Palliative Nccn 12

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Version 1.2012, 04/02/12 © National Comprehensive Cancer Network, Inc. 2012,All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .® ®

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) ®

Palliative Care

Version 1.2012






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NCCN Guidelines Panel Disclosures

NCCN Guidelines Version 1.2012 Panel MembersPalliative Care

Michael H. Levy, MD, PhD/Chair

Fox Chase Cancer Center

Michael D. Adolph, MD, MPH, MBA, FACSThe Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute

Anthony Back, MDFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

Susan Block, MDDana-Farber/Brigham and Women’s Cancer Center

Shirley N. Codada, MDH. Lee Moffitt Cancer Center &

Research Institute

Shalini Dalal, MDThe University of TexasMD Anderson Cancer Center

Teresa L. Deshields, PhDSiteman Cancer Center at Barnes-Jewish Hospital and Washington

University School of Medicine

Elisabeth Dexter, MDRoswell Park Cancer Institute

† £

† £

£

£ Þ

£

Sydney M. Dy, MD

The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Sara J. Knight, PhDUCSF Helen Diller FamilyComprehensive Cancer Center

Sumathi Misra, MD Vanderbilt-Ingram Cancer Center

Christine S. Ritchie, MD, MSPHUniversity of Alabama at BirminghamComprehensive Cancer Center

Todd M. Sauer, MDUNMC Eppley Cancer Center atThe Nebraska Medical Center

Thomas Smith, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

David Spiegel, MDStanford Cancer Institute

Linda Sutton, MD

Duke Cancer Institute

Robert M. Taylor, MDThe Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute

£

Þ £

£

£

† £

£

₪

₪

Jennifer Temel, MD

Jay Thomas, MD, PhDCity of Hope Comprehensive Cancer Center

Roma Tickoo, MD, MPHMemorial Sloan-Kettering Cancer Center

Susan G. Urba, MDUniversity of MichiganComprehensive Cancer Center

Jamie H. Von Roenn, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University

Joseph L. Weems, MD

Sharon M. Weinstein, MD, FAAHPMHuntsman Cancer Instituteat the University of Utah

St. Jude Children`s Research Hospital/University of Tennessee Cancer Institute

† £

Þ £

† £

† £

£

Massachusetts General HospitalCancer Center

‡ Hematology/hematology oncology

† Medical oncology

Þ Internal medicine

£ Supportive care including palliativeand pain management

Psychiatry and psychology, includinghealth behavior

Neurology/neuro-oncology

Anesthesiology

* Writing committee member

₪ Geriatric medicine

*

NCCNDeborah Freedman-Cass, PhD

Mary Anne Bergman

Printed by Randy Stevian on 4/23/2012 11:00:25 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.

http://contents.pdf/

http://www.nccn.org/disclosures/panel_list.asp?ID=69


http://www.nccn.org/disclosures/panel_list.asp?ID=69




http://www.nccn.org/clinical_trials/physician.html

























Note: All recommendations are category 2Aunless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

NCCN Guidelines Version 1.2012Palliative Care

Uncontrolled symptoms

Moderate-to-severe distress related to cancer

diagnosis and/or cancer therapy

Serious comorbid physical, psychiatric, and

psychosocial conditions

Life expectancy 6 moIndicators include:

Poor performance status

ECOG 3 or KPS 50HypercalcemiaBrain or cerebrospinal fluid metastasisDelirium

Superior vena cava syndromeSpinal cord compressionCachexiaMalignant effusions

Bilirubin 2.5 m

Creatinine 3 mor

Patient/family concerns about course of disease

and decision-makingor

Patient/family requests for palliative care

or

or

Many stage IV cancers

g/dL

g/dL

or

Present

Not present

Rescreen at next visit

See PAL-4

SCREENINGc,d ASSESSMENT BY ONCOLOGY TEAM

PAL-3

Benefits/risks of

anticancer therapy

Symptoms

Psychosocial distress

See PAL-5

See PAL-6

Personal goals/expectations

Educational and informational

needs

Cultural factors affecting care

Criteria for early

consultation with a

palliative care specialist

Inform the patient and family of the role and benefits of palliative care services

Discuss anticipation and prevention of symptoms and advance

care planning

c

d

Management of any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, social workers and other mentalhealth professionals, chaplains, nurse practitioners, physician assistants, and dietitians.

Oncologists should integrate palliative care into general oncology care. Early consultation/collaboration with a palliative care specialist/hospice team should be

considered to improve quality of life and survival.




http://fatigue.pdf/

http://distress.pdf/









Natural history of specific tumor

Potential for response to further treatment

Potential for treatment-related toxicities

Meaning of anticancer therapy to patientand family

Impairment of vital organs

Performance status

Serious comorbid conditions

ASSESSMENT BY ONCOLOGY TEAM

Anticancer therapyinterventions (See PAL-8)

PAL-4

Benefits/risks of

anticancer therapy

Psychosocial distress

Psychosocial/psychiatric

Depression/anxietyIllness-related distress

Social support problems

Resources problems

Spiritual or existential crisis

HomeFamilyCommunity

Financial

Symptoms

Pain

Dyspnea

Anorexia/cachexia

Nausea/vomiting (NV)

Constipation

Malignant bowel obstruction

Fatigue/weakness/astheniaInsomnia/s

Delirium

edation

Pain I (See PAL-9)nterventions

See NCCN Distress Management Guidelines

Delirium I (See PAL-20)nterventions

Anorexia/Cachexia Interventions (See PAL-12)

See NCCN Cancer-Related Fatigue Guidelines

Constipation I (See PAL-16)nterventions

Nausea/Vomiting I (See PAL-14)nterventions

Malignant Bowel Obstruction (See PAL-17)

Dyspnea I (See PAL-10)nterventions

Social Support/Resource Management(See PAL-22)

Insomnia/Sedation I (See PAL-19)nterventions

Consider Consultation with Palliative Care

Specialist (See PAL-6)




http://fatigue.pdf/



http://fatigue.pdf/









PAL-5

Palliative Care Tableof Contents

Patient goals and expectationsAdvance care planning

Family goals and expectations

Priorities for palliative careGoals and meaning of anticancer therapyQuality of life

Eligibility for hospice, with needs that might bemet by hospice

Patient/family values and preferences aboutinformation and communication

Patient/family perceptions of disease status

Personal goals/

expectations

Educational and

informational needs

Cultural factors affectingcare

Interventions (See PAL-24)Advance Care Planning(See PAL-26)

Interventions (See PAL-24)

(See PAL-6)

Criteria for early

consultation with palliativecare specialist

PALLIATIVE CARE ASSESSMENT















Consult with palliative care

specialist/teamCollaborate with other health careprofessionals treating the patient

Refer to appropriate health careprofessionals

Mental health and social servicesHealth care interpretersOthers

Mobilize community supportReligiousSchoolCommunity agencies

Expedite referral to hospiceservices when appropriate

c,d

REASSESSMENT

Unacceptable

Ongoing reevaluation and

communication betweenthe patient and health

care team

Acceptable

Adequate pain and symptom control

Reduction of patient/family distress

Acceptable sense of controlRelief of caregiver burden

Strengthened relationships

Optimized quality of life

Personal growth and enhanced

meaning

Advance care planning in progress

:

Patient satisfied with response to

anticancer therapy

PAL-7

Ongoing

reassessment

ONCOLOGY TEAM INTERVENTIONS

Intensify palliative care efforts to

communicate palliative care options

Consult with a mental healthprofessional to evaluate and treatundiagnosed psychiatric disorders,substance abuse, and inadequatecoping methods

See NCCN Distress Management

Guidelines

c

d

Management of any patient with positive screening requires a care plan developed by an interdisciplinary team of physicians, nurses, social workers and other mentalhealth professionals,chaplains, nurse practitioners, physician assistants, and dietitians.

Oncologists should integrate palliative care into general oncology care. Early consultation/collaboration with a palliative care specialist/hospice team should beconsidered to improve quality of life and survival.













Years

to

months

Months

to

weeks

Weeks to

days(Dying

patient)

Provide appropriate prevention and managementof symptoms caused by anticancer therapy

Discuss intent, goals, benefits, and risks of

anticancer therapy, including possible effects on

quality of life

Provide appropriate anticancer therapy as

outlined in

Provide appropriate palliative care

Prepare patient psychologically for possible

disease progression

NCCN disease-specific guidelines

See above interventions

Redirect goals and hopes to those that areachievable

Provide guidance regarding anticipated courseof disease

Consider potential discontinuation of anticancer treatment

Offer best supportive care, including referral topalliative care or hospice

Provide guidance regarding anticipated dyingprocess

Focus on symptom control and comfort

Foster patient participation in preparing lovedones

Refer to palliative care/hospice team

Encourage discontinuation of anticancer therapy

Intensify palliative care in preparation for death

Continueanticancer therapy

and palliative care

BENEFITS/RISKS OF ANTICANCER THERAPYESTIMATED

LIFEEXPECTANCY

INTERVENTIONS

REASSESSMENT

PAL-8

Years

Acceptable:

Adequate pain and

symptom control

Reduction of

patient/family distress

Acceptable sense of control

Relief of caregiver

burden

Strengthened

relationships


Personal growth and

enhanced meaning

Ongoing

reassessment

Change or

discontinue

anticancer therapy

Review patient

hopes about and

meaning of

anticancer therapy

Intensify palliativecare efforts

Review advance

care planning

Consult or refer to

specialized

palliative care

services or hospice



Unacceptable






http://pain.pdf/

http://pain.pdf/









Years to

months

Monthsto weeks

Weeks to

days(Dying

patient)

Treat according to NCCNAdult Cancer Pain Guidelines

In addition:

and hyperalgesia

Treat according to

Do not reduce dose of opioid solely for

decreased blood pressure, respiration rate, or

level of consciousness

Maintain analgesic therapy; titrate to optimal

comfortRecognize and treat opioid-induced neurotoxicity,

including myoclonus

If opioid reduction is indicated, reduce by 50%

per 24 h to avoid acute opioid withdrawal or pain

crisis. Do not administer opioid antagonist

Balance analgesia against reduced level of

consciousness based on patient preference

Modify routes of administration as needed (PO,IV, PR, subcutaneous, sublingual, transmucosal,

and transdermal) applying equianalgesic dose

conversions

Consider sedation for refractory pain

( )

Consult with a pain management/palliative carespecialist

NCCN Adult Cancer Pain

Guidelines

See PAL-30

Continue to treataccording to

Monitor symptoms andquality of life todetermine

whether additional end-of-life measuresare required

NCCNCancer PainGuidelines

Adult

INTERVENTIONS REASSESSMENT

PAL-9

Ongoing

reassessment

Years

Acceptable:

Adequate pain and

symptom controlReduction of


Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationshipsOptimized quality of

life

Personal growth and

enhanced meaning

PAIN

Continue to

treat according

to

Consider aconsultationwith a painmanagement/palliative carespecialist

NCCN

Cancer PainGuidelines

Adult

ESTIMATED

LIFEEXPECTANCY

Unacceptable



http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/


http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/

http://pain.pdf/









Years to

months

Assess symptom intensity

Treat underlying causes/comorbidconditions:

Radiation/chemotherapyTherapeutic procedure for cardiac,

pleural, or abdominal fluidBronchoscopic therapy

Bronchodilators, diuretics, steroids,antibiotics, or transfusions

Relieve symptoms

Educational, psychosocial, and emotional

support for the patient and family

Nonpharmacologic therapies, including

fans, cooler temperatures, stress

management, relaxation therapy, andphysical comfort measuresIf opioid naive, morphine, 2.5-10 mg PO q

4 hr prn, 1-3 mg IV q 1 hr prnBenzodiazepines (if benzodiazepine

naive, starting dose lorazepam, 0.5-1 mg

PO q 4 hr prn)

f

Oxygen therapy for hypoxia

Temporary ventilatory (CPAP, BiPAP)

support if clinically indicated for severe

reversible condition


Weeks to

days(Dying

patient)

See Interventions (PAL-11)

Months

to weeks

DYSPNEA

Ongoing

reassessment

Years

Acceptable:

Adequate dyspnea and

symptom control

Reduction of

patient/family distressAcceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships


Personal growth andenhanced meaning

Continue to treat andmonitor symptoms

and quality of life to

determine whether

status warrants

change in strategies

PAL-10

Intensify palliative care

efforts

Consult or refer to

specialized palliative

care services or hospice

ESTIMATED

LIFE

EXPECTANCY

f For acute progressive dyspnea, more aggressive titration may be required.

Unacceptable












Assess symptom intensity

Nonpharmacologic therapies; educational,

psychosocial, and emotional support

If opioid naive, morphine, 2.5-10 mg PO q 4 hr

prn, 1-3 mg IV q 1 hr prnBenzodiazepines (if benzodiazepine naive,

starting dose lorazepam, 0.5-1 mg PO q 1 hr prn)

Reduce excessive secretions withscopolamine, 0.4 mg SC q 4 hr prn; 1.5 mg

patches, 1-6 patches q 3 d; atropine 1%

ophthalmic solution 1-2 drops SL q 4 h pr; or

glycopyrrolate 0.2-0.4 mg IV or SQ q 4 hr prn

Provide anticipatory guidance for patient/familyregarding dying of respiratory failureProvide emotional and spiritual support

Use physical signs of distress as potentialdyspnea in noncommunicative patients

Focus on comfortContinue to treat underlying condition asappropriate

Relieve symptoms

Withhold/withdraw/initiate time-limited trial of mechanical ventilation as indicated

Address patient and family preferences,prognosis, and reversibility

Provide sedation as neededDiscontinue fluid support/consider low-dosediuretics if fluid overload may be a contributingfactor

f

g

4

FansOxygen if hypoxic and/or subjective relief is

reported

( )See PAL-10

Continue to

treat and

monitor

symptoms and

quality of lifeto determine

whether status

warrants

change in

strategies


DYSPNEA

Acceptable:dyspnea

Adequateand symptom controlReduction of

patient/family distressAcceptable sense of

controlRelief of caregiver

burdenStrengthened


lifePersonal growth and

enhanced meaning

PAL-11

Months toweeks

Years to

months

Weeks to days(Dying patient)

SeeInterventions(PAL-10)

Years

Ongoing

reassessment

Intensify palliative

care interventions

and consider a

consultation with a

palliative care

specialistConsider sedationfor intractablesymptoms( )See PAL-30

ESTIMATED

LIFEEXPECTANCY

Unacceptable

f For acute progressive dyspnea, more aggressive titration may be required.gHughes A et al. Audit of three antimuscarinic drugs for managing retained secretions. Palliative Medicine. 2000; 14:221-222.












Evaluate rate/severity of weight loss

Treat readily reversible cause of anorexia:Early satiety

MetoclopramideSymptoms that interfere with intake

Dysgeusia

DyspneaDepression/Anorexia

(Mirtazapine 7.5-30 mg hs)ConstipationPain

Review/modify medications that interfere with

intake

Evaluate for endocrine abnormalities:HypogonadismThyroid dysfunctionMetabolic abnormalities (eg, increased calcium)

Consider appetite stimulant (eg, megestrol acetate,

400-800 mg/d; prednisone 10-20 mg BID)Consider an exercise program

Assess social and economic factors

Consider nutrition consult

Consider nutrition support,

Xerostomia

Oral-pharyngeal candidiasisMucositisNausea and/or Vomiting

Eating disorders/body image

enteral and parenteral

feeding (as appropriate)

h

i

Fatigue

Months to

weeks

Years

to

months

Weeks to

days(Dying

patient)

Continue to

treat and

monitor

symptoms and

quality of life to

determinewhether status

warrants

change in

strategies

ANOREXIA/CACHEXIA


Ongoing

reassessment

Years

Acceptable:

Weight stabilization or

gain

Improvement in

symptoms that

interfere with intake

Improved energy

Resolution of

metabolic or endocrine

abnormalities


PAL-12


care interventions

Provide dietary

consultation

Consider clinical trial

ESTIMATED

LIFEEXPECTANCY

Unacceptable

hDy S, Lorenz K, et al. Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea. 2008 J Clin Oncol. 26:3886-3895.

i August DA, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapyduring adult anticancer treatment and in hematopoietic cell transplantation.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-500.










Assess importance of symptoms of anorexia and cachexiato patient and family

If important, consider short course of

Provide education and support to patient and familyregarding emotional aspects of withdrawal of nutritionalsupport.

Inform patient and family of natural historyof disease, including the following points:

Absence of hunger and thirst is normal in the dyingpatientNutritional support may not be metabolized in patientswith advanced cancer There are risks associated with artificial nutritionand hydration, including fluid overload, infection, andhastened deathIV hydration may increase excretion of drugmetabolites providing benefit to the patientSymptoms like dry mouth should be treated with localmeasures, eg, mouthcare, small amounts of liquidsWithholding or withdrawal of enteral or parenteral nutritionis ethically permissible in this setting. It will not causeexacerbation of symptoms and may improve somesymptoms

prednisone 10-20 mg BID

Focus on patient goals and preferences

Provide family with alternate ways of caring for the patient

Provide emotional support

Treat for depression, if appropriate (Mirtazapine7.5-30 mg hs)

Continue to

treat and

monitor

symptoms and

quality of life to

determine

whether status

warrantschange in

strategies


Ongoing

reassessment

Acceptable:

Adequate a

c symptom

control

Reduction of


Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships

Optimized quality of

life

Personal growth and

enhanced meaning

norexia/

achexia

PAL-13

Months

to weeks

Years to

months

Weeks to

days(Dying

patient)

Years See Interventions (PAL-12)

ANOREXIA/CACHEXIA


care efforts

Consult or refer to

specialized

palliative care

services or hospice

ESTIMATED

LIFE

EXPECTANCY

Unacceptable









http://antiemesis.pdf/









Add a 5-HT3 antagonist (eg, ondansetron)

± anticholinergic agent (eg, scopolamine)± antihistamine (eg, meclizine)± cannabinoid.If NV persists:

Add a corticosteroid(eg, dexamethasone).If NV persists:

Consider using a continuous IV/SCinfusion of antiemetics; consider an opioid rotation if patient is onopioids.

If NV persists:

Consider adding alternative therapies(eg, acupuncture, hypnosis, cognitivebehavioral therapy)

INTERVENTIONS

PAL-15

Acceptable:

Adequate NV symptom

control


Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships


REASSESSMENT

Continue to treatand monitor

symptoms and

quality of life to

determine

whether status

warrants change

in strategies

OngoingreassessmentSee Interventions(PAL-14)

PERSISTENT NAUSEA AND VOMITING


efforts

Consult or refer to

specialized palliative

care services or hospice

Consider palliative

sedation ( )See PAL-30

Titrate dopamine receptor antagonist

(eg, prochlorperazine, haloperidol, )

to maximum benefit and tolerance

metoclopramide

Unacceptable

















PAL-17

Weeks to

days(Dying

patient)n

Months

to weeks

Years tomonths

MALIGNANT BOWEL OBSTRUCTIONm

ASSESSMENT

Years

Screen for and treat underlying benign reversible

causesAdhesionsRadiation-induced stricturesInternal hernias

Assess for malignant causesTumor massCarcinomatosis

Assess the goals of treatment for the patient, which

can help guide the intervention (eg, decrease NV,

allow patient to eat, decrease pain, allow patient to

go home/to hospice)

n

Consider only if other measures fail to reduce

vomiting Endoscopic management

Pharmacologic management

Intravenous or subcutaneous fluids

Enteral tube drainage

Consider medical management

rather than surgical

management

Assess the goals of treatment

for the patient, which can help

guide the interventionn

(eg, decrease NV, allow patientto eat, decrease pain, allow

patient to go home/to hospice)

Provide education and support

to patient and family

SeeInterventions(PAL-18)

SeeReassessment(PAL-18)

m

n

Plain film radiography evaluation is usually enough to establish the diagnosis of bowel obstruction. Consider a computed tomography scan if surgical intervention iscontemplated, as it is more sensitive and helps identify the cause of obstruction.

Most malignant bowel obstructions are partial, allowing time to discuss appropriate intervention with the patient and family.

ESTIMATED

LIFEEXPECTANCY










NCCN Guidelines IndexNCCN G id li V i 1 2012













Assess for delirium(eg, DSM-IV criteria)Screen for and treat

underlying reversible

causesMetabolic causesHypoxiaBowel obstruction/obstipationInfectionCNS eventsBladder outlet

obstructionMedication or

substance effect or

withdrawal (eg,

benzodiazepines,

opioids,

anticholinergics)Assess, screen for,

and maximize

nonpharmacologic

interventions (eg,

reorientation,cognitive stimulation,

sleep hygiene)

Severe

delirium(agitation)

Avoid benzodiazepines unless

patient has refractory delirium

on antipsychoticsAdminister haloperidol

0.5-10 mg IV q 1-4 h prnAdminister alternative agents:

olanzapine, 2.5-7.5 mg/d PO/IV

q 2-4 h prn (maximum = 30

mg/d); chlorpromazine, 25-100

mg PO/PR/IV q 4 h prn for bed-

bound patients

Titrate starting dose to optimal

effectConsider opioid dose

reduction or rotation

If agitation is refractory to high

doses of neuroleptics,

consider adding lorazepam,

0.5-2 mg SQ/IV q 4 h

Support caregivers

Administer haloperidol

0.5-2 mg PO BID/TID

Administer alternative agents:

risperidone, 0.5-1 mg PO BID;olanzapine, 5-20 mg PO daily;or quetiapine fumarate,25-200 mg PO/SL BIDTitrate starting dose tooptimal effectOrient patient with familypresence

Weeks to

days(Dying

patient)

Months

to weeks

Years to

months

Continue to

treat and

monitor symptoms and

quality of life to

determine

whether status

warrants

change in

strategies

See Interventions(PAL-21)

DELIRIUM


Ongoingreassessment

Years

Acceptable:delirium

Adequate

symptom controlReduction of

patient/family

distress

Acceptable senseof controlRelief of caregiver

burdenStrengthened


lifePersonal growth

and enhanced

meaning

PAL-20


care interventions

Consider consultation with a

palliative care

specialist or

psychiatrist

Mild/

moderatedelirium

ESTIMATED

LIFE

EXPECTANCY

Unacceptable

NCCN Guidelines IndexNCCN Guidelines Version 1 2012













PAL-21

Evaluate

for

iatrogenic

causes

Disease

progression

Consider that agitation may bemistaken for pain resulting inhigher doses of opioids, whichmay exacerbate delirium

Rotate opioids

Focus on symptom control

Focus on family support andcoping mechanism

Provide appropriate upward dosetitration of haloperidol,risperidone, olanzapine, or quetiapine fumarate

Consider rectal or intravenoushaloperidol or administration of chlorpromazine ± lorazepam

Remove unnecessarymedications, tubes, etc.

Educate family and caregiver(s)

Provide appropriate upward dosetitration of lorazepam

Decrease doses of medicationsdependent upon hepatic or renalfunction

for patientswith refractory agitation despitehigh doses of neuroleptics

IatrogenicTreat cause if possible and

provide symptomatic relief

Weeks

to days(Dying

patient)

Months

to weeks

Years to

months

Continue totreat and

monitor

symptoms and

quality of life

to determine

whether status

warrants

change instrategies

Unacceptable

See Interventions(PAL-20)


Ongoing

reassessment

Years

Acceptable:

Adequate delirium

symptom control

Reduction of

patient/family

distress

Acceptable sense

of control

Relief of caregiver

burden

Strengthened

relationships

Optimized quality

of life

Personal growth

and enhanced

meaning

DELIRIUM

Intensify

palliative care

interventions

Consult with apalliative care

specialist or

psychiatrist

Consider

palliative

sedation (

)

See

PAL-30

ESTIMATED

LIFE

EXPECTANCY














Ensure that caregiver(s) are available

Ensure a safe home environment

Ensure adequate access to transportationEnsure sufficient financial resources

Refer to social services as needed to

assist with mobilization of family,

community, and financial resources

Ensure support and education to

caregiver(s) and family membersCounselingSupport groups

Respond to caregiver-specific burdens

and stresses

Assess bereavement risk

Discuss personal, spiritual, and cultural

issues relating to illness and prognosis

Obtain medical interpreters/translators

who are not related to the patient and

family as needed

Assist family/caregiver(s) with respite

care

Unacceptable

Weeks to

days

(Dying

patient)

Months

to weeks

Years

to

months


Ongoing

reevaluation and

communication

between thepatient,

caregiver(s),

family members,

and health care

team

REASSESSMENT

Ongoing

reassessment

Years

SOCIAL SUPPORT/RESOURCE MANAGEMENT

Acceptable:

Adequate social

support and resource

management

Reduction of



Relief of caregiver

burden

Strengthened

relationships


Personal growth and

enhanced meaning

PAL-22

INTERVENTIONS

Intensify efforts to

communicate palliative

care options

Consider referral topsychologist or

psychiatrist to evaluateand treat psychologicdisordersSee NCCN DistressManagement Guidelines

ESTIMATED

LIFEEXPECTANCY






















Discuss prognosis on an ongoing basis inclear, consistent language with the patient,caregiver(s), and family, includinginformation about the natural history of thespecific tumor

Evaluate and support the patient’s desiresfor comfort

Explain the dying process and expectedevents to the patient, caregiver(s), andfamily members

Respond to caregiver-specific demandsand stresses

Reassess bereavement riskEnsure that care conforms with culturaland spiritual/religious practices

Provide emotional support and addressany patient-family or intra-family conflictsregarding intervention

Consider palliative care consultation toassist in conflict resolution when thepatient, family, and/or professional team donot agree on benefit/utility of interventions

Obtain medical interpreters/translatorswho are not related to the patient andfamily as needed

Determine eligibility and readiness for specialized palliative/hospice care andneeds that might be best met by hospice

Weeks to

days

(Dying

patient)

Months

to weeks

Years to

monthsSee Interventions (PAL-22)

Ongoing

reevaluation andcommunication

between the

patient and health

care team


Ongoing

reassessment

YearsAcceptable

Adequate social

support and resource

management

:

Reduction of


Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships


Personal growth and

enhanced meaning

PAL-23

SOCIAL SUPPORT/RESOURCE MANAGEMENT

Reassess patient andfamily

Consult or refer to

specialized palliative care

services, hospice, or ethics committee


efforts

Consider referral topsychologist or psychiatrist to evaluateand treat psychologicdisordersSee NCCN DistressManagement Guidelines

ESTIMATED

LIFE

EXPECTANCY

Unacceptable









NCCN Guidelines IndexNCCN Guidelines Version 1.2012












Assess patient/family understanding of

the dying process

Educate patient and family on dying

process

Prepare for patient’s deathFacilitate anticipatory grief work

Ensure continuing care process and refer

to appropriate care

Promote that patient does not die alone

Offer spiritual support

Encourage planning for funeral/memorial

services, as determined by personal

preferences, cultural customs and beliefs


REASSESSMENT

Acceptable:



Relief of caregiver burden

Strengthened relationships


Personal growth and enhanced

meaning

Years to

months

Monthsto weeks

Years

Weeks to

days(Dying

patient)

INTERVENTIONS

PAL-25

Ongoingreassessment(See PAL-24)

GOALS AND EXPECTATIONS, EDUCATIONAL AND INFORMATIONAL NEEDS, AND CULTURAL FACTORS AFFECTING CARE FOR THE PATIENT AND FAMILY

Reassess patient and

family


efforts

Consult or refer to

hospice or specialized

palliative care services

ESTIMATED

LIFE

EXPECTANCY

Unacceptable


P lli i C TOCNCCN Guidelines Version 1.2012












Initiate discussion of palliative care options,including hospice if appropriate

Introduce palliative care team if appropriate

Refer to state and institutional guidelines for

additional guidance

Encourage designation of health care proxy,

medical power of attorney, or patient

surrogate for health care

Explore fears about dying and address

anxiety

Assess decision-making capacity and need

for surrogate decision-maker

Initiate discussion of personal values and

preferences for end-of-life care

If patient values and goals lead to a clear

recommendation regarding future treatment

in light of disease status, physician should

make a recommendation about future care

Document patient values and preferences

and any decisions in accessible site in

medical record (including MOLST/POLST if

completed)

Encourage the patients to discuss wishes

with family/proxy

Ongoing reevaluation

and communication

between the patient and

health care team

Weeks to

days(Dying

patient)

Months to

weeks

Years to

months


ADVANCE CARE PLANNING


PAL-26

Ongoingreassessment

Years

Acceptable:

Adequate advance

care planning

Reduction of

patient/family

distress

Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships

Optimized quality of

life

Personal growth and

enhanced meaning

Explore patient reluctance to

engage in advance care

planning

Explore fears and worries

about illness

Refer to palliative care if the

patient is having difficultyengaging in discussion of

advance care planning

Consider referral to a mental

health clinician to evaluate

mental health issues

See NCCN DistressManagement Guidelines

ESTIMATED

LIFEEXPECTANCY

Unacceptable


P lli ti C TOCNCCN Guidelines Version 1.2012















Palliative Care

Confirm the patient’s values and decisions in light of

changes in statusIf not previously done, make recommendations aboutappropriate medical treatment to meet the patient’svalues and goals

Ensure complete documentation of the advance careplan in the medical record, including MOLST/POLSTif applicable, to assure accessability of the plan to allproviders across care settings

Explore family concerns about the patient’s plan and

seek resolution of conflict between patient and familygoals and wishes

Consider consultation with a palliative care specialistto assist in conflict resolution when the patient,family, and health care team disagree

Explore fears about the future and provide emotionalsupport

Address years-to-months interventions

Determine patient and family preferences for the

location of the patient’s death

Assure that all items identified above are complete

Implement and ensure compliance with advance care

plan

Clarify and confirm the patient’s decision about life-

sustaining treatments, including CPR, if necessary

Explore desire for organ donation and/or autopsy

Weeks to

days

(Dying

patient)

Months

to weeks

Years

to

months


Ongoing

reevaluation

and

communication

between the

patient/family

and health care

team


PAL-27

Ongoingreassessment

Years

Acceptable:

Adequate advance care

planning

Reduction of


Acceptable sense of

control

Relief of caregiver

burden

Strengthened

relationships


Personal growth and

enhanced meaning

ADVANCE CARE PLANNING

Explore patient reluctance to

engage in advance care

planning

Explore fears and worries about

illness

Refer to palliative care if the

patient is having difficultyengaging in discussion of

advance care planning

Consider referral to a mental

health clinician to evaluate

mental health issues

See NCCN Distress ManagementGuidelines

ESTIMATED

LIFE

EXPECTANCY

Unacceptable



































































http://www.qualityforum.org/Projects/n-r/Palliative_and_Hospice_Care_Framework/Palliative___Hospice_Care__Framework_and_Practices.aspx



















NCCN Guidelines IndexPalliative Care Table of Contents

Discussion







Version 1.2012, 04/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express writ ten permission of NCCN®. REF-9

132. Irvin S. The experiences of the registered nurse caring for theperson dying of cancer in a nursing home. Collegian 2000;7:30-34.

Available at: http://www.ncbi.nlm.nih.gov/pubmed/11858309.

133. Hartmann LC. Unrealistic expectations. J Clin Oncol2005;23:4231-4232; discussion 4233-4234. Available at:http://www.ncbi.nlm.nih.gov/pubmed/15961772.

134. Kalemkerian GP. Commentary on "Unrealistic Expectations". JClin Oncol 2005;23:4233-4234. Available at:

http://jco.ascopubs.org/content/23/18/4233.short.

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Palliative Nccn 12

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