptom control
Reduction of
patient/family
distress
Acceptable sense
of control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality
of life
Personal growth
and enhanced
meaning
DELIRIUM
Intensify
palliative care
interventions
Consult with apalliative care
specialist or
psychiatrist
Consider
palliative
sedation (
)
See
PAL-30
ESTIMATED
LIFE
EXPECTANCY
NCCN Guidelines Version 1.2012Palliative Care
NCCN Guidelines IndexNCCN Guidelines Version 1 2012
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NCCN Guidelines Index
Palliative Care TOCDiscussion
Ensure that caregiver(s) are available
Ensure a safe home environment
Ensure adequate access to transportationEnsure sufficient financial resources
Refer to social services as needed to
assist with mobilization of family,
community, and financial resources
Ensure support and education to
caregiver(s) and family membersCounselingSupport groups
Respond to caregiver-specific burdens
and stresses
Assess bereavement risk
Discuss personal, spiritual, and cultural
issues relating to illness and prognosis
Obtain medical interpreters/translators
who are not related to the patient and
family as needed
Assist family/caregiver(s) with respite
care
Unacceptable
Weeks to
days
(Dying
patient)
Months
to weeks
Years
to
months
See Interventions (PAL-23)
Ongoing
reevaluation and
communication
between thepatient,
caregiver(s),
family members,
and health care
team
REASSESSMENT
Ongoing
reassessment
Years
SOCIAL SUPPORT/RESOURCE MANAGEMENT
Acceptable:
Adequate social
support and resource
management
Reduction of
patient/family distress
Acceptable sense of control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
Personal growth and
enhanced meaning
PAL-22
INTERVENTIONS
Intensify efforts to
communicate palliative
care options
Consider referral topsychologist or
psychiatrist to evaluateand treat psychologicdisordersSee NCCN DistressManagement Guidelines
ESTIMATED
LIFEEXPECTANCY
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
NCCN Guidelines IndexNCCN Guidelines Version 1 2012
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Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Discuss prognosis on an ongoing basis inclear, consistent language with the patient,caregiver(s), and family, includinginformation about the natural history of thespecific tumor
Evaluate and support the patient’s desiresfor comfort
Explain the dying process and expectedevents to the patient, caregiver(s), andfamily members
Respond to caregiver-specific demandsand stresses
Reassess bereavement riskEnsure that care conforms with culturaland spiritual/religious practices
Provide emotional support and addressany patient-family or intra-family conflictsregarding intervention
Consider palliative care consultation toassist in conflict resolution when thepatient, family, and/or professional team donot agree on benefit/utility of interventions
Obtain medical interpreters/translatorswho are not related to the patient andfamily as needed
Determine eligibility and readiness for specialized palliative/hospice care andneeds that might be best met by hospice
Weeks to
days
(Dying
patient)
Months
to weeks
Years to
monthsSee Interventions (PAL-22)
Ongoing
reevaluation andcommunication
between the
patient and health
care team
INTERVENTIONS REASSESSMENT
Ongoing
reassessment
YearsAcceptable
Adequate social
support and resource
management
:
Reduction of
patient/family distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
Personal growth and
enhanced meaning
PAL-23
SOCIAL SUPPORT/RESOURCE MANAGEMENT
Reassess patient andfamily
Consult or refer to
specialized palliative care
services, hospice, or ethics committee
Intensify palliative care
efforts
Consider referral topsychologist or psychiatrist to evaluateand treat psychologicdisordersSee NCCN DistressManagement Guidelines
ESTIMATED
LIFE
EXPECTANCY
Unacceptable
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Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Assess patient/family understanding of
the dying process
Educate patient and family on dying
process
Prepare for patient’s deathFacilitate anticipatory grief work
Ensure continuing care process and refer
to appropriate care
Promote that patient does not die alone
Offer spiritual support
Encourage planning for funeral/memorial
services, as determined by personal
preferences, cultural customs and beliefs
See Interventions (PAL-24)
REASSESSMENT
Acceptable:
Reduction of patient/family distress
Acceptable sense of control
Relief of caregiver burden
Strengthened relationships
Optimized quality of life
Personal growth and enhanced
meaning
Years to
months
Monthsto weeks
Years
Weeks to
days(Dying
patient)
INTERVENTIONS
PAL-25
Ongoingreassessment(See PAL-24)
GOALS AND EXPECTATIONS, EDUCATIONAL AND INFORMATIONAL NEEDS, AND CULTURAL FACTORS AFFECTING CARE FOR THE PATIENT AND FAMILY
Reassess patient and
family
Intensify palliative care
efforts
Consult or refer to
hospice or specialized
palliative care services
ESTIMATED
LIFE
EXPECTANCY
Unacceptable
NCCN Guidelines Index
P lli i C TOCNCCN Guidelines Version 1.2012
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Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Version 1.2012Palliative Care
Initiate discussion of palliative care options,including hospice if appropriate
Introduce palliative care team if appropriate
Refer to state and institutional guidelines for
additional guidance
Encourage designation of health care proxy,
medical power of attorney, or patient
surrogate for health care
Explore fears about dying and address
anxiety
Assess decision-making capacity and need
for surrogate decision-maker
Initiate discussion of personal values and
preferences for end-of-life care
If patient values and goals lead to a clear
recommendation regarding future treatment
in light of disease status, physician should
make a recommendation about future care
Document patient values and preferences
and any decisions in accessible site in
medical record (including MOLST/POLST if
completed)
Encourage the patients to discuss wishes
with family/proxy
Ongoing reevaluation
and communication
between the patient and
health care team
Weeks to
days(Dying
patient)
Months to
weeks
Years to
months
See Interventions (PAL-27)
ADVANCE CARE PLANNING
INTERVENTIONS REASSESSMENT
PAL-26
Ongoingreassessment
Years
Acceptable:
Adequate advance
care planning
Reduction of
patient/family
distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of
life
Personal growth and
enhanced meaning
Explore patient reluctance to
engage in advance care
planning
Explore fears and worries
about illness
Refer to palliative care if the
patient is having difficultyengaging in discussion of
advance care planning
Consider referral to a mental
health clinician to evaluate
mental health issues
See NCCN DistressManagement Guidelines
ESTIMATED
LIFEEXPECTANCY
Unacceptable
NCCN Guidelines Index
P lli ti C TOCNCCN Guidelines Version 1.2012
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Palliative Care TOCDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Palliative Care
Confirm the patient’s values and decisions in light of
changes in statusIf not previously done, make recommendations aboutappropriate medical treatment to meet the patient’svalues and goals
Ensure complete documentation of the advance careplan in the medical record, including MOLST/POLSTif applicable, to assure accessability of the plan to allproviders across care settings
Explore family concerns about the patient’s plan and
seek resolution of conflict between patient and familygoals and wishes
Consider consultation with a palliative care specialistto assist in conflict resolution when the patient,family, and health care team disagree
Explore fears about the future and provide emotionalsupport
Address years-to-months interventions
Determine patient and family preferences for the
location of the patient’s death
Assure that all items identified above are complete
Implement and ensure compliance with advance care
plan
Clarify and confirm the patient’s decision about life-
sustaining treatments, including CPR, if necessary
Explore desire for organ donation and/or autopsy
Weeks to
days
(Dying
patient)
Months
to weeks
Years
to
months
See Interventions (PAL-26)
Ongoing
reevaluation
and
communication
between the
patient/family
and health care
team
INTERVENTIONS REASSESSMENT
PAL-27
Ongoingreassessment
Years
Acceptable:
Adequate advance care
planning
Reduction of
patient/family distress
Acceptable sense of
control
Relief of caregiver
burden
Strengthened
relationships
Optimized quality of life
Personal growth and
enhanced meaning
ADVANCE CARE PLANNING
Explore patient reluctance to
engage in advance care
planning
Explore fears and worries about
illness
Refer to palliative care if the
patient is having difficultyengaging in discussion of
advance care planning
Consider referral to a mental
health clinician to evaluate
mental health issues
See NCCN Distress ManagementGuidelines
ESTIMATED
LIFE
EXPECTANCY
Unacceptable
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NCCN Guidelines IndexPalliative Care Table of Contents
Discussion
NCCN Guidelines Version 1.2012Palliative Care
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132. Irvin S. The experiences of the registered nurse caring for theperson dying of cancer in a nursing home. Collegian 2000;7:30-34.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/11858309.
133. Hartmann LC. Unrealistic expectations. J Clin Oncol2005;23:4231-4232; discussion 4233-4234. Available at:http://www.ncbi.nlm.nih.gov/pubmed/15961772.
134. Kalemkerian GP. Commentary on "Unrealistic Expectations". JClin Oncol 2005;23:4233-4234. Available at:
http://jco.ascopubs.org/content/23/18/4233.short.