NCCN指南姑息治疗.V1

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1、Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionPalliative CareVersion Prelim

2、inary1.2014NCCN.orgCVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guid

3、elines Version 1.2014 Panel MembersPalliative CareMaria Dans, MD Siteman Cancer Center at Barnes-Jewish Hospital and WashingtonUniversity School of MedicineJean S. Kutner, MDUniversity of Colorado Cancer CenterElizabeth Kvale, MD University of Alabama at BirminghamComprehensive Cancer CenterSumathi

4、Misra, MD Vanderbilt-Ingram Cancer CenterWilliam Mitchell, MDUC San Diego Moores Cancer CenterTodd M. Sauer, MD Fred & Pamela Buffett Cancer Center atThe Nebraska Medical CenterDavid Spiegel, MD qStanford Cancer InstituteLinda Sutton, MD Duke Cancer InstituteContinueRobert M. Taylor, MD YThe Ohio St

5、ate University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research InstituteJennifer Temel, MD Massachusetts General HospitalCancer CenterRoma Tickoo, MD, MPH Memorial Sloan-Kettering Cancer CenterSusan G. Urba, MD University of MichiganComprehensive Cancer CenterCarin Van Zyl, MD

6、City of Hope Comprehensive Cancer CenterSharon M. Weinstein, MD YHuntsman Cancer Instituteat the University of Utah Hematology/Hematology oncology Medical oncology Internal medicine Supportive care including palliativeand pain managementq Psychiatry and psychology, includinghealth behaviorYNeurology

7、/Neuro-oncologyj AnesthesiologyGeriatric medicine Pediatric oncology* Writing committee member* Michael H. Levy, MD, PhD/Chair Fox Chase Cancer Center* Thomas Smith, MD/Vice-ChairThe Sidney Kimmel Comprehensive CancerCenter at Johns HopkinsAmy Alvarez-Perez, MDRoswell Park Cancer InstituteAnthony Ba

8、ck, MD Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care AllianceJustin N. Baker, MD St. Jude Childrens Research Hospital/The University of TennesseeHealth Science CenterSusan Block, MD qDana-Farber Cancer InstituteShirley N. Codada, MD Moffitt Cancer CenterShalini Dalal, MD The University o

9、f TexasMD Anderson Cancer CenterNCCNMary Anne BergmanJillian Scavone, PhDNCCN Guidelines Panel DisclosuresPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights RVersion 1.2014, 04/1

10、8/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Palliative Care Panel MembersSummary of the

11、Guidelines UpdatesClinical Trials: NCCN believes thatthe best management for any cancerpatient is in a clinical trial.Participation in clinical trials isespecially encouraged.To find clinical trials online at NCCNMember Institutions, click here:nccn.org/clinical_trials/physician.html.NCCN Categories

12、 of Evidence andConsensus: All recommendationsare category 2A unless otherwisespecified.See NCCN Categories of Evidenceand ConsensusNCCN Guidelines Version 1.2014 Table of ContentsPalliative CareDefinition and Standards of Palliative Care(PAL-1)Palliative Care Overview (PAL-2)Screening and Assessmen

13、t by OncologyTeam (PAL-3)Criteria for Consultation with Palliative CareSpecialist (PAL-6)Oncology Team Interventions andReassessment (PAL-8)Benefits/Risks of Anticancer Therapy(PAL-9)Symptoms: Pain (PAL-10)Symptoms: Dyspnea (PAL-11)Symptoms: Anorexia/Cachexia (PAL-13)Symptoms: Nausea and Vomiting (P

14、AL-15)Symptoms: Constipation (PAL-17)Symptoms: Malignant Bowel Obstruction(PAL-18)Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical warranties of any kind regarding their content, use or application and

15、 disclaims any responsibility for their application or use in any way. The NCCNbe reproduced in any form without the express written permission of NCCN. 2014.Symptoms: Sleep/WakeDisturbances Including Insomnia andSedation (PAL-20)Symptoms: Delirium (PAL-21)Social Support/ResourceManagement (PAL-23)G

16、oals and Expectations, Educationaland Informational Needs, andCultural Factors Affecting Care forthe Patient and Family (PAL-25)Advance Care Planning (PAL-27)Response to Requests for HastenedDeath (PAL-29)Care of the Imminently Dying Patient(PAL-30)Palliative Sedation (PAL-31)After-Death Interventio

17、ns (PAL-32)Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights RVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines

18、 and this illustration may not be reproduced in any form without the express written permission of NCCN . NCCN Guidelines IndexPalliative Care TOCDiscussion1 of 2NCCN Guidelines Version 1.2014 UpdatesPalliative Careachievable based upon likely prognosis and life expectancy 12th bullet modified to: C

19、onsider potential discontinuation of anticancertreatment 13th bullet modified: Encourage Discontinue of anticancer therapyPAL-11 Under Interventions, 2nd bullet, 5th sub-bullet is new to the page:Anticoagulants for pulmonary emboli Under “Relieve symptoms,” 1st sub-bullet modified: Oxygen therapy fo

20、rsymptomatic hypoxia 5th sub-bulllet modified: If dyspnea is not relieved by opioids and isassociated with anxiety. 6th sub-bullet modified to include: Temporary ventilatory NoninvasivePositive-Pressure Ventilation (NPPV).PAL-15 5th bullet, 1st sub-bullet: changed TID-QID to BID-TID 6th bullet, modi

21、fied as follows: Gastric outlet obstruction (squashedstomach syndrome ) from intra-abdominal tumor or liver metastasis 1st sub-bullet modified as follows: If not contraindicated by comorbidconditions, treat with corticosteroids, a proton pump inhibitor, and 7th bullet modified: Treat metabolic abnor

22、malities In the 1st sub-bullet, modified: Correct Hypercalcemia 2nd sub-bullet, modified: Treat Uremia 8th bullet is new to the page: Gastritis/GERD Proton pump inhibitor H2-blockerplanning and care plan Deleted footnote “e” Communication barriers include: language, literacy, 2nd sub-bullet now incl

23、udes Endoscopic stentingand physical barriers and instead included sub-bullets under 3rd sub-bullet is new to the page: Decompressing G-TubeUpdates in Version 1.2014 of the NCCN Guidelines for Palliative Care from Version 2.2013 include:PAL-1 PAL-9 (continued) Under Standards of Palliative Care, 5th

24、 bullet modified to include social 10th bullet modified: Redirect goals and hopes to those that arethe page (Also for PAL-9) “Look for opportunities to use single agents to treat multiple symptoms” 5th bullet, 1st sub-bullet, modified: Address patient and familyis a new footnote and corresponds to S

25、ymptoms (Also for PAL-5,corresponding to Psychosocial/psychiatric)workers, chaplains, and pharmacistsPAL-2 Bottom branch, 1st sub-bullet modified as follows: Discuss Anticipatesymptoms and discuss preventative measures (Also for PAL-3) Interventions has replaced efforts throughout the guidelinesPAL-

26、3 Under Life Expectancy 6 mo, Palliative stenting or venting gastrostomyis new to the page (Also for PAL-6)PAL-4 4th bullet modified: Goals and meaning of anticancer therapy to forpatient and family Confirm the patients understanding of incurability of disease is new toPAL-6 6th bullet modified: Com

27、plex ICU admissions (those involving multi-organ system failure or prolonged mechanical ventilations) multiplecomplications or those requiring lengthy ventilator support) Last bullet modified: Inability Resistance to engaging in advance care“Communication barriers” to replace the footnotePAL-7 Child

28、ren under 18 years of age living in the household is new to thepagePAL-9 8th bullet is new to the page: Reassess understanding of goals oftherapy and prognosisPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive C

29、ancer Network, Inc., All Rights Reserved.UPDATESVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative

30、 Care TOCDiscussionNCCN Guidelines Version 1.2014 UpdatesPalliative CarePAL-20 Under Interventions, 7th bullet, 1st sub-bullet, 3rd sub-sub-bulletZolpidem has changed from 5-10 mg PO at bedtime to 5 mg 5th sub-sub-bullet is new to the page, Olanzapine, 2.5-5 mg PO atbedtime 2nd sub-bullet, 2nd sub-s

31、ub-bullet, second dose no later than 2:00PMhas been modified to 6 hours before bedtime 3rd sub-sub-bullet, second dose no later than 2:00PM has beenmodified to 12 hours before bedtimePAL-21the page and are as follows: Hyperactive Hypoactive 2nd bullet, 2nd sub-bullet is new to the page: Unrelieved p

32、ain Interventions, 1st bullet has been modified, Avoid benzodiazepinesReduce or eliminate delirium-inducing medications as possible (eg,steroids, anticholinergenics, and benzodiazepines)PAL-26 Interventions, 6th bullet, Respect goals and needs of the patient andfamily regarding the dying process is

33、new to the page 7th bullet has been modified: Promote that patient does not die aloneunless dying alone is an established preference of patientPAL-27 Under Interventions: Encourage designation of Ask patient if he/she has aliving will, medical power of attorney, health care proxy, or patientsurrogat

34、e for health care If not, encourage patient to prepare onePAL-29 Vermont was added to the list of states where Physician-assisted suicideis legalMS-1 The discussion section was updated to reflect the changes in thealgorithmileus and mechanical bowel obstruction, 0.15 mg/kg SC every other day, Two su

35、b-bullets under Assess for delirium (eg, DSM-IV criteria) are new toPAL-16 Under Interventions, olanzapine is new to the page and it reads asfollows: Titrate dopamine receptor antagonist (eg, prochlorperazine,haloperidol, metoclopramide, olanzapine) to maximum benefit andtolerance Under “If NV Persi

36、sts, olanzapine was added as follows: Add acorticosteroid (eg, dexamethasone) olanzapine, if not already triedPAL-17 Under Interventions, 10th bullet, modified as follows: Considermethylnaltrexone for opioid-induced constipation, except for post-opno more than once a dayPAL-18 The word may was added

37、 to footnote “m” and reads as follows: Plainfilm radiography may be helpful in confirming the clinical diagnosis ofbowel obstruction. Consider a computed tomography scan if surgicalintervention is contemplated, as it is more sensitive and may helpidentify the cause of obstructionPAL-19 3rd bullet, 1

38、st sub-bullet, modified as follows: Ultrasound-guidedgastrostomy tube for drainage venting tube 4th bullet now reads: Pharmacologic management when the goal ismaintaining gut function 2nd sub-bullet has been removed: Consider as an adjunct to aninvasive procedure when invasive procedures are not an

39、option 5th bullet, Pharmacologic management when gut function cannot bemaintained is new to the page 2nd sub-bullet, Consider early in the diagnosis due to high efficacyand tolerability has been removed Footnote “o” has been modified, Risk factors for poor surgical outcomeprognosis criteria for surg

40、ery include: ascites, carcinomatosis, palpableintraabdominal masses, multiple bowel obstructions, previousabdominal radiation, very advanced disease, and poor overall clinicalstatus2 of 2Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2

41、014 National Comprehensive Cancer Network, Inc., All Rights Reserved.UPDATESVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN

42、 Guidelines IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CarePAL-1DEFINITION OF PALLIATIVE CAREaPalliative care is a special kind of patient- and family-centered health care that focuses on effective management of pain and otherdistressing symptoms, while incorporating

43、psychosocial and spiritual care according to patient/family needs, values, beliefs, and cultures.The goal of palliative care is to anticipate, prevent, and reduce suffering and to support the best possible quality of life for patients andtheir families, regardless of the stage of the disease or the

44、need for other therapies. Palliative care begins at diagnosis and should bedelivered concurrently with disease-directed, life-prolonging therapies and should facilitate patient autonomy, access to information, andchoice. Palliative care becomes the main focus of care when disease-directed, life-prol

45、onging therapies are no longer effective,appropriate, or desired. Palliative care should be initiated by the primary oncology team and then augmented by collaboration with aninterdisciplinary team of palliative care experts.STANDARDS OF PALLIATIVE CAREbInstitutions should develop processes for integ

46、rating palliative care into cancer care, both as part of usual oncology care and forpatients with specialty palliative care needs.All cancer patients should be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically indicated.Patients and families shoul

47、d be informed that palliative care is an integral part of their comprehensive cancer care.Educational programs should be provided to all health care professionals and trainees so that they can develop effective palliative careknowledge, skills, and attitudes.Palliative care specialists and interdisc

48、iplinary palliative care teams, including board-certified palliative care physicians, advancedpractice nurses, physician assistants, social workers, chaplains, and pharmacists, should be readily available to provide consultative ordirect care to patients/families who request or require their experti

49、se.Quality of palliative care should be monitored by institutional quality improvement programs.aHui D, Mori M, Parsons HA, et al. The lack of standard definitions in supportive and palliative oncology literature. J Pain Symptom Manage 2012;43:582-592.bFerris FD, Bruera E, Cherny N, et al. Palliativ

50、e cancer care a decade later: accomplishments, the need, next steps from the American Society of Clinical Oncology.J Clin Oncol 2009;27:3052-3058.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a

51、 clinical trial. Participation in clinical trials is especially encouraged.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved. Symptom managementMonths to Consultation w

52、ithdays Hospice referral Response to request towithdraw or withholdVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guideline

53、s IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless 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 1.2014Pall

54、iative Care - OverviewSCREENINGc,dPALLIATIVE CAREINTERVENTIONSdREASSESSMENTAFTER-DEATHINTERVENTIONS Benefits/risks ofanticancer therapy Personalgoals/expectations Symptoms Psychosocial orspiritual distress Educational andinformationalneeds Cultural factorsaffecting care Criteria forconsultation with

55、palliative carespecialistAcceptable: Patient satisfiedwith response toanticancertherapy Adequate painand symptomcontrol Reduction ofpatient/familydistress Acceptablesense of control Relief ofcaregiver burden Strengthenedrelationships Optimizedquality of life Personal growthand enhancedmeaningUnaccep

56、tableDeath Uncontrolledsymptoms Moderate-to-severe distressrelated to cancerdiagnosis andcancer therapy Serious comorbidphysical andpsychosocialconditions Life expectancy6 mo Metastatic solidtumors Patient/familyconcerns aboutcourse of diseaseand decision-making Patient/familyrequests forpalliative

57、carePresentNotpresent Inform patients and familiesabout palliative care services Anticipate symptomsand discuss preventative measures Discuss advance care planning Rescreen at next visitAssessment byOncology Team(PAL-3)ASSESSMENTc,dOngoing reassessment Anticancer therapy Appropriate treatment ofcomo

58、rbid physical andpsychosocial conditions Coordination of carewith other health careprovidersYears Advance care planningYears to Psychosocial andmonths spiritual support Culturally appropriatecareweeks Resource management/social supportWeeks topalliative care specialist(Dyingpatient)life-sustaining t

59、reatment Response to requestsfor hastened death(physician-assistedsuicide and euthanasia) Care of imminentlydying patient Palliative sedationPAL-2Ongoing reassessmentFor family andcaregiver(s): Immediateafter-deathcare Bereavementsupport Cancer riskassessmentandmodificationFor healthcare team: Gener

60、alsupport After-deathsupport Intensify palliative care interventions Consult or refer to specialized palliativecare services or hospicecManagementof any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, social workers, and other mental

61、 health professionals, chaplains, nursepractitioners, physician assistants, and dietitians.dOncologists 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 sur

62、vival.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guideli

63、nes and this illustration may not be reproduced in any form without the express written permission of NCCN . orPatient/family concerns about course of diseaseand decision-makingorPatient/family requests for palliative carediagnosis and/or cancer therapyorSerious comorbid physical, psychiatric, andps

64、ychosocial conditionsorLife expectancy 6 mo Indicators include:7 Metastatic solid tumors7 Many stage IV cancers7 Poor performance statusECOG 3 or KPS 507 Hypercalcemia7 Brain or cerebrospinal fluid metastasis7 Delirium7 Superior vena cava syndrome7 Spinal cord compression7 Cachexia7 Malignant effusi

65、ons7 Palliative stenting or venting gastrostomyPresentNot presentSee PAL-4NCCN Guidelines Version 1.2014Palliative CareSCREENINGc,dUncontrolled symptomsorModerate-to-severe distress related to cancerNCCN Guidelines IndexPalliative Care TOCDiscussionASSESSMENT BY ONCOLOGY TEAMBenefits/risks ofantican

66、cer therapySymptomsPsychosocial distressSee PAL-5See PAL-6and PAL-7Personal goals/expectationsEducational and informationalneedsCultural factors affecting careCriteria for consultationwith a palliative carespecialist Inform the patient and family about palliative care services Anticipate symptoms an

67、d discuss preventative measures Discuss advance care planning Rescreen at next visitcManagementof 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 practitioner

68、s, physician assistants, and dietitians.dOncologists 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.Note: All recommendations are category 2A unle

69、ss 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.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014

70、National Comprehensive Cancer Network, Inc., All Rights Reserved.PAL-Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidel

71、ines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless 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 1.2014Pa

72、lliative CareASSESSMENT BY ONCOLOGY TEAMNatural history of specific tumorPotential for response to further treatmentPotential for treatment-related toxicitiesGoals and meaning of anticancer therapy forPAL-4eLook for opportunities to use single agents to treat multiple symptoms.Benefits/risks ofantic

73、ancer therapyPersonal goals/expectationsSymptomseAnticancer therapyinterventions (See PAL-9)Interventions (See PAL-25)Advance Care Planning(See PAL-27)Pain Interventions (See PAL-10)Dyspnea Interventions (See PAL-11)Anorexia/Cachexia Interventions (See PAL-13)Nausea/Vomiting Interventions (See PAL-1

74、5)Constipation Interventions (See PAL-17)Malignant Bowel Obstruction (See PAL-18)See NCCN Cancer-Related Fatigue GuidelinesInsomnia/Sedation Interventions (See PAL-20)Delirium Interventions (See PAL-21)patient and familyImpairment of vital organsPerformance statusSerious comorbid conditionsConfirm t

75、he patients understanding ofincurability of diseasePatient goals and expectations Advance care planningFamily goals and expectationsPriorities for palliative care Goals and meaning of anticancer therapy Quality of lifeEligibility for hospice, with needs that might bemet by hospicePainDyspneaAnorexia

76、/cachexiaNausea/vomiting (NV)ConstipationMalignant bowel obstructionFatigue/weakness/astheniaInsomnia/sedationDeliriumPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.

77、Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN Note: All recommendations are category 2A unless otherwise indicated.Clinical Tr

78、ials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.PAL-5NCCN Guidelines Version 1.2014Palliative CarePALLIATIVE CARE ASSESSMENTPsychosocial/psychiatrice Depression/anxiety Illness-related distressSpirit

79、ual or existential crisisSocial support problems Home Family CommunityResources problems FinancialPatient/family values and preferences aboutinformation and communicationPatient/family perceptions of disease statusNCCN Guidelines IndexPalliative Care TOCDiscussionSee NCCN Distress Management Guideli

80、nesConsider Consultation with Palliative CareSpecialist (See PAL-6)Psychosocial distressEducational andinformational needsCultural factorsaffecting careCriteria for consultationwith palliative carespecialistSocial Support/Resource Management(See PAL-23)Interventions (See PAL-25)(See PAL-6)eLook for

81、opportunities to use single agents to treat multiple symptoms.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer N

82、etwork, Inc. 2014, 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 IndexPalliative Care TOCDiscussionSeeOncologyTeamInterventions(PAL-8)NCCN Guidelines Version 1.2014Palliative CareCRITER

83、IA FOR CONSULTATION WITH PALLIATIVE CARE SPECIALISTASSESSMENTLimited treatment optionsHigh risk of poor pain control or pain that remains resistant to conventional interventions, eg: Neuropathic pain Incident or breakthrough pain Associated psychosocial and family distress Rapid escalation of opioid

84、 dose Multiple drug “allergies” or a history of multiple adverse reactions to pain and symptommanagement interventions History of drug or alcohol abuseNon-pain symptoms that are suboptimally controlled by conventional management, highsymptom burden (See PAL-4 for symptoms)Palliative stenting or vent

85、ing gastrostomyFrequent ED visits or hospital readmissionsComplex ICU admissions (those involving multi-organ system failure or prolonged mechanicalventilations)PAL-6PatientcharacteristicsHigh distress score (4) (See NCCN Guidelines for Distress Management)Cognitive impairmentSevere comorbid conditi

86、onsCommunication barriers language literacy physical barriersRequest for hastened deathResistance to engaging in advance care planning and care planContinued next pageNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any c

87、ancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/

88、14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CareCRITERI

89、A FOR CONSULTATION WITH PALLIATIVE CARE SPECIALISTASSESSMENTNote: All recommendations are category 2A unless 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.Family/care

90、giver limitationsInadequate social supportIntensely dependent relationship(s)Financial limitationsLimited access to careFamily discordPatients concerns regarding care of dependentsSpiritual or existential crisisUnresolved or multiple prior lossesChildren under 18 years of age living in the household

91、Compassion fatigueMoral distressSocialcircumstancesorAnticipatorybereavementissuesStaffissuesSeeOncologyTeamInterventions(PAL-8)PAL-7Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All R

92、ights Reserved.UnacceptableVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCC

93、N Guidelines Version 1.2014Palliative CareConsult with palliative carespecialist/teamc,dCollaborate with other health careprofessionals treating the patientRefer to appropriate health careprofessionals Mental health and social services Pastoral care Health care interpreters OthersMobilize community

94、support Religious School Community agenciesExpedite referral to hospiceservices when appropriateREASSESSMENTAcceptable:Patient satisfied with response toanticancer therapyPAL-8OngoingreassessmentONCOLOGY TEAM INTERVENTIONSAdequate pain and symptom controlReduction of patient/family distress Ongoing

95、re-evaluationAcceptable sense of control and communicationRelief of caregiver burden between the patient andStrengthened relationships health care teamOptimized quality of lifePersonal growth and enhancedmeaningAdvance care planning in progressIntensify palliative care interventionsConsult with a me

96、ntal healthprofessional to evaluate and treatundiagnosed psychiatric disorders,substance abuse, and inadequatecoping methodsSee NCCN Guidelines for DistressManagementcManagementof any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, s

97、ocial workers and other mentalhealth professionals, chaplains, nurse practitioners, physician assistants, and dietitians.dOncologists should integrate palliative care into general oncology care. Early consultation/collaboration with a palliative care specialist/hospice team should beconsidered to im

98、prove quality of life and survival.Note: All recommendations are category 2A unless 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.Printed by Maria Chen on 5/27/2014 1

99、0:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be repro

100、duced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionYeartomonthsMonthstoweeksWeeks todays(Dyingpatient)Provide appropriate anticancer therapy asoutlined in NCCN disease-specific guidelinesProvide appropriate prevention and managementof

101、symptoms caused by anticancer therapyProvide appropriate palliative carePrepare patient psychologically for possibledisease progressionProvide guidance regarding anticipated courseof diseaseReassess understanding of goals of therapy andprognosisOffer best supportive care, including referral topallia

102、tive care or hospiceRedirect goals and hopes to those that areachievable based upon likely prognosis and lifeexpectancyConsider discontinuation of anticancer treatmentDiscontinue anticancer therapyIntensify palliative care in preparation for deathProvide guidance regarding anticipated dyingprocessFo

103、cus on symptom control and comfortFoster patient participation in preparing lovedonesRefer to palliative care/hospice teamContinueanticancer therapyand palliative careNCCN Guidelines Version 1.2014Palliative CareBENEFITS/RISKS OF ANTICANCER THERAPYESTIMATEDINTERVENTIONSDiscuss whether intent and goa

104、ls of therapy arepalliative or curativeReview the, risks of anticancer therapy, includingpossible effects on quality of lifeConfirm the patients understanding ofincurability of diseasePAL-9LIFEEXPECTANCYYearsREASSESSMENTAcceptable:Adequate pain andsymptom controlReduction ofpatient/family distressAc

105、ceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality of lifePersonal growth andenhanced meaningOngoingreassessmentChange ordiscontinueanticancer therapyReview patienthopes about andmeaning ofanticancer therapyIntensify palliativecare interventionsReview advance

106、care planningConsult or refer tospecializedpalliative careservices or hospiceNote: All recommendations are category 2A unless 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 encou

107、raged.UnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The

108、NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of an

109、y cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.NCCN Guidelines Version 1.2014Palliative CareYear tomonthsMonthsto weeksWeeks todays(Dyingpatient)consciousness based on patient preferenceModify routes of administration as needed (PO,Treat according

110、to NCCNGuidelines for Adult Cancer PainTreat according to NCCN Guidelines for AdultCancer PainIn addition:Do not reduce dose of opioid solely fordecreased blood pressure, respiration rate, orlevel of consciousnessMaintain analgesic therapy; titrate to optimalcomfortRecognize and treat opioid-induced

111、 neurotoxicity,including myoclonus and hyperalgesiaIf opioid reduction is indicated, reduce by 50%per 24 h to avoid acute opioid withdrawal or paincrisis. Do not administer opioid antagonistBalance analgesia against reduced level ofIV, PR, subcutaneous, sublingual, transmucosal,and transdermal) appl

112、ying equianalgesic doseconversionsConsult with a pain management/palliative carespecialist Consider sedation for refractory pain(See PAL-31)INTERVENTIONSREASSESSMENTPAL-10OngoingreassessmentAcceptable:Adequate pain andsymptom controlReduction ofpatient/family distressAcceptable sense ofcontrolRelief

113、 of caregiverburdenStrengthenedrelationshipsOptimized quality oflifePersonal growth andenhanced meaningPAINContinue to treataccording toNCCN Guidelinesfor Adult CancerPainMonitorsymptoms andquality of life todeterminewhetheradditional end-of-life measuresare requiredContinue to treataccording toPain

114、Consider aconsultation witha painmanagement/palliative carespecialistNCCN Guidelinesfor Adult CancerESTIMATEDLIFEEXPECTANCYYearsUnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc.

115、, All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNote: Al

116、l recommendations are category 2A unless 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 1.2014Palliative Care(NPPV) (eg, CPAP, BiPAP) support i

117、fclinically indicated for severe reversibleINTERVENTIONSAssess symptom intensityTreat underlying causes/comorbid conditions: Radiation/chemotherapy Therapeutic procedure for cardiac, pleural,or abdominal fluid Bronchoscopic therapy Bronchodilators, diuretics, steroids,antibiotics, or transfusions An

118、ticoagulants for pulmonary emboliRelieve symptoms Oxygen therapy for symptomatic hypoxia Educational, psychosocial, and emotionalsupport for the patient and family Nonpharmacologic therapies, includingfans, cooler temperatures, stressmanagement, relaxation therapy, andphysical comfort measures If op

119、ioid naive, morphine, 2.5-10 mg PO q 4hr prn, 1-3 mg IV q 1 hr prnf If dyspnea is not relieved by opioids and isassociated with anxiety, addbenzodiazepines (if benzodiazepine naive,starting with lorazepam, 0.5-1 mg PO q4 hr prn) Noninvasive positive-pressure ventilationWeeks todays(Dyingpatient)cond

120、itionSee Interventions (PAL-12 )DYSPNEAOngoingreassessmentPAL-11Continue to treat andmonitor symptomsand quality of life todetermine whetherstatus warrantschange in strategiesIntensify palliative careinterventionsConsult or refer tospecialized palliativecare services or hospiceESTIMATEDLIFEEXPECTANC

121、YYearsYear tomonthsMonthsto weeksfFor acute progressive dyspnea, more aggressive titration may be required.REASSESSMENTAcceptable:Adequate dyspnea andsymptom controlReduction ofpatient/family distressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality of lif

122、ePersonal growth andenhanced meaningUnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.SeeInterventions Reduce excessive secretions withReduction oftreat and

123、Acceptable sense ofsymptoms andRelief of caregiverStrengthenedrelationshipsOptimized quality oflifePersonal growth andUnacceptableVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any for

124、m without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical tri

125、als is especially encouraged.regarding dying or respiratory failureProvide emotional and spiritual supportFocus on comfort Continue to treat underlying condition asappropriateRelieve symptoms Fans Oxygen if hypoxic and/or subjective relief isreported Nonpharmacologic therapies; educational,psychosoc

126、ial, and emotional support(See PAL-11)If fluid overload is a contributing factor Decrease/discontinue enteral or parenteral fluid Consider low-dose diuretics If opioid naive, morphine, 2.5-10 mg PO q 4 hrprn, 1-3 mg IV q 1 hr prnf Benzodiazepines (if benzodiazepine naive,starting dose lorazepam, 0.5

127、-1 mg PO q 1 hr prn)gscopolamine, 0.4 mg SC q 4 hr prn; 1.5 mgpatches, 1-6 patches q 3 d; atropine 1%ophthalmic solution 1-2 drops SL q 4 h pr; orglycopyrrolate 0.2-0.4 mg IV or SQ q 4 hr prnWithhold/withdraw/initiate time-limited trial ofmechanical ventilation as indicated Address patient and famil

128、y preferences,prognosis, and reversibility of respiratory failure Provide sedation as neededProvide anticipatory guidance for patient/familyINTERVENTIONSAssess symptom intensity Use physical signs of distress as potentialdyspnea in noncommunicative patientsNCCN Guidelines Version 1.2014Palliative Ca

129、reDYSPNEAREASSESSMENTAcceptable:Adequate dyspneaPAL-12YearsYear tomonths(PAL-11)Months toweeksWeeks to days(Dying patient)Ongoingreassessmentand symptom controlContinue topatient/family distressmonitorcontrolquality of lifeburdento determinewhether statuswarrantschange instrategiesenhanced meaningIn

130、tensify palliativecare interventionsand consider aconsultation with apalliative carespecialistConsider sedationfor intractablesymptoms(See PAL-31)ESTIMATEDLIFEEXPECTANCYfFor acute progressive dyspnea, more aggressive titration may be required.gHughes A, et al. Audit of three antimuscarinic drugs for

131、 managing retained secretions. Palliative Medicine. 2000; 14:221-222.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.feeding (as appropriate)Version 1.2014, 04/18/14

132、National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless otherw

133、ise 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 1.2014Palliative CareReview/modify medications that interfere withintakeEvaluate rate/severity of weig

134、ht lossTreat readily reversible cause of anorexia: Early satiety7 Metoclopramide Symptoms that interfere with intake7 Dysgeusia7 Xerostomia7 Oral-pharyngeal candidiasis7 Mucositis7 NV7 Dyspnea7 Depression/anorexia(Mirtazapine 7.5-30 mg hs)7 Constipation7 Pain7 Fatigue7 Eating disorders/body imagemon

135、thsMonths toweeksWeeks todays(Dyingpatient)Continue totreat andmonitorsymptoms andquality of life todeterminewhether statuswarrantschange instrategiesANOREXIA/CACHEXIAINTERVENTIONSREASSESSMENTOngoingreassessmentAcceptable:Weight stabilization orgainImprovement insymptoms thatinterfere with intakeImp

136、roved energyResolution ofmetabolic or endocrineabnormalitiesEvaluate for endocrine abnormalities: Hypogonadism Thyroid dysfunction Metabolic abnormalities (eg, increased calcium)Consider appetite stimulant Megestrol acetate, 400-800 mg/d Prednisone 10-20 mg BIDhConsider an exercise programAssess soc

137、ial and economic factorsConsider nutrition consultConsider nutrition support, enteral and parenteraliSee Interventions (PAL-14 )PAL-13ESTIMATEDLIFEEXPECTANCYYearsYeartoIntensify palliativecare interventionsUnacceptable Provide dietaryconsultationConsider clinical trialhDy S, Lorenz K, et al. Evidenc

138、e-based recommendations for cancer fatigue,anorexia, depression, and dyspnea. 2008 J Clin Oncol 26:3886-3895.iAugust 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 an

139、d Enteral Nutrition (A.S.P.E.N.) JPEN J ParenterEnteral Nutr 2009 Sep-Oct;33(5):472-500.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 Natio

140、nal Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CareAssess importan

141、ce of symptoms of anorexia and cachexiato patient and familyIf important, consider appetite stimulant Megestrol acetate, 400-800 mg/d Prednisone 10-20 mg BIDhFocus on patient goals and preferencesProvide family with alternate ways of caring for the patientProvide emotional supportTreat for depressio

142、n, if appropriate (mirtazapine7.5-30 mg hs)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 dyingpat

143、ient Nutritional support may not be metabolized in patientswith advanced cancer There are risks associated with artificial nutritionand hydration, including fluid overload, infection, andhastened death Symptoms like dry mouth should be treated with localmeasures (eg, mouth care, small amounts of liq

144、uids) Withholding or withdrawal of enteral or parenteral nutritionis ethically permissible in this setting. It will not causeexacerbation of symptoms and may improve somesymptoms.REASSESSMENTOngoingPAL-14Year tomonthsMonthsto weeksWeeks todays(Dyingpatient)INTERVENTIONSSee Interventions (PAL-13 )ANO

145、REXIA/CACHEXIAreassessmentContinue totreat andmonitorsymptoms andquality of life todeterminewhether statuswarrantschange instrategiesIntensify palliativecare interventionsConsult or refer tospecializedpalliative careservices or hospiceESTIMATEDLIFEEXPECTANCYYearsAcceptable:Adequate anorexia/cachexia

146、 symptomcontrolReduction ofpatient/family distressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality oflifePersonal growth andenhanced meaningUnacceptableNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes tha

147、t the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.hDy S, Lorenz K, et al. Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea. 2008 J Clin Oncol 26:3886-3895.Printed by Maria Chen on 5/27/201

148、4 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Medication-inducedcarbamazepine, tricyclic antidepressants)Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserv

149、ed. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CareMonthstoweeksjWeeksto days(Dyingpatient)jtomonthsBowel obstruction (See PAL-1

150、8)Central nervous system (CNS) involvement(eg, brain, meninges) Corticosteroids (dexamethasone,4-8 mg BID-TID) Palliative radiation therapyGastric outlet obstruction from intra-abdominaltumor or liver metastasis If not contraindicated by comorbid conditions,treat with corticosteroids, a proton pumpi

151、nhibitor, and metoclopramide Endoscopic stenting Decompressing G-TubeTreat metabolic abnormalities Hypercalcemia Uremia DehydrationGastritis/GERD Proton pump inhibitor H2-blockerPAL-15If NV persists:See Interventions(PAL-16)If NV stops:See Reassessment(PAL-16)jIn patients with advanced cancer, NV ma

152、y be secondary to the cachexia syndrome (chronic nausea, anorexia, asthenia, changing body image, and autonomic failure).kAn around-the-clock dosing schedule would likely provide the greatest benefit to the patient.lContinuous intravenous or subcutaneous infusions of different antiemetics may be nec

153、essary for the management of intractable NV.Note: All recommendations are category 2A unless 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.ESTIMATEDLIFEEXPECTANCYYear

154、sYearcognitive behavioral therapyNAUSEA AND VOMITINGINTERVENTIONSk,l Discontinue any unnecessary medications Check available blood levels of necessaryChemotherapy/radiation therapy-induced medications (eg, digoxin, phenytoin,( See NCCN Guidelines for Antiemesis)Severe constipation/fecal impaction Tr

155、eat medication-induced gastropathy (eg,(See PAL-17) proton pump inhibitor, metoclopramide)Gastroparesis (metoclopramide, 5-20 mg PO If due to opioids, initiate opioid rotationQID 30 min before meals and at bedtime) and/or consider reducing opioid requirementwith non-nauseating coanalgesics orprocedu

156、ral interventionsPsychogenic Consider psychiatric consultation if patienthas an eating disorder, somatization, phobia,or panic disorder causing NV. See NCCNGuidelines for Distress ManagementNon-specific NV Initiate pharmacologic management withdopamine receptor antagonists (eg,haloperidol, metoclopr

157、amide,prochlorperazine) If anxiety contributes to NV, consider addinglorazepam, 0.5-1 mg q 4 hr prn If oral route is not feasible, considersublingual, rectal, subcutaneous, orintravenous administration of anti-nauseatherapy Consider non-pharmacologic therapies,such as acupuncture, hypnosis, andPrint

158、ed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and thi

159、s illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionAdd a 5-HT3 antagonist (eg, ondansetron) anticholinergic agent (eg, scopolamine) antihistamine (eg, meclizine) cannabinoid.If NV persists:Add a corticost

160、eroid (eg, dexamethasone) olanzapine, if not already tried.If NV persists:Consider using a continuous IV/SCinfusion of antiemetics; consideran opioid rotation if patient is onopioids.INTERVENTIONSPAL-16Adequate NV symptomcontrolReduction ofpatient/family distressAcceptable sense ofcontrolRelief of c

161、aregiverburdenStrengthenedrelationshipsOptimized quality of lifeREASSESSMENTContinue to treatand monitorsymptoms andquality of life todeterminewhether statuswarrants changein strategiesOngoingreassessment(See Interventions ,PAL-15)NCCN Guidelines Version 1.2014Palliative CarePERSISTENT NAUSEA AND VO

162、MITINGIntensify palliative careinterventionsConsult or refer tospecialized palliativecare services or hospiceConsider palliativesedation (See PAL-31)Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is i

163、n a clinical trial. Participation in clinical trials is especially encouraged.If NV persists:Titrate dopamine receptor antagonist(eg, prochlorperazine, haloperidol, metoclopramide,olanzapine) to maximum benefit and tolerance.Acceptable:UnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For

164、personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any for

165、m without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionCONSTIPATIONINTERVENTIONSYearsYeartomonthsMonthstoweeksWeeksto days(Dyingpatient)Preventive measuresIncrease fluidsIncrease dietaryfiber if patient hasadequate fluidintake and physicalactivityExercise

166、, ifappropriateAdministerprophylacticmedications Stimulant laxative stool softener(senna docusate, 2tablets everynight) Increase dose oflaxative stoolsoftener (senna docusate, 2-3tablets BID-TID)with goal of 1non-forced bowelmovement every1-2 daysESTIMATEDLIFE EXPECTANCYIf constipation is present:As

167、sess for cause and severity of constipationRule out impaction, especially if diarrheaaccompanies constipation (overflow aroundimpaction)Rule out obstruction (physical exam,abdominal x-ray/consider GI consult)Treat other causes (eg, hypercalcemia,hypokalemia, hypothyroidism, diabetesmellitus, medicat

168、ions)Add and titrate bisacodyl 10-15 mg daily-TIDwith a goal of 1 non-forced bowel movementevery 1-2 daysIf impacted: Administer glycerine suppository mineraloil retention enema Perform manual disimpaction followingpre-medication with analgesic anxiolyticIf constipation persists:Reassess for cause a

169、nd severity ofconstipationRecheck for impaction or obstructionConsider adding other laxatives, such asbisacodyl suppository (one rectally daily-BID);polyethelene glycol (1 capful/8 oz water BID);lactulose, 30-60 mL BID-QID; sorbitol,30 mL every 2 h x 3, then prn; magnesiumhydroxide, 30-60 mL daily-B

170、ID; or magnesiumcitrate, 8 oz dailyConsider methylnaltrexone for opioid-inducedconstipation, except for post-op ileus andmechanical bowel obstruction, 0.15 mg/kg SCevery other day, no more than once a dayREASSESSMENTContinue to treat andmonitor symptomsand quality of life todetermine whetherstatus w

171、arrantschange in strategiesOngoingreassessmentIntensify palliativecare interventionsConsult or refer tospecializedpalliative careservices or hospiceAcceptable:Adequateconstipationsymptom controlReduction ofpatient/familydistressAcceptablesense of controlRelief ofcaregiver burdenStrengthenedrelations

172、hipsOptimized qualityof lifeUnacceptableTap water enema until clearConsider use of a prokinetic agent (eg,metoclopramide, 10-20 mg PO QID)Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinica

173、l trial. Participation in clinical trials is especially encouraged.NCCN Guidelines Version 1.2014Palliative CarePAL-17Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.

174、can help guide the intervention (eg, decrease NV,Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliativ

175、e Care TOCDiscussionWeeks todays(Dyingpatient)nNCCN Guidelines Version 1.2014Palliative CareMALIGNANT BOWEL OBSTRUCTIONmASSESSMENTYearsYear tomonthsMonthsScreen for and treat underlying reversible causes Adhesions Radiation-induced strictures Internal herniasAssess for malignant causes Tumor mass Ca

176、rcinomatosisAssess the goals of treatment for the patient, whichnallow patient to eat, decrease pain, allow patient togo home/to hospice)Pharmacologic managementIntravenous or subcutaneous fluidsEnteral tube drainage Consider only if other measures fail to reducevomitingEndoscopic managementto weeks

177、Consider medical managementrather than surgicalmanagementAssess the goals of treatmentfor the patient, which can helpguide the interventionn(eg, decrease NV, allow patientto eat, decrease pain, allowpatient to go home/to hospice)Provide education and supportto patient and familySeeInterventions(PAL-

178、19)SeeReassessment(PAL-19)mPlain film radiography may be helpful in confirming the clinical diagnosis of bowel obstruction. Consider a computed tomography scan if surgical intervention iscontemplated, as it is more sensitive and may help identify the cause of obstruction.nMost malignant bowel obstru

179、ctions are partial, allowing time to discuss appropriate intervention with the patient and family.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trial

180、s is especially encouraged.ESTIMATEDLIFEEXPECTANCYPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.PAL-Version 1.2014, 04/18/14 National Comprehensive Cancer Network,

181、Inc. 2014, 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 IndexPalliative Care TOCDiscussionPAL-19 Operative managemento Risks must be discussed with the patient/family (eg, mortality, m

182、orbidity,re-obstruction) Improved quality of life should be the primary goal of surgical treatment Endoscopic management Percutaneous endoscopic gastrostomy tube for drainage Endoscopic stent placement Interventional radiology management Ultrasound-guided gastrostomy tube for drainage Pharmacologic

183、management when the goal is maintaining gut function: Use rectal, transdermal, subcutaneous, or intravenous routes ofadministration Administer opioids: Transdermal, subcutaneous, intravenous Administer antiemetics: Do not use antiemetics that increasegastrointestinal mobility such as metoclopramide;

184、 however, these may bebeneficial in incomplete bowel obstruction Administer corticosteroids: Dexamethasone 4 mg IV TID-QID, discontinueif no improvement is noted in 3-5 days Pharmacologic management when gut function cannot be maintained: Administer anticholinergics (eg, scopolamine, hyoscyamine,gly

185、copyrrolate) Administer octreotide: (100-300 mcg SC BID-TID or 10-40 mcg/hrcontinuous SC/IV infusion) Intravenous or subcutaneous fluids Consider if there is evidence of dehydration Enteral tube drainage Usually uncomfortable Increased risk of aspiration Consider on a limited trial basis only if oth

186、er measures fail to reducevomiting Total parenteral nutrition (TPN) Consider only if there is expected improvement of quality of life with lifeexpectancy of many months to yearsINTERVENTIONSREASSESSMENTOngoingreassessment(See PAL-18 )oRisk factors for poor surgical outcome include: ascites, carcinom

187、atosis, palpable intraabdominal masses, multiple bowel obstructions, previous abdominal radiation,very advanced disease, and poor overall clinical status.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient

188、 is in a clinical trial. Participation in clinical trials is especially encouraged.NCCN Guidelines Version 1.2014Palliative CareMALIGNANT BOWEL OBSTRUCTIONContinue to treatand monitorsymptoms andquality of life todeterminewhether statuswarrants changein strategies Intensify palliativecare interventi

189、ons Consult or refer tospecialized palliativecare services orhospiceAcceptable: Adequate control ofmalignant bowelobstruction symptoms Reduction ofpatient/family distress Acceptable sense ofcontrol Relief of caregiverburden Strengthenedrelationships Optimized quality of life Personal growth andenhan

190、ced meaningUnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.REASSESSMENT Provide cognitive-behavioral treatment Adequate control of Evaluate type/severity

191、of sleep-wake disturbance, including Reduction of Consider polysomnography if history is suggestive of sleep-patient/family distress Acceptable sense of Pain, depression, anxiety, delirium, and nausea Relief of caregiverburden Strengthenedrelationships Optimized quality of life Personal growth andVe

192、rsion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Pa

193、lliative CarePAL-20Weeks todays(Dyingpatient)Months toweeks Assess patients desire to have insomnia and sedation treated Adjust doses of pharmacologic therapies7 Consider chlorpromazine, 25-100 mg PO/PR at bedtime7 Consider quetiapine 25-50 mg PO at bedtimedisturbance Insomnia:7 Lorazepam, 0.5-1 mg

194、PO at bedtime7 Trazodone, 25-100 mg PO at bedtime7 Zolpidem, 5 mg PO at bedtime7 Mirtazapinep, 7.5-30 mg PO at bedtime7 Olanzapine, 2.5-5 mg PO at bedtime Daytime sedation:7 Caffeine 100-200 mg PO q 6 hrs, last dose 4 PM7 Methylphenidate, start with 2.5-20 mg PO BID, second doseno later than 6 hours

195、 before bedtime7 Dextroamphetamine, 2.5-10 mg PO BID, second dose no laterthan 12 hours before bedtime7 Modafinil, 100-400 mg PO each morningESTIMATEDLIFEEXPECTANCYYearsYear tomonthsContinue to treatand monitorsymptoms andquality of life todeterminewhether statuswarrants changein strategiesSLEEP/WAK

196、E DISTURBANCES INCLUDING INSOMNIA AND SEDATIONINTERVENTIONS Explore fears and anxiety regarding death/disease Provide sleep-hygiene educationAcceptable: Includes stimulus control, progressive muscle relaxationsymptomsdaytime impairments (eg, Epworth Sleepiness Scale)disordered breathing Treat contri

197、buting factors:control Medication side effects or withdrawal syndromes(eg, corticosteroids, opioids, anticonvulsants, caffeine,hormones, herbals, barbiturates, benzodiazepines, alcohol,tricyclic antidepressants) Primary sleep disorders such as obstructive sleep apneaand periodic limb movement disord

198、er7 CPAP/BiPAP enhanced meaning For restless leg syndrome consider trial of the following:7 Ropinirole7 Pramipexole7 Carbidopa-levodopa Provide pharmacologic therapies for refractory sleep/wakeOngoingreassessment Re-evaluate contributingetiologies Change insomnia orantisedation therapy Intensify pal

199、liative careinterventions Consult or refer tospecialized palliative careservices or hospice Consider referral forpolysomnographyUnacceptableNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clini

200、cal trial. Participation in clinical trials is especially encouraged.pKim SW, Shin IS, Kim JM, Kim YC, Kim KS, Kim KM, Yang SJ, Yoon JS.Effectiveness of mirtazapine for nausea and insomnia in cancer patientswith depression. Psychiatry Clin Neurosci 2008;62:75-83.Printed by Maria Chen on 5/27/2014 10

201、:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved. Hypoxia Bowel obstruction/ Medication orsubstance effect orVersion 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved.

202、 The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management

203、of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.benzodiazepines,opioids,Severedelirium(agitation)reduction or rotation Support caregivers Administer haloperidol0.5-2 mg PO BID/TID Administer alternative agents:risperidone, 0.5-1 mg PO BID;olanz

204、apine, 5-20 mg PO daily;or quetiapine fumarate,25-200 mg PO/SL BID Titrate starting dose tooptimal effect Orient patient with familypresenceWeeks todays(Dyingpatient) Continue totreat andmonitorsymptomsand qualityof life todeterminewhetherstatuswarrantschange instrategies,includingtapering ofdosesan

205、ticholinergics) Assess, screen for,and maximizenonpharmacologicinterventions (eg,reorientation,cognitive stimulation,sleep hygiene)See Interventions(PAL-22 )NCCN Guidelines Version 1.2014Palliative CareDELIRIUMINTERVENTIONS Reduce or eliminate delirium-inducing medications aspossible (eg, steriods,a

206、nticholinergics,benzodiazepines) Administer haloperidol0.5-10 mg IV q 1-4 h prn Administer alternative agents:olanzapine, 2.5-7.5 mg/d PO/SLq 2-4 h prn (maximum = 30mg/d); chlorpromazine, 25-100mg PO/PR/IV q 4 h prn for bed-bound patients If agitation is refractory to highdoses of neuroleptics,consi

207、der adding lorazepam,0.5-2 mg SQ/IV q 4 h Titrate starting dose to optimaleffect Consider opioid doseOngoingreassessmentREASSESSMENTAcceptable: Adequate deliriumsymptom control Reduction ofpatient/familydistress Acceptable senseof control Relief of caregiverburden Strengthenedrelationships Optimized

208、 qualityof life Personal growthand enhancedmeaningPAL-21 Intensify palliativecare interventions Considerconsultation with apalliative carespecialist orpsychiatristMild/moderatedeliriumESTIMATEDLIFEEXPECTANCY Assess for delirium(eg, DSM criteria) Hyperactive Hypoactive Screen for and treatunderlying

209、reversiblecauses Metabolic causes Unrelieved painYearsobstipationYear to Infectionmonths CNS events Bladder outletobstructionMonthsto weekswithdrawal (eg,UnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehe

210、nsive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative

211、Care TOCDiscussionNote: All recommendations are category 2A unless 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-22EvaluateforiatrogeniccausesDiseaseprogressionti

212、tration of haloperidol, risperidone,olanzapine, or quetiapine fumarateProvide appropriate upward dosetitration of lorazepam for patientswith refractory agitation despitehigh doses of neurolepticsConsider rectal or intravenoushaloperidol or administration ofchlorpromazine lorazepamFocus on family sup

213、port andcoping mechanismEducate family and caregiver(s)Consider that agitation may bemistaken for pain resulting inhigher doses of opioids, which mayexacerbate deliriumRemove unnecessarymedications, tubes, etc.Decrease doses of medicationsdependent upon hepatic or renalfunctionFocus on symptom contr

214、olRotate opioidsProvide appropriate upward doseTreat cause if possible andprovide symptomatic reliefto weeksWeeksto days(Dyingpatient)Year tomonthsMonthsContinue totreat andmonitorsymptoms andquality of lifeto determinewhether statuswarrantschange instrategiesSee Interventions(PAL-21)IatrogenicINTER

215、VENTIONSREASSESSMENTOngoingreassessmentAcceptable:Adequate deliriumsymptom controlReduction ofpatient/familydistressAcceptable senseof controlRelief of caregiverburdenStrengthenedrelationshipsOptimized qualityof lifePersonal growthand enhancedmeaningUnacceptableDELIRIUMIntensifypalliative careinterv

216、entionsConsult with apalliative carespecialist orpsychiatristConsiderpalliativesedation (SeePAL-31)ESTIMATEDLIFEEXPECTANCYYearsNCCN Guidelines Version 1.2014Palliative CarePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Co

217、mprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalli

218、ative Care TOCDiscussionand stressesEnsure that caregiver(s) are availableEnsure a safe home environmentEnsure adequate access to transportationEnsure sufficient financial resourcesRefer to social services as needed toassist with mobilization of family,community, and financial resourcesEnsure suppor

219、t and education tocaregiver(s) and family members Counseling Support groupsRespond to caregiver-specific burdensUnacceptableMonthsto weeksWeeks todays(DyingAssess bereavement riskDiscuss personal, spiritual, and culturalissues relating to illness and prognosisObtain medical interpreters/translatorsw

220、ho are not related to the patient andfamily as neededAssist family/caregiver(s) with respitecareSee Interventions (PAL-24 )Ongoing re-evaluation andcommunicationbetween thepatient,caregiver(s), familymembers, andhealth care teamREASSESSMENTOngoingreassessmentYearsYear tomonthsmanagementReduction ofp

221、atient/family distressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality of lifePersonal growth andenhanced meaningPAL-23INTERVENTIONSIntensify efforts tocommunicate palliativecare optionsConsider referral topsychologist orpsychiatrist to evaluateand treat

222、psychologicdisordersSee NCCN Guidelines forDistress ManagementESTIMATEDLIFEEXPECTANCYAcceptable:Adequate socialsupport and resourcepatient)Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinic

223、al trial. Participation in clinical trials is especially encouraged.NCCN Guidelines Version 1.2014Palliative CareSOCIAL SUPPORT/RESOURCE MANAGEMENTPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Networ

224、k, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionN

225、ote: All recommendations are category 2A unless 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 1.2014Palliative CareDiscuss prognosis on an ong

226、oing basis inclear, consistent language with the patient,caregiver(s), and family, includinginformation about the natural history of thespecific tumorEvaluate and support the patients desiresfor comfortExplain the dying process and expectedevents to the patient, caregiver(s), andfamily membersRespon

227、d to caregiver-specific demandsand stressesReassess bereavement riskEnsure that care conforms with culturaland spiritual/religious practicesProvide emotional support and addressany patient-family or intra-family conflictsregarding interventionConsider palliative care consultation toassist in conflic

228、t resolution when thepatient, family, and/or professional team donot agree on benefit/utility of interventionsObtain medical interpreters/translatorswho are not related to the patient andfamily as neededDetermine eligibility and readiness forspecialized palliative/hospice care andneeds that might be

229、 best met by hospicemonthsMonthsto weeksWeeks todays(Dyingpatient)INTERVENTIONSSee Interventions (PAL-23)OngoingreassessmentREASSESSMENTAcceptable:Adequate socialSOCIAL SUPPORT/RESOURCE MANAGEMENTOngoing re-evaluation andcommunicationbetween thepatient and healthcare teamReassess patient andfamilyIn

230、tensify palliative careinterventionsConsult or refer tospecialized palliative careservices, hospice, orethics committeeConsider referral topsychologist orpsychiatrist to evaluateand treat psychologicdisordersSee NCCN Guidelines forDistress ManagementESTIMATEDLIFEEXPECTANCYYearsYear tosupport and res

231、ourcemanagementReduction ofpatient/family distressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality of lifePersonal growth andenhanced meaningUnacceptablePAL-24Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribu

232、tion. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of

233、NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless 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

234、 Version 1.2014Palliative CarePAL-25information should be given tothe family Desire for information maychange and may need to bechallenged as deathapproaches Provide information aboutexpected course of diseaseand anticipated care needs Provide anticipatory guidanceon dying processFacilitate decision

235、s onproviding information to familyDetermine the decision-makingpreferences/styles of thepatient and family Facilitate congruence ofpatient goals andexpectations with those ofthe family Recognize that theinvolvement of the family maychange over timeYeartomonthsMonthstoweeksReassess patientand family

236、Intensify palliativecare interventionsConsult or refer tospecializedpalliative careservices or hospiceSee Advance CarePlanning (PAL-27 )GOALS AND EXPECTATIONS, EDUCATIONAL AND INFORMATIONAL NEEDS, AND CULTURAL FACTORS AFFECTING CARE FOR THE PATIENT AND FAMILYOngoingreassessmentYearsREASSESSMENTAccep

237、table:Reduction of patient/family distressAcceptable sense of controlRelief of caregiver burdenStrengthened relationshipsOptimized quality of lifePersonal growth and enhancedmeaningWeeks to days(Dying patient)See Interventions (PAL-26)ESTIMATED INTERVENTIONSLIFEEXPECTANCY Assess patient/familyunders

238、tanding of expectedcourse of diseaseAssess for decision-makingcapacity and need for asurrogate decision makerClarify with the patient howmuch information he or shewishes to have and how muchand put affairs in order(providers should demonstratecultural sensitivity)Determine eligibility andreadiness f

239、or specializedpalliative/hospice care andneeds that might be best met byhospiceFoster realistic expectationsProvide clear, consistentdiscussion with the patient andfamily about prognosis on anongoing basisRespect goals and needs of thepatient and family regardingthe dying processAddress cultural cus

240、toms andbeliefs directly orthrough a cultural liaisonAnticipate patient and familyneedsProvide anticipatory griefsupport and end-of-lifeeducationDetermine the patient/familyvalues and preferences withrespect to quality of lifeFacilitate advance care planning(See PAL-27)Encourage the patient to revie

241、wand revise personal priorities,identify “unfinished business,”heal interpersonal relationships,UnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.

242、2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNote: All recommendations are category 2

243、A unless 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 1.2014Palliative CareAssess patient/family understanding ofthe dying processEducate pat

244、ient and family on dyingprocessPrepare for patients deathFacilitate anticipatory grief workEnsure continuing care process and referto appropriate careRespect goals and needs of the patientand family regarding the dying processPromote that patient does not die aloneunless dying alone is an establishe

245、dpreference of patientOffer spiritual supportEncourage planning for funeral/memorialservices, as determined by personalpreferences, cultural customs, and beliefsREASSESSMENTMonthsto weeksWeeks todays(Dyingpatient)INTERVENTIONSSee Interventions (PAL-25)PAL-26Ongoingreassessment(See PAL-25 )GOALS AND

246、EXPECTATIONS, EDUCATIONAL AND INFORMATIONAL NEEDS, AND CULTURAL FACTORS AFFECTING CARE FOR THE PATIENT AND FAMILYESTIMATEDLIFEEXPECTANCYYearsYear tomonthsAcceptable:Reduction of patient/family distressAcceptable sense of controlRelief of caregiver burdenStrengthened relationshipsOptimized quality of

247、 lifePersonal growth and enhancedmeaningReassess patient andfamilyIntensify palliative careUnacceptableinterventionsConsult or refer tohospice or specializedpalliative care servicesPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 Na

248、tional Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 I

249、ndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless 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.anxietyAssess decision-making capacity

250、 and needfor surrogate decision-makerInitiate discussion of personal values andpreferences for end-of-life careIf patient values and goals lead to a clearrecommendation regarding future treatmentin light of disease status, physician shouldOngoing re-evaluationand communicationbetween the patient and

251、health care teamYear tomonthsMonths toweeksWeeks todays(Dyingpatient)make a recommendation about future careDocument patient values and preferencesand any decisions in accessible site inmedical record (including MOLST/POLST ifcompleted)Encourage the patients to discuss wisheswith family/proxyInitiat

252、e discussion of palliative care options,including hospice if appropriateIntroduce palliative care team if appropriateRefer to state and institutional guidelines foradditional guidanceSee Interventions (PAL-28 )NCCN Guidelines Version 1.2014Palliative CareADVANCE CARE PLANNINGINTERVENTIONSAsk patient

253、 if he/she has a living will,medical power of attorney, health care proxy,or patient surrogate for health care If not, encourage patient to prepare oneExplore fears about dying and addressPAL-27OngoingreassessmentYearsREASSESSMENTAcceptable:Adequate advancecare planningReduction ofpatient/familydist

254、ressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality ofExplore patient reluctance toengage in advance careplanningExplore fears and worriesabout illnessRefer to palliative care if thepatient is having difficultyengaging in discussion ofadvance care planni

255、ngConsider referral to a mentalhealth clinician to evaluatemental health issuesSee NCCN Guidelines forDistress ManagementESTIMATEDLIFEEXPECTANCYlifePersonal growth andenhanced meaningUnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Cop

256、yright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCC

257、N Guidelines IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unless 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

258、1.2014Palliative CareConsider consultation with a palliative care specialistto assist in conflict resolution when the patient,family, and health care team disagreeExplore fears about the future and provide emotionalsupportAddress years-to-months interventionsDetermine patient and family preferences

259、for thelocation of the patients deathConfirm the patients values and decisions in light ofchanges in statusIf not previously done, make recommendations aboutappropriate medical treatment to meet the patientsvalues and goalsEnsure complete documentation of the advance careplan in the medical record,

260、including MOLST/POLSTif applicable, to assure accessability of the plan to allproviders across care settingsExplore family concerns about the patients plan andseek resolution of conflict between patient and familygoals and wishesAssure that all items identified above are completeImplement and ensure

261、 compliance with advance careplanClarify and confirm the patients decision about life-sustaining treatments, including CPR, if necessaryExplore desire for organ donation and/or autopsyWeeks todays(Dyingpatient)YeartomonthsMonthsto weeksOngoing re-evaluation andcommunicationbetween thepatient/familya

262、nd health careteamINTERVENTIONSSee Interventions (PAL-27 )REASSESSMENTPAL-28OngoingreassessmentAcceptable:Adequate advance careplanningReduction ofpatient/family distressAcceptable sense ofcontrolRelief of caregiverburdenStrengthenedrelationshipsOptimized quality of lifePersonal growth andenhanced m

263、eaningADVANCE CARE PLANNINGExplore patient reluctance toengage in advance careplanningExplore fears and worries aboutillnessRefer to palliative care if thepatient is having difficultyengaging in discussion ofadvance care planningConsider referral to a mentalhealth clinician to evaluatemental health

264、issuesSee NCCN Guidelines forDistress ManagementESTIMATEDLIFEEXPECTANCYYearsUnacceptablePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 Natio

265、nal Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative Care.PAL-29RESPONSE

266、 TO REQUESTS FOR HASTENED DEATH(PHYSICIAN AID-IN-DYING, PHYSICIAN-ASSISTED SUICIDE, EUTHANASIA)The NCCN Palliative Care Panel believes that the most appropriate response to a request for assistance in suicide is to intensifypalliative care. All such patients should be referred to a palliative care s

267、pecialist. However, evaluating a patients request for physician-assisted suicide is an important skill, even for clinicians who feel this practice is never morally acceptable. A request for hastened deathoften has important meanings that require exploration. Clarifying these meanings can sometimes e

268、nlarge the range of useful therapeuticoptions instead of providing a lethal prescription.Address the request explicitly. If a patient uses a euphemism for death or refers to it indirectly, ask for clarification. Do not assume that awish for death to come soon is a wish for a lethal prescription.Dist

269、inguish wishing not to live in the patients current state from wishing for a hastened death including euthanasia and physician-assistedsuicide.Explore the reasons for the request for a hastened death, and find out why now?” Reassess symptom control. Reassess psychological/psychiatric issues, especia

270、lly depression, anxiety, grief, psychosis, and delirium. Ask about the patients relationship to family or other important people. Ask about individual values and personal views of spiritual/existential suffering. Assess for fears of caregiver burden and abandonment and re-emphasize physician commitm

271、ent to the patient.Offer information about the natural history of the disease and explain the process of dying.Address the role of medical caregivers, including hospice if appropriate.Discuss alternatives to physician-assisted suicide such as withdrawal of life-sustaining treatment, voluntary cessat

272、ion of eating or drinking,and/or sedation for refractory symptoms.Request a consult with a mental health professional to diagnose and treat reversible causes of psychological suffering.Know the local legal status of hastened death. Some patients may be confused about legal/ethical distinctions; trea

273、tmentwithdrawal and aggressive treatments for symptoms, such as pain, are not physician-assisted suicide. Physician-assisted suicide is legalonly in Oregon, Montana, Vermont, and Washington and has specific guidelines. Euthanasia is not legal in any state in the United States.Examine your own respon

274、se as a clinician to a particular patients request. Requests for hastened death can force clinicians to confront theirown personal, professional, moral, and legal responsibilities. Dealing with an individual patient can be quite different from thinking about theissue in abstract circumstances. Consi

275、der a consultation with an ethics committee, palliative care service, or experienced colleague. Thesecases are usually complex and often benefit from consideration of multiple perspectives.Clarify the care plan. Requests for hastened death should prompt ongoing discussion and active attempts to amel

276、iorate physical,psychological, and spiritual distress. Re-emphasize your own commitment to providing continuing care for the patient. Maintain medicationsfor symptom control.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management o

277、f any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014,

278、 04/18/14 National Comprehensive Cancer Network, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNote: All recommendations are category 2A unle

279、ss 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 1.2014Palliative CareInterventions (PAL-32 )PAL-30Physical Intensify comfort measures:7 Impl

280、ement skin safety protocol according to risk assessment,including using a pressure-relieving mattress and regularlyrepositioning the patient for comfort as indicated; keep skinfluids.7 For refractory secretions (See PAL-12) Treat dyspnea by adjusting the dose of medication (See PAL-11) Treat refract

281、ory restlessness and agitation with palliative sedation(See PAL-31) Prepare to meet a request for organ donation and autopsyPsychosocial Help support the patient and family to accept discontinuation ofTPN and transfusions, dialysis, IV hydration, and medications thatwill not add to the patients comf

282、ort Consider social work and chaplain consultsCARE OF THE IMMINENTLY DYING PATIENTFor an imminently dying patient, consider using an end-of-life care order set, which may contain physical, psychosocial, and practicalinterventions, including the following:moist; reassess wound care for comfort; and p

283、remedicate for Allow the patient and family to have uninterrupted time togetherwound care as needed Ensure that the patient and family understand the signs and7 Provide mouth care to keep mouth/lips moist symptoms of imminent death and that they are supported7 Treat for urinary retention and fecal i

284、mpaction throughout the dying process Ensure deactivation of implanted defibrillator and consider Offer anticipatory bereavement supportdeactivation of implanted pacemaker Provide support to children and grandchildren Discontinue unnecessary diagnostic tests and interventions such Encourage visits b

285、y children if consistent with family valuesas transfusions, needle sticks, blood glucose monitoring, oxygen Support culturally meaningful ritualssaturation monitoring, and suctioningdirectivescontrol assessments Switch routes of medication administration when the oral route is Practicalno longer fea

286、sible Mobilize in-hospital end-of-life care policies and procedures Adjust doses of medications to optimal comfort Ensure that the patients advance directives are documented and Treat unclearable terminal secretions (death rattle) by changing implementedthe patients positioning and reducing parenter

287、al and enteral Recommend that the patients wishes for resuscitation and/ordo-not-attempt-resuscitation (DNAR) are documented and followed7 If the patient/family have not documented a DNAR order, intensifypatient/family education, counsel the family on the importance of aDNAR, or allow natural death

288、(AND) Ensure privacy for the patient and family; if not at home, arrange fora private room if possible Facilitate around-the-clock family presence Provide the patient and family with respectful space anduninterrupted time together Facilitate funeral planningSee After-DeathPrinted by Maria Chen on 5/

289、27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not

290、 be reproduced in any form without the express written permission of NCCN NCCN Guidelines IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CarePALLIATIVE SEDATIONConfirm that the patient has refractory symptoms and is imminently dying. Refractory symptoms are symptoms that

291、 cannot be adequately controlled despite aggressive, skilled palliative care that does notcompromise consciousness. Imminently dying is a prognosis of hours to days confirmed by two physicians.Obtain informed consent for sedation from the patient and/or surrogate/family. Discuss the patients disease

292、 status, treatment goals, prognosis, and expected outcomes with the patient and/or surrogate. Clarify that sedation will consist of the continuous administration of medications that will render the patient unconscious. Review the ethical justification of the use of sedation with the patient/surrogat

293、e/family and members of the health care team.7 An ethics consult may be considered in accordance with institutional guidelines and state regulations. Explain that consent for sedation must be accompanied by consent for:7 Discontinuation of life-prolonging therapies7 Withholding of cardiopulmonary re

294、suscitationPermit reassignment of health care professionals who cannot provide sedation due to personal or professional values and beliefs as longas patient care can be safely transferred to the care of another health care professional.Select an appropriate sedative treatment plan based upon the pat

295、ients response to recent and current medications.Typical sedatives used for palliative sedation parenteral infusions include: Thiopental: Initial infusion rate 20-80 mg/h; range 160-440 mg/h Pentobarbital: Initial infusion 2-3 mg per kg load then 1-2 mg per kg/h Midazolam: Initial infusion rate 0.4-

296、0.8 mg/h; range 20-102 mg/hContinue current pain and symptom management control interventions.Monitor patient symptoms regularly and titrate sedatives and other medications based on response and drug/drug interactions to establishand maintain a level of sedation that relieves the patients refractory

297、 symptoms.Provide ongoing psychosocial and spiritual support for the patients surrogate, family, and health care professionals.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Pa

298、rticipation in clinical trials is especially encouraged.PAL-31Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/14 National Comprehensive Cancer N

299、etwork, Inc. 2014, 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 IndexPalliative Care TOCDiscussionNCCN Guidelines Version 1.2014Palliative CareAFTER-DEATH INTERVENTIONSFor family and

300、caregiver(s)! Immediate after-death care: Provide the family time with the body Remove tubes, drains, lines, and the foley catheter unless an autopsy is planned Inform family (if not present) of death Ensure culturally sensitive, respectful treatment of the body Address survivor concerns about organ

301、 donation and/or autopsy File the death certificate, complete forms, and provide necessary information for thefuneral director Offer condolences Inform other health care providers of the patients death! Bereavement support: Formally express condolences on the patients death (eg, card, call, letter)

302、Refer to appropriate bereavement services within the institution or in the community Attend a debriefing meeting with the family if they desire one! Discuss cancer risk assessment and modification with family membersIdentify family members at risk for complicated bereavement or prolonged grief disor

303、derFor health care professionalsGeneral support:Legitimize discussion of personal issues that impact patient careCreate a climate of safety for discussion of patient deathsProvide regular opportunities for reflection and remembering for staff through a memorialritualAfter-death support:Review medica

304、l issues related to the patients death Explore concerns and questions regarding quality of patient careReview the familys emotional responses to the patients deathReview the staffs emotional responses to the patients death Include nurses, nursing assistants, physician team members (including medical

305、 students,residents, and fellows), social workers, and chaplaincy, as appropriate Consider a bereavement ritual for staff (eg, brief reading, moment of quiet)Identify health care professionals at risk for complicated bereavement, moral distress, orcompassion fatigueNote: All recommendations are cate

306、gory 2A unless 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.DEATHDeathASSESSMENTA “peaceful death”:Free from avoidabledistress andsuffering for thepatient, family, a

307、ndcaregiver(s)In general accordwith the patientsand familys wishesConsistent withclinical, cultural,and ethicalstandardsPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserve

308、d.PAL-NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CareDiscussionNCCN Categories of Evidence and ConsensusCategory 1: Based upon high-level evidence, there is uniform NCCNconsensus that the intervention is appropriate.Category 2A: Based upo

309、n lower-level evidence, there is uniformNCCN consensus that the intervention is appropriate.Category 2B: Based upon lower-level evidence, there is NCCNconsensus that the intervention is appropriate.Category 3: Based upon any level of evidence, there is major NCCNdisagreement that the intervention is

310、 appropriate.All recommendations are category 2A unless otherwise noted.Table of ContentsOverview.MS-2Palliative Care in Oncology.MS-2The Definition of Palliative Care .MS-2Impact of Palliative Care .MS-3Provision of Palliative Care.MS-4Hospice Care .MS-4Palliative Care Standards .MS-5Barriers to Ti

311、mely Provision of Palliative Care .MS-6Training in Palliative Care.MS-7Communication Skills Training.MS-7NCCN Guidelines for Palliative Care.MS-8Palliative Care Screening.MS-8Palliative Care Assessment.MS-9Assessment for Benefits and Risks of Anticancer Therapy .MS-9Assessment of Personal Goals and

312、Expectations.MS-9Assessment of Physical Symptoms .MS-9Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-1Assessment of Psychos

313、ocial Distress.MS-9Assessment of Educational and Informational Needs and CulturalFactors Affecting Care.MS-9Criteria for Consultation with Palliative Care.MS-9Palliative Care Interventions .MS-10Anticancer Therapy.MS-11Symptom Management .MS-12Pain.MS-12Dyspnea .MS-13Anorexia/Cachexia.MS-14Nausea an

314、d Vomiting.MS-15Constipation.MS-16Malignant Bowel Obstruction .MS-16Fatigue/Weakness/Asthenia .MS-17Sleep/Wake Disturbances.MS-17Delirium .MS-18Psychosocial Distress Social Support/Resource Management.MS-19Advance Care Planning.MS-20Palliative Care Reassessment.MS-21Special Palliative Care Intervent

315、ions.MS-21Requests for Hastened Death .MS-21Palliative Sedation.MS-22Care of the Imminently Dying Patient .MS-22A Peaceful Death .MS-23After-Death Care Interventions.MS-23Palliative Care Research .MS-24Putting Palliative Care Guidelines into Practice .MS-24Psychosocial Support for Palliative Care Pr

316、oviders .MS-26Hope.MS-26Table 1: Palliative Care Internet Resources for Cliniciansa .MS-28References.MS-29Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.20

317、14, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-2NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version

318、 1.2014Palliative CareOverviewThe aim of the NCCN Guidelines for Palliative Care is to help assurethat each patient with cancer experiences the best quality of lifepossible throughout the illness trajectory by providing guidance for theprimary oncology team. The NCCN Palliative Care Panel is aninter

319、disciplinary group of representatives from NCCN MemberInstitutions, consisting of medical oncologists, hematologists andhematologic oncologists, pediatric oncologists, neurologists andneuro-oncologists, anesthesiologists, psychiatrists and psychologists,internists, palliative care and pain managemen

320、t specialists, and geriatricmedicine specialists. These guidelines were developed and areupdated annually by the collaborative efforts of these experts based ontheir clinical experience and available scientific evidence.Palliative Care in OncologyMore than 1.65 million people are expected to be diag

321、nosed withcancer in the United States in 2014, and almost 0.6 million people areexpected to die of the disease.1 Global cancer rates are increasing, withan associated rise in the number of cancer survivors living withsymptoms and disabilities as a result of their disease and/or itstreatment (see the

322、 NCCN Guidelines for Survivorship).2-4 The need forcomprehensive care for patients with cancer and their families is great.Approximately 16% of patients with cancer being discharged from asingle hospital in Germany were assessed as having palliative careneeds, with the greatest needs in patients wit

323、h head and neck cancer,melanoma, and brain tumors.5 More than one-third of patients withcancer in a large observational cohort study reported moderate tosevere symptoms in the majority of categories (pain, nausea, anxiety,depression, shortness of breath, drowsiness, well-being, loss ofappetite, and

324、tiredness) in the last weeks of life.6 Thus, the need forpalliative oncologic care is great.Palliative care in oncology mainly began as hospice and end-of-lifecare. During the past 20 years, increasing attention has been paid toquality-of-life issues in oncology throughout the disease trajectory.3,7

325、-11As the hospice movement has grown in this country, palliative care hasdeveloped into an integral part of comprehensive cancer care.3,12-16The Definition of Palliative CareThese guidelines define palliative care as a special kind of patient- andfamily-centered health care that focuses on effective

326、 management ofpain and other distressing symptoms, while incorporating psychosocialand spiritual care according to patient/family needs, values, beliefs, andculture(s). The goals of palliative care are to anticipate, prevent, andreduce suffering and to support the best possible quality of life forpa

327、tients and their families, regardless of the stage of the disease or theneed for other therapies. Palliative care begins at diagnosis and shouldbe delivered concurrently with disease-directed, life-prolongingtherapies and should facilitate patient autonomy, access to information,and choice. Palliati

328、ve care becomes the main focus of care whendisease-directed, life-prolonging therapies are no longer effective,appropriate, or desired. Palliative care should be initiated by the primaryoncology team and then augmented by collaboration with aninterdisciplinary team of palliative care experts.Buildin

329、g on the WHOs recommended model of resource allocation incancer care,12 a 1999 NCCN Task Force recommended that palliative,symptom-modifying therapy should be provided simultaneously withdisease-modifying therapy from diagnosis.17 While palliative carepreviously focused on end-of-life care, the idea

330、 that palliative careneeds to be integrated earlier into the continuum of cancer care isincreasingly understood.18-22 Palliative care needs to exist right from thetime of diagnosis through survivorship and/or end-of-life care. PalliativePrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal us

331、e only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without

332、 the express written permission of NCCN.MS-3NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carecare should begin with the presentation of symptoms, even before thesource of those symptoms has been fully determined. As the cancerprogresses and

333、 anticancer therapy becomes less effective, appropriateand desired palliative care becomes the major focus of the continuingcare of the patient and family.23 Patients with increased risk for cancershould also be provided with supportive care along with risk-reductiontherapies. Palliative care should

334、 continue even after the patients deathin the form of bereavement support for the patients survivors.Impact of Palliative CareA remarkable study showed that early introduction of palliative care cannot only improve quality of life for patients with advanced cancer but canalso improve survival.24 A s

335、econdary analysis of this study furthershowed that patients receiving early palliative care were less likely toreceive chemotherapy in the last 60 days of life (odds ratio, 0.47; 95%CI, 0.23 to 0.99; P = .05),25 likely because these patients had a moreaccurate understanding of their prognosis, which

336、 impacted decisionsabout their care.26Palliative care consultations in patients with advanced cancers havealso been shown to reduce the quantity and intensity of life-prolongingcare received towards the end of life. In one study, early referral tocommunity-based palliative care services reduced the

337、number ofemergency department visits in the last 90 days of life in patients withcancer.27 Likewise, in another study, the lack of palliative care teamconsultation was shown to be a predisposing factor for futile life-sustaining treatments at the end of life.28 Moreover, in a cohort of 6076patients

338、with advanced pancreatic cancer, patients who had received atleast one palliative care consultation had lower odds of intensive careunit (ICU) admission, multiple emergency department visits, andmultiple hospitalizations near death.29Palliative care has been shown to reduce symptom burden, improvequ

339、ality of life, and increase the odds of dying at home. In a recent studycomparing standard care with ongoing palliative care in patients withadvanced cancer who had a prognosis of 6 to 24 months to live,palliative care resulted in improved patient quality of life, satisfactionwith care, and decrease

340、d symptom severity.30 Furthermore, a recentCochrane Database systematic review analyzing home palliative care inpatients with advanced illness demonstrated reliable reduction ofsymptom burden and increased likelihood of dying at home without anegative impact on caregiver grief.31 Finally, a study by

341、 Kamal andcolleagues showed that provider conformance with supportive carequality measures significantly improved quality of life for patients withcancer who were receiving palliative care.32Provider education and training in palliative care can also positivelyimpact providers and patients. The OPTI

342、M (Outreach Palliative Caretrial of Integrated Regional Model) study is a multiregional, mixed-methods study that examined the effects of a palliative care interventionimplemented across 4 regions of Japan.33 The intervention consisted ofprovider education and training; education and awareness initi

343、atives forthe general public/patients; establishment of community-based palliativecare teams to instruct community health care institutions; andestablishment of regional palliative care centers to coordinatemultidisciplinary community resources. Surveys were provided topatients, bereaved family memb

344、ers, physicians, and nurses both beforeand after the intervention; the results indicated an increased percentageof patients receiving palliative care and dying at home, increasedpatient- and family-reported quality of care, and decreased physician-and nurse-reported difficulties in providing palliat

345、ive care.Overall, research suggests that successful integration of palliative careearly in the continuum of care reduces morbidity for patients with cancerPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cance

346、r Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-4NCCN Guidelines IndexPalliative Care T

347、able of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Careand enhances patient and family/caregiver satisfaction (reviewed byRocque and Cleary34 and Khan, et al.35).In February 2012, ASCO published a provisional clinical opinion, basedon 7 randomized controlled trials and expert consens

348、us.36 The ASCOpanel stated that there is substantial evidence to show that “palliativecarewhen combined with standard cancer care or as the main focusof careleads to better patient and caregiver outcomes.” The ASCOpanel concluded that strong consideration should be given to theintegration of palliat

349、ive care with standard oncology care early in thecourse of illness for patients with metastatic cancer and/or highsymptom burden.Provision of Palliative CareInitially, the primary oncology team (interdisciplinary team of physicians,nurses, social workers, other mental health professionals, chaplains

350、,physician assistants, pharmacists, and dietitians) can provide most ofthe palliative care needed by the patient and family. Intractablesymptoms or complex psychosocial problems can benefit from theinclusion of palliative care experts.Palliative care should be integrated into patient care throughcol

351、laboration between the primary oncology team and palliative carespecialists as needed over the course of disease.37 Additionally,palliative care efforts should reach beyond the patient, to family andcaregivers.When further anti-cancer therapy is likely to do more harm than good,palliative care becom

352、es the predominant care offered to patients withadvanced cancer. When possible, inpatient palliative care can facilitatetransfer to home hospice or inpatient hospice care. For patients toounstable for transfer out of the inpatient setting, palliative care providesend-of-life care for patients who di

353、e in the hospital. Several groups havedescribed their ideas and approaches for, experience and outcomeswith, and barriers to developing successful programs that integratepalliative care into routine oncologic care.21,22,37-47Hospice CareHospice is the most established model of palliative care for pa

354、tients witha prognosis of less than 6 months and is eligible for coverage by third-party payers and Medicare. Enrollment in hospice has been shown toreduce hospitalization and receipt of high-intensity nonhospice care atthe end of life. An analysis of the SEER database revealed that menwith advanced

355、 prostate cancer who were enrolled in hospice were lesslikely to receive high-intensity care, including ICU admission andinpatient stays, at the end of life.48 Moreover, a study of 207 deceasedpatients with cancer who had stopped cancer treatment showedreduced emergency department visits, hospitaliz

356、ations, and othernoncancer clinic visits among patients enrolled in hospice.49Additionally, analyses of data from 3069 deceased patients over 50years of age (extracted from the Health and Retirement Study) revealedthat hospice enrollment significantly decreased hospitalization, non-hospice health ca

357、re utilization, and cost of care.50According to the National Home and Hospice Care Survey, the numberof adult patients with cancer using hospice care tripled during 1991through 1992 to 1999 through 2000.51 The 2013 edition of NHCPOFacts and Figures: Hospice Care in America states that 43.3% ofMedica

358、re decedents with a cancer diagnosis accessed 3 days ofhospice in 2007, increasing from 36.6% in 2001.52 However, the medianlength of hospice service was just under 19 days in 2012.52 Mostpatients who receive hospice care in this country are referred too latefor hospice care to exert its full benefi

359、t, and many patients are neverPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights

360、reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-5NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carereferred at all.48,53 A recent study of Medicare patie

361、nts with advancedlung cancer in New York and California suggested that hospice wasunderutilized, with a significant proportion of patient deaths occurringwithout enrollment in hospice.54End-of-life care can often be more aggressive than what is supported bycurrent evidence. Generally, Medicare patie

362、nts with poor-prognosiscancer received highly intensive end-of life-care.55 Furthermore,administration of chemotherapy late in the course of cancer care,including in the last days of life, is growing more common,56,57 andoncologists have reported that they have found hospice regulations andreimburse

363、ment limitations too restrictive.58 Overall, provision of end-of-life care was inconsistent and varied widely across regions, evenamong comprehensive cancer centers.55,59Palliative Care StandardsAssessing outcomes and evaluating palliative cancer care is essentialto ensure high-quality, evidence-bas

364、ed care. Lorenz et al performed asystematic review of end-of-life care and outcomes and found that manyaspects of palliative care lack high-quality evidence.60 The third editionof the Clinical Practice Guidelines for Quality Palliative Care by theNational Consensus Project was published in 2013,61 a

365、nd the NationalQuality Forum has developed a national quality framework forevaluating palliative care programs, extending beyond terminally illpatients with cancer to include a broad spectrum of patients withmultiple illnesses.62 These guidelines provide an in-depth assessment ofmany issues surround

366、ing palliative care (eg, cultural, ethical, legal,physical, psychological, social, spiritual, and existential aspects of care).In addition, the American College of Physicians has developedevidence-based guidelines to improve palliative care of pain, dyspnea,and depression experienced at the end of l

367、ife.63In the United Kingdom in 2004, the National Consensus Project and theNational Institute for Health and Clinical Excellence (NICE) issuedguidance on how supportive and palliative care services should beprovided for adults with cancer (www.nice.org.uk/page.aspx?o=csgsp).Some of the key recommend

368、ations are listed below:1. Patients and their caregivers should have access to a range ofspecialist services that help them cope with cancer and itstreatment.2. Whenever possible, significant information should be given topatients by a senior health professional who has receivedadvanced-level traini

369、ng and is assessed as being an effectivecommunicator.3. Good-quality information should be available free of charge tohelp people affected by cancer make decisions about their care.ASCO recently published a statement on individualized care for patientswith advanced cancer.10 While significant improv

370、ements over the pastdecade were noted (eg, improvements in palliative care education andtraining for oncologists; an increase in hospital-based palliative careprograms and community-based hospice organizations), the statementpoints out that conversations with patients about their palliative needsare

371、 still happening too late in the progression of their disease. Some ofthe key elements of individualized care listed in the report state thatpatients should be given:enough information to enable them to make informed choicesregarding their treatment;encouragement to focus on symptom-directed palliat

372、ive carewhen disease-directed therapies fail;the opportunity to participate in clinical trials that may improvetheir outcome or that of future patients; andthe opportunity to die with dignity and peace of mind.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for di

373、stribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permis

374、sion of NCCN.MS-6NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CareIn August 2011, the Commission on Cancer (CoC) of the AmericanCollege of Surgeons (ACS) released new accreditation standards forhospital cancer programs (http:/www.facs.org/n

375、ews/2011/coc-standards0811.html).64 Their patient-centered focus requires thatpatients have access to palliative and hospice care, psychosocialsupport, and pain managementeither on-site or by referral. Thestandards also state that palliative care should be provided by aninterdisciplinary team of med

376、ical and mental health professionals, socialworkers, and spiritual counselors and should be available beginning atthe time of diagnosis and continuously throughout treatment,surveillance, and bereavement.Barriers to Timely Provision of Palliative CareThe major reason for delayed referral to Palliati

377、ve Care is professionaland public confusion about the definition of Palliative Care. WHO firstdefined palliative care as care aimed at improving quality of life.12 WHOexpanded its earlier definition of palliative care as an approach thatimproves the quality of life of patients and their families fac

378、ing life-threatening illness through the prevention, assessment, and treatmentof pain and other physical, psychosocial, and spiritual problems.65 Thedefinition of palliative care in this Guideline (PAL-1) is adapted from theNational Consensus on Palliative Care and the National Quality ForumFramewor

379、k for Palliative Care.61,62 Hospice is the oldest and most widelyutilized model of palliative care in the United States. Its primary focus ison patients with a prognosis of 6 months or less, for whom no furtherlife-prolonging therapy is appropriate or desired, and who have thedesire and capacity to

380、spend most of their final months at home.Patients with cancer accounted for the largest percentage of hospicepatients in the late 1970s but now account for only 37% of patientsreceiving hospice care in this country.52 Despite the 6-month prognosiseligibility, the median length of service for hospice

381、 patients in 2012 was18.7 days with an average stay of 71.8 days. Approximately 36% ofhospice patients died or were discharged within 7 days of admission tohospice care.52Despite the growth of clinical and academic palliative care over the pasttwo decades and the efforts of most palliative care orga

382、nizationsclarifying that palliative care should be given at the time of diagnosis orwhen there are poorly controlled symptoms regardless of prognosis,many people think that palliative care still refers only to care given at theend of life, leading to an inappropriate association of palliative care w

383、ithdeath.66-69 Supportive care has been suggested as an alternative name,to help break this association and facilitate earlier use of palliative carefor patients in need. Supportive care in cancer initially focused on thesupport of patients receiving active cancer therapy with antiemetics,antibiotic

384、s, bone marrow stimulants, and transfusions.70 However, somestudies suggest that patients and providers may prefer supportive careterminology to refer to palliative care services.71,72 At MD AndersonCancer Center, a switch in the service name from “Palliative Care” to“Supportive Care” was associated

385、 with increased patient referrals,referrals at an increased interval before death, and referrals earlier inthe course of disease.73 Regardless of the terminology, patients andfamilies should be informed that palliative care is an integral part of theircomprehensive cancer care.66,74,75A retrospectiv

386、e review of patients with advanced cancer seen at MDAnderson Cancer Center found that only 45% of patients had apalliative care consultation before death, and many of those occurredclose to death.76 Similarly, a retrospective study of 6076 patients withadvanced pancreatic cancer revealed that only 5

387、2% of patients receiveda palliative care consultation.29 Interestingly, in a recent survey only37% of physicians reported that they had access to a specializedPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive C

388、ancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-7NCCN Guidelines IndexPalliative Ca

389、re Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carepalliative care service that accepted patients on chemotherapy.77 Thus,barriers to early referrals still exist (reviewed by Davis et al.22). TheAmerican Academy of Hospice and Palliative Medicine(www.aahpm.org), founded in 19

390、88, and the Center to AdvancePalliative Care (www.capc.org), established in 1999, are organizationsdedicated to advancing the discipline of hospice and palliative medicine.These organizations seek to expand access to quality palliative careservices in hospitals and other health care settings for peo

391、ple withadvanced illness.Training in Palliative CareEducational programs should be provided to all health careprofessionals and trainees so they can develop effective palliative careknowledge, skills, and attitudes. The number of palliative care programsin the United States is rapidly increasing. Th

392、e establishment of hospiceand palliative medicine as a medical subspecialty in 2008 receivedsupport from at least 10 cosponsoring American Board of MedicalSpecialties (ABMS; www.abms.org) boards, including Anesthesiology,Family Medicine, Internal Medicine, Physical Medicine andRehabilitation, Psychi

393、atry and Neurology, Surgery, and Pediatrics.Support for expansion of palliative medicine education has been offeredby the Liaison Committee on Medical Education (LCME;www.lcme.org), which has mandated palliative medicine education formedical schools. In addition, the Accreditation Council for Gradua

394、teMedical Education (ACGME; www.acgme.org) now requires training inpalliative medicine for oncology fellows, including training in pain,psychosocial care, personal awareness, and hospice care.Researchers at a large urban teaching hospital recently demonstratedthe effectiveness of education on pallia

395、tive care and referral criteria forincreasing overall referrals to palliative care services and enhancedreferrals for the purpose of pain management.78 Effective training inpalliative care can also positively impact provider, patient, and caregiverquality of life. One study suggested that an online

396、palliative careeducation intervention for primary care physicians led to measurableimprovements in patient outcomes such as pain, symptoms, and qualityof life.79 In a survey study, oncology fellows reported that training onend-of-life issues and goal-of-care discussions mitigated burnout anddistress

397、.80Another recent survey of 254 hematology/oncology fellows found thatpalliative care education is still lacking, with only 32% of respondentsreporting formal training in managing end-of-life depression and only33% reporting explicit training in opioid rotation.81Palliative care resources that may b

398、e useful for clinicians are listed inTable 1, below.Communication Skills TrainingClear, consistent, and empathetic communication with the patient andfamily about the natural history of the cancer and its prognosis is at thecore of effective palliative care.82-84 It is important to assess andreassess

399、 patient goals and preferences regarding communication ofdifficult news over the course of disease.85 When patients understandthe goals of treatment, they can make choices that are consistent withtheir life goals. In addition, effective patient-physician communicationcan decrease patient stress, inc

400、rease adherence to treatment, andimprove outcomes.86,87 Open communication with relatives or caregiversof patients with cancer is also critical, particularly when patients nearthe end of life. A nationwide survey of cancer-bereaved childrendemonstrated that this population valued communication of me

401、dicalinformation about disease, treatment, and death; the results showedthat communication of this information prior to their loss improvedPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc.,

402、 All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carechildrens trust in the care provided and decreased their depressionrates.88However, doctors are often hesitant to have honest discussions withtheir patients, in part beca

403、use these discussions can be very difficultand emotionally draining for the physicians.89 Survey data from 620oncologists revealed a high level of perceived burden regardingdiscussions about discontinuing anticancer treatments, and manyindicated a desire for additional communication skills training.

404、90 A recentsurvey of 1193 patients in the Cancer Care Outcomes Research andSurveillance (CanCORS) study found that 69% of patients withadvanced lung cancer and 81% of those with advanced colorectalcancer thought that their palliative chemotherapy could cure them.91While it is unclear whether these p

405、atients were told their prognosis, ifthey did not understand or choose to understand the information, or ifthey merely answered the survey with a high degree of optimism,92 thisresult demonstrates a clear need for improvement in the area ofphysician-patient communication. Similar misconceptions also

406、 apply topalliative radiation therapy. In a study of 384 patients with inoperablelung cancer, 64% of patients did not understand that their radiationtherapy was not curative.93Training in communication has been shown to improve cliniciancommunication skills94-97 and to possibly decrease physician bu

407、rnoutand improve physician empathy and mood.98 For example, a recentrandomized controlled trial showed that an 11-hour communicationskills training workshop for oncologists was effective at improvingcommunication skills, including those specific to the transition topalliative care.99NCCN Guidelines

408、for Palliative CareThe NCCN Guidelines for Palliative Care were developed to facilitatethe appropriate integration of palliative care into oncology practice. Theguidelines outline procedures for screening, assessment, palliative careinterventions, reassessment, and after-death care. The panel initia

409、llyfocused on the needs of patients in their last 12 months of life. Thepanel chose this period to distill the content of textbooks and curriculainto guidelines that could facilitate clinical decision-making in the sameway that NCCN disease-oriented and symptom-oriented guidelineshave. More recent v

410、ersions of these guidelines have expanded thefocus to all patients and family experiencing cancer throughout thedisease trajectory, consistent with the Provisional Clinical Opinion fromASCO.36Palliative Care ScreeningThe primary oncology team should screen all patients at every visit for:1) uncontro

411、lled symptoms; 2) moderate to severe distress related tocancer diagnosis and therapy; 3) serious comorbid physical, psychiatric,and psychosocial conditions; 4) life expectancy of 6 months or less;and/or 5) patient or family concerns about the course of disease anddecision-making. Patients who meet t

412、hese screening criteria and thosewho make a specific request for palliative care should undergo a fullpalliative care assessment.Patients who do not meet these screening criteria should bere-screened at the next visit. In addition, the oncology team shouldinform patients and their family members abo

413、ut palliative care services.Anticipation of palliative care needs and prevention of symptoms shouldalso be discussed, and conversations regarding advance care planningshould be initiated.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidel

414、ines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-8Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Versio

415、n 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-9NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines V

416、ersion 1.2014Palliative CarePalliative Care AssessmentPatients who meet screening criteria (see above) should undergo acomprehensive palliative care assessment by their primary oncologyteam evaluating the benefits and risks of anticancer therapy; physicalsymptoms; psychosocial or spiritual distress;

417、 personal goals andexpectations; educational and informational needs; and cultural factorsaffecting care.7-9Assessment for Benefits and Risks of Anticancer TherapyMany cancer symptoms can be relieved by control of the cancer withanti-cancer therapy. Assessment of the benefits and risks of anticancer

418、therapy for each individual is based on the existing NCCNdisease-specific guidelines (the most recent version of all guidelinescan be found on the NCCN website at www.NCCN.org). Specialattention should be given to the natural history of the specific tumor; thepotential for response to further treatm

419、ent; the meaning of anticancertherapy to the patient and family; the potential for treatment-relatedtoxicities including impairment of vital organs and performance status;and serious comorbid conditions. Specific recommendations regardinganticancer therapy for patients with various life expectancies

420、 arediscussed in Palliative Care Interventions, below.Assessment of Personal Goals and ExpectationsPatients and their families should also be asked about their personalgoals and expectations. Their priorities for palliative care, including theirgoals and perceived meaning of anticancer therapy and t

421、he importancethey place on quality of life, should be assessed. Goals andexpectations that might be better met by the hospice model of palliativecare should be identified. When appropriate, it is important to determinethe patients understanding of the incurability of their disease andwhether patient

422、s wish to know survival statistics.Assessment of Physical SymptomsThe most common symptoms that need to be assessed are pain,dyspnea, anorexia, cachexia, nausea, vomiting, constipation, malignantbowel obstruction, fatigue, weakness, asthenia, insomnia, daytimesedation, and delirium.100 Palliative in

423、terventions for these symptomsare discussed individually below.Assessment of Psychosocial DistressAssessment of psychosocial distress should focus on illness-relateddistress and psychosocial, spiritual, or existential issues according tothe NCCN Guidelines for Distress Management. Special problems w

424、ithsocial support and resources (ie, home, family, community, or financialissues) must also be assessed. Recommendations for the managementof psychosocial distress can be found below and in the NCCNGuidelines for Distress Management.Assessment of Educational and Informational Needs and CulturalFacto

425、rs Affecting CareThe values and preferences of patients and families about informationand communication should also be assessed. The oncology teamshould inquire about cultural factors affecting care and perceptions ofthe patient/family regarding the patients disease status.Criteria for Consultation

426、with Palliative CareCriteria for consultation with a palliative care specialist are based onpatient characteristics, social circumstances, and anticipatorybereavement issues. The oncology team should consider consultationfor patients with limited treatment options; non-pain symptoms that aresuboptim

427、ally controlled by conventional management or a highsymptom burden; history of allergies or adverse effects to multiplepalliative interventions; frequent emergency department visits orhospital readmissions; complicated ICU admissions (multi-organ systemPrinted by Maria Chen on 5/27/2014 10:08:49 PM.

428、 For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in

429、any form without the express written permission of NCCN.MS-10NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carefailure or prolonged mechanical ventilation); palliativestenting/gastrostomy; a high distress score (eg, 4 on the DistressThermome

430、ter; see the NCCN Guidelines for Distress Management);cognitive impairment; severe comorbid conditions; or communicationbarriers. In addition, consultation with palliative care specialists shouldbe considered for those at high risk for poor pain control: those whomake a request for hastened death; a

431、nd/or those who are resistant toengaging in advance care planning.Social circumstances or anticipatory bereavement issues that indicate aneed for referral for consultation with a palliative care specialist includefamily/caregiver limitations, inadequate social support, financiallimitations, limited

432、access to care, family discord, intensely dependentrelationships, financial limitations, limited access to care, patientsconcern regarding care of dependents, spiritual or existential distress,and/or unresolved or multiple prior losses.Palliative care consultation should also be considered when staf

433、fissues, such as compassion, fatigue, or moral distress, are present. Formore information regarding psychosocial issues affecting careproviders, see section on Psychosocial Support for Palliative CareProviders.Palliative Care InterventionsThe oncology team should initiate palliative treatments follo

434、wing thespecific recommendations described in these guidelines for commonsymptoms. Comorbid physical and psychosocial conditions should betreated by appropriate clinicians. Consultation or collaboration withpalliative care specialists or teams is recommended for patients withmore complex problems to

435、 improve their quality of life and survival.24,36Referrals should be made as needed to mental health and socialservices, pastoral care, health care interpreters, hospice services, orother specialists. Finally, the oncology team can be helpful in mobilizingcommunity support through religious organiza

436、tions, schools, orcommunity agencies.The panel divided patients into 3 groups to address the effect of lifeexpectancy on the delivery of palliative care interventions: 1) patientswith years to months to live; 2) patients with months to weeks to live;and 3) dying patients in their final weeks to days

437、. Patients in their finalhours of life are referred to as imminently dying and may require specialinterventions. The panel recognizes the lack of precision in estimatinglife expectancy but believes that this delineation will be useful for thedelivery of appropriate palliative care interventions. The

438、 patient andfamilys personal, spiritual and existential, cultural, and religious goalsand expectations may change throughout these timeframes. Optimalprovision of palliative care requires ongoing reassessment andmodification of strategies, as well as ongoing communication betweenthe patient, family,

439、 and health care team.Indicators that patients are in their last 6 months of life includedecreased performance status (ECOG score 3; KPS score 50),hypercalcemia, central nervous system metastases, delirium, superiorvena cava syndrome, spinal cord compression, cachexia, malignanteffusions, liver fail

440、ure, kidney failure, or other serious comorbidconditions. Many patients with stage IV cancers, especially those withmetastatic lung cancer, pancreatic cancer, and glioblastoma multiforme,would benefit from palliative care beginning at diagnosis, becauseexpected survival is limited.101-103For patient

441、s whose life expectancy is “years to months” or “months toweeks,” it is important to determine how much information a patientwishes to know and how much of that information should be shared withthe patients family. In patients queried regarding preferences aboutPrinted by Maria Chen on 5/27/2014 10:

442、08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be repro

443、duced in any form without the express written permission of NCCN.MS-11NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carereceiving prognostic information and detailed information on theirdisease, studies show that the majority express a desir

444、e to receive thisinformation.104-107 Patients will also require answers to any questionsabout what to expect in the next few months and anticipatory guidanceon the dying process. In addition, determining the decision-makingstyles of patients and their families helps facilitate congruence of apatient

445、s goals and expectations with those of the family. Cliniciansshould also determine the patients assessment of the relativeimportance of quality of life compared with length of life. Patients shouldbe assisted in reviewing and revising their life priorities, resolving theirunfinished business, and pu

446、tting their financial and personal affairs inorder.Dying patients may wish to prepare for death and to help prepare familymembers to go on without them. Both patients and families benefit fromeducation on the dying process. Families should be guided throughtheir anticipatory grief, and arrangements

447、should be made to ensurethat the patients and familys needs and goals regarding the dyingprocess are respected. Planning to ensure continuing care and referralsto appropriate care is important. Arrangements should be available toensure that the patient does not die alone unless that is the patientsp

448、reference.Clinicians should discuss the prognosis with patients and their familiesclearly and consistently to help them develop realistic expectations.Information about the natural history of the specific tumor and therealistic outcomes of anticancer therapy should be included in thediscussion. Many

449、 investigators have shown that seriously illmiddle-aged and older patients tend to be more optimistic and lessaccurate about their prognosis than their physicians; suchmisunderstanding of the situation can affect their preferences forcardiopulmonary resuscitation and for life-extending measures.108S

450、piritual, existential, and cultural issues are often best addressedthrough collaboration with pastoral care counselors, professionaltranslators, the patients personal clergy, and representatives from thepatients cultural community. Religious and cultural issues surroundingthe beliefs and practices n

451、ear the time of death must be anticipated andcarefully managed.109Finally, social and spiritual support and resourcemanagement interventions should be provided to ensure a safeend-of-life care environment, a competent primary caregiver, andaccess to necessary medications and treatments. Providers mu

452、st besensitive to cultural values that may influence the best way for thisinformation to be presented and discussed.Palliative care interventions for managing specific symptoms and thebenefits and risks of anticancer therapy are discussed below as outlinedin the algorithms. Additional palliative car

453、e interventions for othersymptoms will be developed as deemed necessary.Anticancer TherapyA recent Institute of Medicine (IOM) report, Communicating withPatients on Health Care Evidence, found that 90% of Americanssurveyed want to know their options for tests and treatments and to beinvolved in deci

454、sion making for their health, with almost 50% wanting todiscuss the option of doing nothing.110,111 However, the report also foundthat far fewer respondents had such discussions with their physicians.Patients who have years to months to live and a good performancestatus are likely to be interested i

455、n continuing anticancer therapy toprolong survival and reduce cancer-related symptoms.112-115Anticancertherapy may be conventional evidence-based treatment as outlined inthe NCCN disease-specific guidelines (available at www.NCCN.org) ortreatment in the context of a clinical trial. In some of the ad

456、vanced-stagecancers, chemotherapy may be superior to best supportive care andPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexPalliative Care Tabl

457、e of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Caremay prolong survival.116,117 Furthermore, patients with advancednon-small cell lung cancer who are not eligible for systemicchemotherapy may benefit from targeted therapies that are effective forrelieving symptoms, maintaining stabl

458、e disease, and improving qualityof life without the adverse events that may be associated with cytotoxiccancer therapies.118 Physicians, patients, and their families shoulddiscuss intent, goals, and range of choices; benefits and risks ofanticancer therapy; and possible effects on quality of life. I

459、n addition,the oncology team should prepare the patient psychologically forpossible disease progression.Anticancer therapy may at times go beyond what is evidence-based.Interestingly, data from a CanCORS study of 1574 patients withmetastatic non-small cell lung cancer suggested that many patientsrec

460、eived higher doses and a greater number of palliative radiationtreatments than what is supported by current evidence.119 Additionally, astudy of patients with metastatic colorectal cancer revealed that over90% of patients consulted with a medical oncologist, and 82% of thesepatients received chemoth

461、erapy.120Patients with months to weeks to live should be provided with guidanceregarding the anticipated course of the disease. Physicians shouldreassess patients understanding of goals of therapy and preferencesregarding prognostic information. These patients are typically tired oftherapy, homeboun

462、d, and more concerned about the side effects ofmore treatment. The focus of treatment for these patients shifts fromprolonging life towards maintaining quality of life. These patients shouldconsider potential discontinuation of anticancer treatment and beoffered best supportive care, including refer

463、ral to palliative care orhospice.121,122 To avoid demeaning the value of end-of-life care,palliative care should not be described as “just hospice.”Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be r

464、eproduced in any form without the express written permission of NCCN.MS-12In general, patients with weeks to days to live (ie, dying patients) shouldnot be given anticancer therapy, but should be given intensive palliativecare focusing on symptom control and preparation for the dyingprocess.Symptom

465、ManagementSpecial considerations in the implementation of these guidelines basedon life expectancy are delineated in the algorithms. The major focus ofthese special considerations is the withholding and withdrawal ofaggressive interventions; prevention and elimination of side effectsassociated with

466、pharmacologic pain management; the acceptance ofloss of function for the sake of relief of symptoms; and the treatment ofthe unique symptoms of patients in their final hours of life.With regard to symptoms, the control of pain, dyspnea,anorexia/cachexia, nausea and vomiting, constipation, malignant

467、bowelobstruction, fatigue, delirium, and psychological distress isfundamental123-125 and discussed in detail below. As a general principle,if/when appropriate, providers should try to use palliative interventionsthat may address multiple symptoms.PainSee the NCCN Guidelines for Adult Cancer Pain. In

468、 addition, it isimportant to note that dying patients in their last weeks of life haveseveral specific requirements. For instance, opioid dose should not bereduced solely for decreased blood pressure, respiration rate, or level ofconsciousness. In fact, opioids can be titrated aggressively formodera

469、te/severe acute/chronic pain.126 In addition, palliative sedationcan be considered for refractory pain (see below) following consultationwith pain management/palliative care specialists.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 20

470、14 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-13NCCN G

471、uidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CareDyspneaDyspnea is one of the most common symptoms in patients withadvanced lung cancer.127 The American Thoracic Society consensusstatement defines dyspnea as “a subjective experience of breathingd

472、iscomfort that consists of qualitatively distinct sensations that vary inintensity.”128Symptom intensity should first be assessed in all patients. Symptomintensity in non-communicative patients with weeks to days to liveshould be assessed using other distress markers of dyspnea. Next,underlying caus

473、es or comorbid conditions should then be treated usingchemotherapy or radiation therapy; therapeutic procedures for cardiac,pleural, or abdominal fluid129-131; bronchoscopic therapy; orbronchodilators, diuretics, steroids, antibiotics, transfusions, oranticoagulants for pulmonary emboli.Both pharmac

474、ologic and non-pharmacologic interventions have beenassessed for management of dyspnea. A recent review concluded thatlittle definitive data evaluating the effectiveness of dyspneainterventions exist and that randomized controlled trials are needed.132Other reviews have determined that there are suf

475、ficient data to maketreatment recommendations.130,133 Pharmacologic interventions mayinclude opioids with or without benzodiazepines.130,134-139Benzodiazepines can be tried for treatment of dyspnea if it is associatedwith anxiety; the beneficial effect of benzodiazepines on dyspnea inpatients with a

476、dvanced cancer is small.139Of the opioids, morphine has undergone the most extensiveinvestigation for treating dyspnea in patient with cancer, but recentstudies have also assessed opioids such as fentanyl and oxycodone. Asingle-institution trial of nebulized fentanyl in patients with cancer withdysp

477、nea showed improved oxygenation and reduced tachypnea, and79% of patients said it improved their breathing.140 An attemptedrandomized placebo-controlled trial at the same institution was notsuccessful, because the practice had already diffused widely with over1000 doses being prescribed.141 Multiple

478、 case reports give promisingdata about fentanyl, buy further placebo-controlled trials are needed.142In a small randomized controlled trial, prophylactic subcutaneousfentanyl was effective for improving dyspnea and fatigue at rest andfollowing a 6-minute walk test.143 A study revealed that nebulized

479、fentanyl reduced intensity and unpleasantness of dyspnea in patientswith chronic obstructive pulmonary disease (COPD).144 Nebulizedfentanyl has not yet been studied in patients with cancer, but it can beconsidered in patients who do not respond well to the otherinterventions in these guidelines. Add

480、itionally, an observational study of136 patients with terminal cancer also suggested that continuousinfusion of subcutaneous oxycodone may provide relief of dyspnea inaddition to relief of pain.145Scopolamine, atropine, hyoscyamine, and glycopyrrolate are options toreduce excessive secretions associ

481、ated with dyspnea.146-150Glycopyrrolate does not effectively cross the blood brain barrier,151 andthus is less likely than the other drug options to cause delirium.152,153Scopolamine can be administered subcutaneously or transdermally;physicians should be aware that the onset of benefit for transder

482、malscopolamine patches is about 12 hours,154 and they are thus not anappropriate choice for imminently dying patients. A subcutaneousinjection of scopolamine can be administered when the patch is appliedor if control of secretions is inadequate. Non-pharmacologicinterventions include the use of hand

483、held fans directed at the face. Arandomized, controlled, crossover trial demonstrated thatbreathlessness was reduced in patients when they directed a handheldfan toward their faces.155 A time-limited trial of mechanical ventilation, asPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use

484、only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Careclinically indicated, and/or oxygen therapy for hypoxia may also bebenefic

485、ial. In a recent feasibility study of 200 patients with solid tumorsrandomized to receive either noninvasive positive-pressure ventilation(biphasic positive airway pressure, BiPAP) or oxygen therapy, patientsin the ventilation group had greater improvements in dyspneasymptoms and required lower dose

486、s of opiates than patients in theoxygen group.156 However, a smaller phase II randomized trialcomparing high-flow oxygen to BiPAP for persistent dyspnea inpatients with advanced cancer revealed no significant differencesbetween the two approaches.157 As life expectancy decreases, the roleof mechanic

487、al ventilation and oxygen diminishes, and the role ofopioids, benzodiazepines, glycopyrrolate, and scopolamine increases. Iffluid overload is a contributing factor, enteral and parenteral fluidsshould be decreased or discontinued, and low-dose diuretics can beconsidered.Anorexia/CachexiaCachexia is

488、physical wasting with loss of skeletal and visceral musclemass and is very common among patients with cancer.158,159 Manypatients with cancer lose the desire to eat (anorexia), which contributesto cachexia. Cachexia can also occur independently from anorexia, asproinflammatory cytokines and tumor-de

489、rived factors directly lead tomuscle proteolysis.158,159 Cachexia leads to asthenia (weakness),hypoalbuminemia, emaciation, immune system impairment, metabolicdysfunction, and autonomic failure. Cancer-related cachexia has alsobeen associated with failure of anti-cancer treatment, increasedtreatment

490、 toxicity, delayed treatment initiation, early treatmenttermination, shorter survival, and psychosocial distress.158-160 A recentstudy that examined cancer cachexia in a cohort of 1473 patientsacross all weight ranges showed that muscle depletion conveys asimilarly poor prognosis as involuntary weig

491、ht loss, regardless of bodymass index.161Treatment includes the relief of symptoms that interfere with food intake(eg, depression, pain, constipation, nausea/vomiting), metoclopramidefor early satiety, and the use of appetite stimulants (megestrol acetateor prednisone) when increased appetite is an

492、important aspect of qualityof life.130,133,162-164 A recent systematic review and meta-analysis ofmegestrol acetate revealed improved appetite and slight improvementsin weight gain when using this drug to treat anorexia/cachexia inpatients with cancer.163 However, the panel cautions that megestrolac

493、etate increases the risk of blood clots and edema, and death occursin 1 in every 23 patients taking this drug.163A combination therapy approach may yield the best possible outcomesfor patients with cancer cachexia. A randomized phase III trial in 332patients with cancer-related anorexia/cachexia rev

494、ealed superioroutcomes for patients receiving a combination regimen that includedmedroxyprogesterone, megestrol acetate, eicosapentaenoic acid and L-carnitine supplementation, and thalidomide, versus therapy with any ofthe above single agents.165 Another phase III trial of 104 patients withadvanced

495、gynecologic cancers and cachexia supported the merits ofcombination therapy; compared with megestrol acetate alone, patientsreceiving megestrol acetate plus L-carnitine, celecoxib, and antioxidantshad improved lean body mass, appetite, and quality of life.166Although cannabinoid-based interventions

496、(eg, dronabinol, cannabis)have some demonstrated efficacy for treating chemotherapy-inducednausea and vomiting and AIDS-related anorexia, the data to supportcannabinoid-based interventions for treating anorexia/cachexia inpatients with cancer are very limited.167 A randomized clinical trial ofcannab

497、is extract and delta-9-tetrahydrocannabinol in patients withVersion 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-14Printed by Mar

498、ia Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illus

499、tration may not be reproduced in any form without the express written permission of NCCN.MS-15NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carecancer-related anorexia-cachexia syndrome did not demonstrate abenefit of these agents over place

500、bo on appetite and quality of life.168Another randomized trial comparing megestrol acetate to dronabinol intreating cancer-associated anorexia revealed megestrol acetate to besuperior for promoting weight gain (75% vs. 49% of patients) andappetite (11% vs. 3%) in patients with advanced cancer.169 Ho

501、wever, toa lesser extent, dronabinol did improve appetite and weight gain insome study patients. Ultimately, for some patients with cancer-relatedanorexia, cannabinoids could be helpful. However, it is important to notethat cannabinoid administration in elderly patients may induce delirium,and provi

502、ders should be aware of the local state rules and regulationsregarding medicinal cannabinoid use.Nutrition consultation should also be considered, because calorie-dense, high-protein supplementation has demonstrated some efficacyfor weight stabilization,130,158,170-172 although some studies shownutr

503、itional interventions to be ineffective.173 A meta-analysis found thatwhile nutritional intervention does not significantly affect weight gain orenergy intake, it can improve some aspects of quality of life, includingemotional functioning, dyspnea, and hunger.174 Nutritional support,including entera

504、l and parenteral feeding as appropriate, should also beconsidered when the disease or treatment affects the ability to eatand/or absorb nutrients and the patients life expectancy is months toyears.175 The goals and intensity of nutritional support change as lifeexpectancy is reduced to weeks to days

505、. Overly aggressive enteral orparenteral nutrition therapies can actually increase the suffering of dyingpatients.175-178 In addition, a recent randomized controlled trial of patientswith cancer enrolled in hospice found that parenteral hydration had noeffect on dehydration symptoms such as fatigue

506、and hallucination andhad no effect on quality of life or survival.179 Therefore, instead ofartificial hydration and nutrition, palliative care in the final weeks of lifefocuses on treating dry mouth and thirst, and providing education andsupport to the patient and family regarding the emotional aspe

507、cts ofwithdrawal of nutritional support. Family members should be informed ofalternate ways to care for dying patients.Nausea and VomitingChemotherapy-induced nausea and vomiting has a major impact on apatients quality of life.180 Nausea and vomiting induced bychemotherapy or radiation therapy shoul

508、d be managed as outlined inthe NCCN Guidelines for Antiemesis. Patients can also experiencenausea and vomiting unrelated to chemotherapy and radiation, resultingfrom gastric outlet obstruction, bowel obstruction, constipation, opioiduse, or hypercalcemia.181 These causes should be identified andtrea

509、ted. Proton pump inhibitors and histamine-2 (H2) receptorantagonists can be used to manage gastritis or gastroesophagealreflux. Gastric outlet obstruction may benefit from treatment withcorticosteroids; alternative treatment options include endoscopicstenting or insertion of a decompressing G-tube.

510、Many medications canalso cause nausea and vomiting, and blood levels of possible culprits,such as digoxin, phenytoin, carbamazepine, and tricyclicantidepressants, should be checked.182,183Non-specific nausea and vomiting can be managed with dopaminereceptor antagonists (eg, prochlorperazine, haloper

511、idol,metoclopramide, olanzapine) or benzodiazepines (anxiety-relatednausea). Persistent nausea and vomiting can be treated by titratingdopamine receptor antagonists to maximum benefit and tolerance .184-188For persistent nausea, adding 5-HT3 (5-hydroxytryptamine 3) receptorantagonists189,190 and/or

512、anticholinergic agents and/or antihistamines,191corticosteroids,191,192 continuous or subcutaneous infusion ofantiemetics, antipsychotics (eg, olanzapine or haloperidol),193 and/orcannabinoids can also be considered.194 Opioid rotation may also helpPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For

513、 personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any

514、form without the express written permission of NCCN.MS-16NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carealleviate symptoms.195 Agents that target the cannabinoid system mayoffer some efficacy in treating refractory chemotherapy-induced na

515、useaand vomiting.196 Dronabinol and nabilone are two cannabinoid agentsapproved for treating chemotherapy-induced nausea and vomiting thatis refractory to standard antiemetic therapies. Alternative therapies (eg,acupuncture, hypnosis, cognitive behavioral therapy) can also beconsidered.197-199 Palli

516、ative sedation (see below) can be considered as alast resort if intensified efforts by specialized palliative care or hospiceservices fail.A systematic review assessed the level of evidence for antiemesisunrelated to chemotherapy.200 While the authors concluded thatantiemetic recommendations have mo

517、derate to weak evidence at best,the strongest evidence supports the use of metoclopramide; studies ofmultidrug combination therapies do not support their effectiveness.ConstipationConstipation occurs in approximately 50% of patients with advancedcancerand most patients treated with opioids.201 Altho

518、ugh several drugsincluding antacids, anticholinergic drugs (antidepressants,antispasmodics, phenothiazines, and haloperidol), and antiemetics areknown to cause constipation,202opioid analgesics are most commonlyassociated with constipation. In addition to physical discomfort,constipation in patients

519、 with advanced cancer can cause psychologicaldistress and anxiety regarding continued opioid use.203 Opioid-inducedconstipation should be anticipated and treated prophylactically with astimulating laxative to increase bowel motility with or without stoolsofteners.204 While there is little evidence o

520、n which is the best initialbowel regimen in patients with cancer, one small study compared theuse of senna alone versus a senna-docusate combination. The resultsdemonstrated that the addition of the stool softener docusate was notnecessary.205 Increasing fluid intake, dietary fiber, and physical act

521、ivityshould also be encouraged, when appropriate.If constipation is present, the cause and severity must be assessed.Impaction, obstruction, and other treatable causes, such ashypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus,should be assessed and treated. Constipation may also be t

522、reated byadding bisacodyl 10 to 15 mg, 2 to 3 times daily with a goal of 1non-forced bowel movement every 1 to 2 days. If impaction is observed,glycerine suppositories may be administered or manual disimpactionperformed.If constipation persists, adding other laxatives may be considered, suchas recta

523、l bisacodyl once daily or oral polyethylene glycol, lactulose,magnesium hydroxide, or magnesium citrate. If gastroparesis issuspected, the addition of a prokinetic agent, such as metoclopramide,may be considered. Recent studies have shown that methylnaltrexone,a peripherally acting antagonist of -op

524、ioid receptors, helps relieveopioid-inducedconstipation while maintaining pain control.206,207 Basedon these results, the NCCN Palliative Care Panel recommendsconsidering 0.15 mg per kilogram of body weight of methylnaltrexoneevery other day (no more than once a day) for patients experiencingconstip

525、ation that has not responded to standard laxative therapy.Methylnaltrexone should not be used in patients with a postoperativeileus or mechanical bowel obstruction.Malignant Bowel ObstructionMalignant bowel obstructions are usually diagnosed clinically andconfirmed with radiography. For patients wit

526、h years to months to live,surgery following CT scan is the primary treatment option. Whilesurgery can lead to improvements in quality of life, surgical risks shouldbe discussed with patients and families. Although surgery is the primaryPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use

527、 only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without

528、the express written permission of NCCN.MS-17NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Caretreatment for malignant obstruction, some patients with advanceddisease or patients in generally poor condition are unfit for surgery andrequire al

529、ternative management to relieve distressing symptoms. Riskfactors for poor surgical outcome include ascites, carcinomatosis,palpable intra-abdominal masses, multiple bowel obstructions, previousabdominal radiation, advanced disease, and poor overall clinicalstatus.208 In these patients, medical mana

530、gement can includepharmacologic measures, parenteral fluids, endoscopic management,and enteral tube drainage.Pharmacologic management of malignant bowel obstruction can beseparated into two groups of patients: those for whom the goal is tomaintain gut function and those for whom gut function is no l

531、ongerpossible. When the goal is maintaining gut function, patients can betreated with opioids, antiemetics, and corticosteroids, alone or incombination. When gut function is no longer considered possible,pharmacologic options also include somatostatin analogs (eg,octreotide) and/or anticholinergics.

532、209-213 Antiemetics that increasegastrointestinal mobility such as metoclopramide should not be used inpatients with complete obstruction, but may be beneficial whenobstruction is partial. Use of octreotide is recommended early in thediagnosis because of its efficacy and tolerability.214,215 Despite

533、 positivefindings from several smaller randomized trials, a recent phase III trial ofoctreotide in 86 patients with malignant bowel obstruction failed todemonstrate a significant effect of this drug on days free of vomiting,number of vomiting episodes, symptom control, and other secondaryendpoints.2

534、16A venting gastrostomy tube (inserted by interventional radiology,endoscopy, or surgery), a percutaneous endoscopic gastrostomy tube,or an endoscopically placed stent can also palliate symptoms ofmalignant bowel obstruction.217,218 Total parenteral nutrition can beconsidered to improve quality of l

535、ife in patients with a life expectancy ofyears to months. These interventions have been shown to have littlepositive impact on survival time, but may improve quality of life.101,102Fatigue/Weakness/AstheniaThe data on methylphenidate for treating cancer-related fatigue havebeen mixed. While some tri

536、als have suggested a dose-dependentbenefit of this agent on fatigue symptoms,245,246 other studies have failedto produce positive results.247 Phase III randomized trials of modafinil fortreating cancer-related fatigue suggested that modafinil had a modestefficacy and was most effective for those wit

537、h severe fatigue.248,249 Formore information, see NCCN Guidelines for Cancer-Related Fatigue.Sleep/Wake DisturbancesPatients with cancer often suffer from insomnia or daytimesedation.219-221 In a recent study of 442 patients with advanced cancer,330 (75%) patients were assessed as having baseline sl

538、eepdisturbance as assessed by the Edmonton Symptom AssessmentSystem (ESAS) sleep item.222 Patients should first be evaluated forsleep/wake disturbances using, for example, the Epworth SleepinessScale.223 If patients have a history of sleep-disordered breathing (eg,excessive snoring, gasping for air,

539、 observed apneas, frequent arousals,sudden involuntary movement of arm or legs during sleep, unexplaineddaytime drowsiness), polysomnography should be considered.Polysomnography should also be considered for patients with head andneck cancers, because obstructive sleep apnea (OSA) is prevalent inpat

540、ients with this disease.224,225 Primary sleep disorders, such as OSAand periodic limb movement disorder, should be treated with continuouspositive airway pressure (CPAP) or BiPAP.226 Restless leg syndrome, ifpresent, can be treated with ropinirole, pramipexole, or carbidopa-levodopa.227-234 Fears an

541、d anxiety regarding death and disease shouldbe explored, and other contributing factors to sleep/wake disturbancesPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN

542、 Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Careshould be treated, including pain, depression, anxiety, delirium, andnausea. Cognitive behavioral therapy may be effective in treatingsleep/wake disturbances in patients with cancer.133,235-239Fo

543、r refractory insomnia, pharmacologic management includes the short-acting benzodiazepine lorazepam, the non-benzodiazepine zolpidem,and sedating antidepressants such as trazodone and mirtazapine.240The panel suggests that mirtazapine may be especially effective inpatients with depression and anorexi

544、a. Benzodiazepines should beavoided in older patients and in patients with cognitive impairment,because they have been shown to cause decreased cognitiveperformance.241 Caution should be exercised when administeringzolpidem due to the known risk of next-morning impairment. In 2013,the U.S. Food and

545、Drug Administration required lower recommendeddoses of zolpidem (ie, from 10 mg to 5 mg for immediate-releaseproducts from 12.5 mg to 6.25 mg for extended-release formulations).242For refractory daytime sedation, the guidelines suggest several options.The central nervous system stimulants methylphen

546、idate ordextroamphetamine should be given with a starting dose of 2.5 to 5 mgorally (PO) with breakfast. If the effect of the drug does not last throughlunch, a second dose can be given at lunch, preferably no later than2:00 PM. Doses can be escalated as needed.243 Another option forrefractory dayti

547、me sedation is the psychostimulant modafinil, which hasbeen approved in adults for excessive sleepiness associated withOSA/hypopnea syndrome (OSAHS), shift work sleep disorder, andnarcolepsy.244 The panel also recommends caffeine anddextroamphetamine as additional options for refractory daytimesedat

548、ion. The last dose of caffeine should be given no later than 4:00PM.Dying patients should be assessed for their desire to have theirinsomnia or sedation treated. The doses of their pharmacologictherapies can be adjusted as appropriate. The addition of an anti-psychotic drug (chlorpromazine or quetia

549、pine) can be considered inpatients whose insomnia is refractory.Please also see the NCCN Guidelines for Adult Cancer Pain and theNCCN Guidelines for Cancer-Related Fatigue for their discussions onsleep/wake disturbances.DeliriumDelirium should be assessed using the Diagnostic and StatisticalManual o

550、f Mental Disorders, Fourth Edition (DSM-IV) criteria.250Reversible causes should be identified and treated appropriately.251Delirium presents as hypoactive or hyperactive subtypes that mayrequire different approaches to management.252 A recent systematicreview suggested that hypoactive delirium was

551、the most prevalentsubtype in palliative care patients and that this condition is oftenunderdiagnosed due to its presentation.253Two comprehensive reviews describe the evidence base forrecommended pharmacologic and non-pharmacologic treatments fordelirium in patients with cancer.133,254 Non-pharmacol

552、ogic interventions(eg, reorientation, cognitive stimulation, sleep hygiene) should bemaximized before pharmacologic interventions are used. Delirium-inducing medications (ie, steroids, anticholinergics) should be reducedor eliminated as much as possible. Benzodiazepines should not beused as initial

553、treatment for delirium in patients not already taking them.The symptoms of moderate delirium can be controlled with oralhaloperidol, risperidone, olanzapine, or quetiapine fumarate.255-257 Thesymptoms of severe delirium (ie, agitation) should be controlled withantipsychotic, neuroleptic drugs such a

554、s haloperidol, olanzapine, orVersion 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-18Printed by Maria Chen on 5/27/2014 10:08:49 P

555、M. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carechlorpromazine.258 Because of its hypotensive side eff

556、ect, intravenouschlorpromazine should only be used in bed-bound patients. Abenzodiazepine, such as lorazepam, may be added for agitation that isrefractory to high doses of neuroleptics.259 The presence of therapeuticlevels of neuroleptics usually prevents the paradoxical excitationsometimes seen whe

557、n delirious patients are given lorazepam. Thedosages of these symptom-control medications should be titrated tooptimal relief. Opioid dose reduction or rotation can also be consideredfor patients with severe delirium. Caregivers should be supported incaring for their loved one and coping with this d

558、istressing condition.Delirium in patients with advanced cancer and limited life expectancymay shorten prognosis.260 In these patients, iatrogenic causes shouldbe eliminated whenever possible. Opioid rotation can be considered(see NCCN Guidelines for Adult Cancer Pain) if the delirium is believedto b

559、e caused by neurotoxicity of the current opioid. If delirium is a resultof disease progression, palliative care must be focused on symptomcontrol and family support. Neuroleptic and benzodiazepine medicationsshould have their dose increased and/or their route of administrationchanged to ensure adequ

560、ate delirium symptom control.261 Unnecessarymedications and tubes should be removed. For refractory delirium indying patients, palliative sedation can be considered followingconsultation with a palliative care specialist and/or psychiatrist (seebelow).Please also see the NCCN Guidelines for Distress

561、 Management forfurther discussion of delirium in patients with cancer.Psychosocial Distress Social Support/Resource ManagementFor distress related to psychological or psychiatric complications andspiritual or existential crisis, please see the NCCN Guidelines forDistress Management.Version 1.2014, 0

562、4/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-19For best outcomes, psychosocial care should be integrated into routinecancer care across al

563、l disease stages and in both the inpatient andoutpatient settings.47,262 A recent systematic review of patients withadvanced cancer identified psychosocial resources among the factorsthat promoted personal growth during the experience of cancer.263For patients with estimated life expectancy ranging

564、from years tomonths experiencing psychosocial distress, social support/resourcemanagement should be offered. Patients should be cared for in a safeenvironment with available caregivers. In addition, it is important toensure that the patient has adequate financial resources and to refer tosocial serv

565、ices as needed. Support and education should be providedto the caregivers and family members.264 Personal, spiritual, or culturalissues related to the patients illness and prognosis should bediscussed. Bereavement risk should be assessed. If language is abarrier, a professional health care interpret

566、er, who is not related to thepatient or family, should be available for patients, caregivers, andfamilies as needed.In a dying patient with an estimated life expectancy of weeks to days,the patients desires for comfort should be evaluated and supported.The process of dying and the expected events sh

567、ould be explained tothe patient, caregivers, and family members. For children of parentswith cancer, a survey-based study demonstrated that receiving end-of-life information enhanced trust in the care provided to their parents. 88Bereavement risk should be reassessed. Patients and family membersshou

568、ld be provided with emotional support to address any intra-familyconflict regarding palliative care interventions. Eligibility and readinessfor specialized palliative/hospice care should be determined.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distributio

569、n. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of N

570、CCN.MS-20NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CareAdvance Care PlanningThe oncology team should initiate discussions of personal values andpreferences for end-of-life care while patients have a life expectancy ofyears to months. Rec

571、ent studies have shown that these discussionsfrequently happen too late in the trajectory of disease, often duringacute hospital care and often with health professionals other than theprimary oncologist.265-267 Further, earlier end-of-life care discussionshave been associated with less aggressive ca

572、re and increased use ofhospice,268,269 while less aggressive care has been associated with animproved quality of life.270 Studies suggest that most patients withcancer would prefer to die at home,271,272 but lack of timely advance careplanning can render this impossible.ASCO has developed a booklet

573、to help patients and their familiesunderstand and discuss the cancer diagnosis and treatment options(http:/ Arecent randomized controlled trial found that a video decision supporttool increased the likelihood that patients would choose to forgoresuscitation.273 A randomized controlled trial of a str

574、ucturedintervention to facilitate end-of-life discussions (consisting of aninformation pamphlet and provider discussion) led to earlier designationof do-not-resuscitate orders and decreased the likelihood of patientsdying in the hospital.274 In addition, a recent study showed thatelectronic prompts

575、and email reminders to doctors could increase ratesof documentation of code status in patients with advanced lungcancer.275Advance care planning should include an open discussion aboutpalliative care options, such as hospice; personal values andpreferences for end-of-life care; the congruence betwee

576、n the patientswishes/expectations and those of the family/health care team; andinformation about advance directives. Patients should be asked if theyhave completed any advance care planning such as living wills, powersof attorney, or delineation of specific limitations regarding life-sustainingtreat

577、ments including cardiopulmonary resuscitation, mechanicalventilation, and artificial nutrition/hydration. The patients values andpreferences and any decisions should be documented in the medicalrecord, including MOLST or POLST (Medical Orders for Life-SustainingTreatment or Physician Orders for Life

578、-Sustaining Treatment) ifcompleted.When the patients life expectancy is reduced to months to weeks, theoncology team should actively facilitate completion of appropriateadvance directives and ensure their availability in all care settings.MOLST/POLST should be documented and accessible to all provid

579、ersacross care settings. The team should also confirm the patients valuesand decisions in light of changes in status. Palliative care consultationcan be considered to assist in conflict resolution when the patient,family, and/or medical professional team do not agree on thebenefit/efficacy of interv

580、entions.Where the patient wants to die should be determined. Most patientswith cancer would prefer to die at home,271,272 but sometimes their careneeds or support system at home cannot support their care. Somepatients request to receive end-of-life care in a skilled nursing facility oran in-patient

581、hospice facility.272,276 A prospective study showed thatpatients dying in an ICU had higher levels of physical and emotionaldistress compared with patients dying at home or in hospice.Additionally, caregivers of these patients had a greater incidence ofprolonged grief disorder.277 Providing palliati

582、ve care services has beenshown to decrease deaths in ICUs.276 A recent retrospective cohortstudy showed that patients who wanted to die at home were more likelyto do so if they had daily hospice visits, if they were married, if they hadPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use

583、 only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without

584、the express written permission of NCCN.MS-21NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Careadvance directives, if they did not have moderate or severe pain, or ifthey had good performance status.272 A second retrospective studysuggested t

585、hat referral to specialist palliative care at a greater interval oftime prior to death increased the likelihood of patients dying at home orin hospice rather than in the hospital.278 If advance care plans have notbeen completed, the oncology team should explore the patientsreluctance to engage in ad

586、vance care planning and refer to palliativecare if needed.In patients with a life expectancy of only weeks to days, the patientsdecision regarding cardiopulmonary resuscitation and other life-sustaining treatments must be clarified and confirmed. The desire fororgan donation and/or autopsy must also

587、 be explored with the patient.Overall, the oncology team must implement and ensure compliance withthe patients advance care plan.Palliative Care ReassessmentThe outcome measures for these guidelines are much more difficult todefine than those for NCCN disease-specific guidelines. The panelreviewed e

588、nd-of-life care outcomes from several surveys of NorthAmerican citizens.66,279-281 The panel chose a modified version ofSingers outcomes until more precise outcome measures are available.Acceptable palliative care should provide the following: 1) adequatepain and symptom management; 2) reduction of

589、patient and familydistress; 3) acceptable sense of control; 4) relief of caregiver burden; 5)strengthened relationships; and 6) optimized quality of life, personalgrowth, and enhanced meaning. The panel added “having an advancecare plan in progress” as part of the criteria for acceptable outcome.Res

590、earch is ongoing regarding better ways to measure dying well.282All patients should be reassessed regularly, and effectivecommunication and information sharing must exist between the patient,caregivers, and health care providers. Patients and family membersbenefit most from ongoing discussions about

591、 the natural history of thedisease and prognosis in clear, consistent language. If the interventionsare unacceptable upon reassessment, the oncology or palliative careteam should intensify palliative care and reassess the patient and familysituation. The oncology team should also consult specialized

592、 palliativecare services, hospice, or an ethics committee. Referral to a psychiatristor psychologist to evaluate and treat undiagnosed psychiatric disorders,substance abuse, and inadequate coping mechanisms should beconsidered. If psychosocial distress persists, palliative care optionsshould be inte

593、nsified, and the patients should be managed according tothe NCCN Guidelines for Distress Management.Patients treatment goals and expectations may change and evolve asdisease progresses. Reassessment should be ongoing, withcontinuation or modification of life-expectancyguided palliative careuntil the

594、 patients death or survivorship.Special Palliative Care InterventionsRequests for Hastened DeathSpecial palliative care interventions include responses to requests forhastened death (ie, physician aid-in-dying, physician-assisted suicide,euthanasia). The most appropriate response to a request for as

595、sistedsuicide is to intensify palliative care. All such patients should be referredto a palliative care specialist. A request for hastened death often hasimportant meanings that require exploration. Clarifying these meaningscan sometimes enlarge the range of useful therapeutic options insteadof prov

596、iding a lethal prescription. Open exploration of the patientsrequest for aid in dying can often identify unmet needs and newpalliative care interventions that may be helpful. Alternatives tophysician-assisted suicide, such as withdrawal of life-sustainingPrinted by Maria Chen on 5/27/2014 10:08:49 P

597、M. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced i

598、n any form without the express written permission of NCCN.MS-22NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Caretreatment, voluntary cessation of eating and drinking, and/or sedation,should be considered and discussed with patients and fami

599、lies.Psychiatric consultation to diagnose and treat reversible causes ofpsychological suffering should be requested. Patients should beassured that their health care team is committed to providing continuingcare. Although physician-assisted suicide, under specified conditions, islegal in the states

600、of Oregon, Montana, Vermont, and Washington,euthanasia is not legal in any of the United States.283-286 It is importantfor physicians to know the local legal status of hastened death, as otherstates have pending legislation regarding either prohibiting or permittingphysician-assisted suicide.Palliat

601、ive SedationPalliative sedation can be an effective symptom-control treatment forimminently dying patients with refractory symptoms and a lifeexpectancy of hours to days. Informed consent must be obtained fromthe patient and/or a surrogate or family member following discussionsthat clarify patients

602、disease status, treatment goals, prognosis, andexpected outcomes. Clinicians may find that applying usual benefit/riskanalysis to this type of intervention will suffice in medical decision-making. Palliative sedation has its ethical justification in the Doctrine ofDouble Effect,287-292 which means t

603、hat the possible harm (possiblerespiratory depression, starvation, and hastened death) that may comeas a side effect of doing good (relieving intolerable suffering) is justified.Furthermore, results from a study that prospectively matched terminallyill patients with cancer receiving or not receiving

604、 palliative sedationsuggest that sedation does not, in fact, shorten life.293 Similar resultswere obtained from a recent systematic review of 10 retrospective orprospective nonrandomized studies, although the overall quality ofstudies was quite poor.294 An ethics consult may be considered inaccordan

605、ce with institutional guidelines and state regulations.Palliative sedation is best performed by palliative care experts. Themost common sedatives used for palliative sedation are thiopental,pentobarbital, and midazolam by parenteral infusions.290 Infusionallorazepam, amobarbital, and propofol may al

606、so be used.290,295 Recentstudies suggested that palliative sedation may also be feasible in thehome setting and could be utilized in patients who wish to die athome.296,297Care of the Imminently Dying PatientAn imminently dying patient is defined as one within hours of death whois not stable enough

607、for transport. Caring for an imminently dyingpatient is intense for the patient, family, and health care team. A recentinternational qualitative study described many of the common non-pharmacologic palliative care activities provided in the last days oflife.298 An end-of-life care order set that inc

608、ludes physical, practical, andpsychosocial interventions may be beneficial for practitioners to use forimminently dying patients.The physical aspects of care for an imminently dying patient focus onadequate symptom management and comfort, keeping in mind thepatients wishes and values. Approaches may

609、 include intensifyingongoing care; adjusting medication doses for optimal comfort;discontinuing unnecessary interventions (eg, diagnostic tests,transfusions, artificial nutrition, hydration, dialysis, needle sticks);ensuring access to symptom-relief medication through alternate routesif oral adminis

610、tration is difficult; providing physical comfort by providinga pressure-relieving mattress and regular repositioning; treating urinaryretention and fecal impaction; deactivation of implanted defibrillator;controlling terminal restlessness and agitation with palliative sedation;reducing death rattle/

611、terminal secretion (eg, repositioning patient;reducing parenteral and enteral fluids; adding medications such asPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Versio

612、n 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-23NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines

613、Version 1.2014Palliative Carescopolamine, hyoscyamine, atropine, or glycopyrrolate)150; andpreparing for patient and family requests for autopsy and/or organdonation.The psychosocial aspects of care for an imminently dying patient takeinto account individual and family goals, preferences, cultures,

614、andreligious beliefs. The care plan may include consultation with socialworkers or chaplains to meet social and spiritual needs; opencommunication between the patient, family, and care team regardingthe physical and psychological aspects of the dying process and theimportance of honoring any advance

615、 directives; and anticipatory griefcounseling to help facilitate caregiver closure. Patients who are activelydying in their final hours of life should be allowed to spend uninterruptedtime with family.The practical aspects of care for an imminently dying patient in thehospital include: mobilizing in

616、-hospital end-of-life care policy andprocedures; ensuring that the patients advance directive is documentedand implemented and a do-not-attempt-resuscitation (DNAR) or allownatural death (AND) order is written and followed; securing a privateroom for the patient; and enabling family presence around-

617、the-clock. Ifthe patient and family have not documented a DNAR order,patient/family education and counseling should be intensified to try tohelp them accept this level of care to prevent harm to the patient fromfutile attempts at cardiopulmonary resuscitation. Providers should beaware that policies

618、regarding resuscitation may differ based ontreatment setting. A patient with a documented inpatient DNAR ordermay also require DNAR orders for out-of-hospital settings (eg,residential care, ambulance transport). In states where theMOLST/POLST is honored across all treatment settings, it will protect

619、the patient.A Peaceful DeathThese NCCN Guidelines are the first to include death as an expectedoutcome and after-death care for the family as an essential part of thecontinuum of cancer care. Many studies have attempted to define a“good death” or a “peaceful death” from the perspective of clinicians

620、,patients, and families.299-302 Interestingly, one study found that patients,families, and physicians had very similar ideas of what constitutes apeaceful death: freedom from pain, being at spiritual peace, and beingwith family ranking among the top three considerations by all threegroups.302 End-of

621、-life care should be flexible enough to ensure that thedeath is viewed as a peaceful death by those involved.302 The definitionof a “peaceful death” used by the NCCN Palliative Care Panel is “onethat is free from avoidable distress and suffering for patients, familiesand caregivers; in general accor

622、d with patients and familys wishes;and consistent with clinical, cultural, and ethical standards.”303Final results of the prospective, longitudinal, cohort Coping With Cancerstudy of 396 patients with advanced cancer and their caregivers wererecently reported. The study found a higher quality of lif

623、e in the lastweeks of life in patients who avoided visits to the ICU and feedingtubes, did not die in the hospital, worried less, prayed or meditated,were visited by a pastor in the hospital or clinic, and felt a strongtherapeutic alliance with their physicians.270After-Death Care InterventionsCompr

624、ehensive palliative care for the patients family and caregiverscontinues after the patients death. Immediate issues include ensuringculturally sensitive and respectful treatment of the body, includingremoval of tubes, drains, lines, and the Foley catheter (unless anautopsy is planned); providing fam

625、ily time with the body; addressingconcerns about organ donation or autopsy; facilitating funeralPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexP

626、alliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carearrangements through completion of necessary paperwork; andinforming insurance companies and other health care providers of thepatients death.Bereavement support should be offered, beginning with a personal visito

627、r telephone call from the patients primary oncology team, followed bya condolence letter. Family members at risk for complicatedbereavement or prolonged grief disorder should be identified, andcomplicated grief should be treated.304-306 Children of patients withcancer represent a uniquely at-risk po

628、pulation for psychosocialdysfunction. Additionally, a recent study suggested that certainpredictors of prolonged grief could be identified in family caregivers atthe time of the patients entry to palliative care; these factors includedpre-death symptoms of prolonged grief, spousal relationship to th

629、epatient, large impact of caring on schedule, poor family functioning, andlow levels of optimism. 307Bereavement care is often best provided by an experienced hospiceteam or a skilled mental health care professional. The family mayrequest a debriefing meeting from the medical team and may requireass

630、istance in identifying community bereavement resources. A well-supported end-of-life care experience will facilitate the familysacceptance of appropriate referrals for cancer risk assessment and riskmodification. If not already recommended, providers should direct familymembers towards genetic scree

631、ning, especially if the deceased patientwas positive for known genetic markers that confer risk. For moreinformation, see the NCCN Guidelines for Genetic/Familial High-RiskAssessment: Breast and Ovarian and Genetic/Familial High-RiskAssessment: Colorectal.Palliative Care ResearchThe evidence base fo

632、r the treatment recommendations for physical andpsychosocial symptoms in patients with cancer is generally weak.308,309Clinical trials in palliative oncology face many challenges, includingrecruitment difficulties, high attrition rates, and insufficient funding.310-312Several groups have recommended

633、 considerations for the design offuture palliative care clinical trials, including standardization of reporting,the integration of technology for data collection, the use of validatedoutcome measures, and the use of trial designs other than therandomized controlled trial.313-317 In addition, formal

634、feasibility studiescan help ensure the success of subsequent larger trials.314,318 Despitethe challenges associated with conducting large-scale palliative careresearch studies, several notable studies have examined the impact ofpalliative care efforts on patient and family/caregiver outcomes(reviewe

635、d by El-Jawahri, et al.308).Putting Palliative Care Guidelines into PracticeThese guidelines have the goal of providing the best quality of lifepossible for each patient and were developed to accompany theappropriate cancer treatment guidelines. Institutions should developprocesses for integrating p

636、alliative care into cancer care, both as part ofusual oncology care and for patients with specialty palliative careneeds. Many approaches have been described.38-46Patients and families should be informed that palliative care is anintegral part of their comprehensive cancer care. Educational programs

637、should be provided to all health care professionals and trainees so thatthey can develop effective palliative care knowledge, skills, andattitudes. Skilled palliative care specialists and interdisciplinary palliativecare teams, including board-certified palliative care physicians,advanced practice n

638、urses, and physician assistants, should be readilyVersion 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-24Printed by Maria Chen on

639、 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Careavailable to provide consultative

640、 or direct care to patients and familieswho request or require the expertise. Finally, the quality of palliativecare should be monitored by institutional quality improvement programs.The experiences of patients with cancer throughout the disease coursebegin with the diagnosis. Patient conditions usu

641、ally move fromambulatory to sedentary as disease advances and performance statusworsens. When life expectancy is a matter of days or hours, patientsmay become unable to communicate. These patients may be at home,living with a family member, or in a health care facility. Throughunderstanding the pati

642、ents status relative to the natural diseasetrajectory and by using these guidelines, the oncology team can providethe most appropriate treatment for each patient. Oncologists andpatients should discuss at the outset whether the treatment will becurative or palliative. Many palliative care questions

643、must be consideredearly in each patients comprehensive cancer care. The primaryoncology team is responsible for working with patients to raise andanswer these questions. Oncologists must identify patients goals forthe remainder of life to get a better sense of whether they understoodand accepted the

644、 diagnosis and prognosis. Additionally, oncologistsmust explain the types of therapies that are available and how thesetherapies can affect the patients daily life. As the cancer progressesand the value of further anticancer therapy diminishes, palliative therapyshould be intensified. The issue of w

645、hether patients want moreanticancer therapy must be openly addressed. The delivery of clear andconsistent prognostic information can help patients make the mostappropriate decisions.Patients should be made aware that undergoing anticancer therapydoes not have to sidetrack them from addressing end-of

646、-life issues.Collaborating with palliative care experts extends oncologiststherapeutic repertoire and diminishes the stress of caring for patientsVersion 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be rep

647、roduced in any form without the express written permission of NCCN.MS-25who have incurable disease. Increasing emphasis on palliative care inoncology should improve patient outcomes and provide new avenuesfor clinical research and professional satisfaction. Timely introduction ofmembers of the insti

648、tutional or community palliative care team allowspatients to meet the individuals who will help them and their familiesthrough their experience. Because the diagnosis of cancer andimpending death is such a frightening experience, oncologists must tryto alleviate those fears by assuring patients that

649、 the members of a teamwill work with them and their families to make things less burdensome.Additionally, oncologists must discuss the natural history of the patientsdisease and prognosis with the family and palliative care team toanticipate and manage symptoms and problems commonly associatedwith t

650、he diagnosis and treatment of cancer.Palliative care is intensified late in the course of disease to help patientsand families understand the disease and begin to make end-of-lifeplans. Sometimes patients and families do not accept the prognosis ordo not begin to make preparations.319,320 These thin

651、gs may be a signthat patients do not fully understand the disease and may lead to thedesire by patients and families for aggressive treatments that may beboth futile and toxic.320 Palliative care supports education so thatpatients can better understand the disease.Oncologists must ensure that advanc

652、e care plans are in place as earlyas possible in the disease trajectory. This focus on the patients wishesassures patients that they will be provided with no more and no lessaggressive care than they desire and also relieves them of concernsabout burdening family members with difficult end-of-life d

653、ecisions. Thecombined efforts of the oncology team and the hospice/palliative careteam can improve the overall outcome for patients and their families.Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Ne

654、twork, Inc., All Rights Reserved.These syndromes can manifest as symptoms of depression, anxiety,Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written p

655、ermission of NCCN.MS-26NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CarePsychosocial Support for Palliative Care ProvidersAfter the loss of a patient, psychosocial support should be provided forthe staff. A bereavement or memorial ritual fo

656、r medical staff (eg, briefreading, moment of quiet) can be considered. Funeral attendance byhealth care professionals can be considered for individual patients.Health care professionals should also review medical issues related topatient death, explore concerns and questions about quality of patient

657、care, and review emotional responses of family and staff to the patientsdeath.Oncology and palliative care teams commonly encounter patient lossand deal with grief, and over time the resultant emotional distress canlead to provider burnout, compassion fatigue, and/or moral distress.321-324fatigue, a

658、nd low mental quality of life.325 Such staff should be identifiedand assisted. Unfortunately, although considerable research has beendedicated to evaluating patterns and interventions to mediate patient,family, and caregiver distress and grief, much less attention has beendevoted to these same issue

659、s among health care providers and teams.For a summary of the literature on provider compassion fatigue inoncology, see reviews by Najjar and colleagues (2009),321 Shanafeltand Dyrbye (2012),325 and Sherman and colleagues (2006).326Although limited in quantity, most studies on compassion fatigue ared

660、erived from the oncology nursing literature. A large survey of hospiceand palliative care providers (ie, clinical, administrative, allied healthworkers) revealed a strong correlation between burnout andcompassion fatigue, and revealed the need for enhanced support ofindividuals in this field.327 Add

661、itionally, a cross-sectional survey ofnurses, medical assistants, and radiology technicians at acomprehensive cancer center revealed concerning levels of burnoutand compassion fatigue in both inpatient and outpatient care settings.328Qualitative research on compassion fatigue interventions reveals t

662、hatoncology clinicians rated the following resources as helpful: educationalinterventions, support programs or resources in the workplace, retreats,and self-care measures.321,329 Unfortunately, despite the reported desirefor such interventions, access can be limited. In a nationwide survey ofoncolog

663、y nurses, only 60% of survey respondents reported access toan employee assistance program, 45% reported no offerings ofeducation addressing workplace coping, and 82% of respondentsreported no off-site programs such as retreats.329 Generally, evidence-based interventions for compassion fatigue and bu

664、rnout in physiciansare lacking. When asked to provide useful preventative measures andcoping strategies, palliative care specialists recommended emphasizingthe rewarding aspects of their work and strategies for “enhancedmeaning-making.”330 Experts in the field have also highlighted theimportance of

665、self-awareness and self-care measures for oncologistsand palliative care specialists to decrease levels of compassionfatigue.331 To this end, self-care was established as a core competencyarea for fellows in hospice and palliative medicine.331 Examples andevidence for additional preventative strateg

666、ies and solutions foroncologist burnout are reviewed by Shanafelt and Dyrbye.325HopeThese guidelines are intended to help oncology teams provide the bestcare possible for patients with incurable cancer. Palliative care can helppatients and families meet short-term goals, such as important life-cycle

667、events, and achieve realistic expectations. In this sense, the careoutlined in these guidelines provides a different kind of hope than thatPrinted by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc.,

668、 All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative Carefor cure of the disease itself. Palliative care provides hope for dignity,comfort, and closure and for growth at the end of life.Version 1.2014, 04/18/2014 National Compr

669、ehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-27Printed by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 201

670、4 National Comprehensive Cancer Network, Inc., All Rights Reserved.NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidelines Version 1.2014Palliative CareTable 1: Palliative Care Internet Resources forCliniciansaPalliative Care Clinical CEducation in Palliative and End-of-life

671、Care (EPEC): Comprehensivecurriculum covering fundamentals of palliative medicine; teachingguideshttp:/www.eperc.mcw.edu/EPERC.htmEnd of Life/Palliative Education Resource Center (EPERC): Medicaleducator resources for peer-reviewed palliative care teachingmaterialswww.StopPain.orgDepartment of Pain

672、Medicine and Palliative Care at Beth IsraelMedical Center: Online education for physicians, nurses, andpharmacistsClinical, Educational, Professional, and Public RP: Extensive information on pharmacologic symptommanagementwww.aahpm.orgAmerican Academy of Hospice and Palliative Medicine: Physicianmem

673、bership organization; board review courses; publicationshttp:/www.abim.orgThe American Board of Internal Medicine: Physician Board Certificationhttp:/www.nhpco.org/templates/1/homepage.cfmNational Hospice and Palliative Care Organization: Nonprofitmembership organization representing hospice and pal

674、liative careprograms and professionals in the United States.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-28http:/www.hpna

675、.org/Hospice and Palliative Nurses Association: Specialty nursingorganization with evidence-based educational tools for the nursing teamwww.hms.harvard.edu/cdi/pallcareCenter for Palliative Care at Harvard Medical School: Facultydevelopment courses, other educational programshttp:/www.nationalconsen

676、susproject.org/National Consensus Project for Quality Palliative Care: Clinicalpractice guidelineswww.americangeriatrics.org/American Geriatrics Society: Clinical guidelines and continuingeducationPalliative Care Program Developmentwww.capc.orgCenter to Advance Palliative Care: Technical assistance

677、for cliniciansand hospitals seeking to establish or strengthen a palliative careprogramwww.capc.org/pclcPalliative Care Leadership Centers: Eight exemplary palliative careprograms providing site visits, hands-on training, and technicalassistance to support new palliative care clinicians and programs

678、nationwideaAllwebsites accessed March 2014.Adapted with permission from Meier DE et al. Oncology 2005;19. Available athttp:/ by Maria Chen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.V

679、ersion 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.MS-29NCCN Guidelines IndexPalliative Care Table of ContentsDiscussionNCCN Guidel

680、ines Version 1.2014Palliative CareReferences1. Cancer Facts & Figures 2014. Atlanta, GA: American Cancer Society;2014. Available at:http:/www.cancer.org/acs/groups/content/research/documents/webcontent/acspc-042151.pdf. Accessed February 28, 2014.2. Cancer survivors-United States, 2007. MMWR Morb Mo

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689、J, et al. Palliative Care InpatientService in a Comprehensive Cancer Center: Clinical and FinancialOutcomes. J Clin Oncol 2004;22:2008-2014. Available at:http:/www.ncbi.nlm.nih.gov/pubmed/15143094.17. Levy M. NCCN Task Force reports: Supportive and Palliative Care.Oncology 1999;13:517-522.18. A cont

690、rolled trial to improve care for seriously ill hospitalizedpatients. The study to understand prognoses and preferences foroutcomes and risks of treatments (SUPPORT). The SUPPORTPrincipal Investigators. JAMA 1995;274:1591-1598. Available at:http:/www.ncbi.nlm.nih.gov/pubmed/7474243.Printed by Maria C

691、hen on 5/27/2014 10:08:49 PM. For personal use only. Not approved for distribution. Copyright 2014 National Comprehensive Cancer Network, Inc., All Rights Reserved.Version 1.2014, 04/18/2014 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustrat

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693、ol 2004;22:3438-3440. Available at:http:/www.ncbi.nlm.nih.gov/pubmed/15277538.20. Meyers FJ, Linder J. Simultaneous care: disease treatment andpalliative care throughout illness. J Clin Oncol 2003;21:1412-1415.Available at: http:/www.ncbi.nlm.nih.gov/pubmed/12663735.21. Greer JA, Jackson VA, Meier D

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