NCCN指南：姑息治疗(.V1).ppt

version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion palliativecareversionpreliminary1 2014nccn orgcontinue version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion nccnguidelinesversion1 2014panelmemberspalliativecare mariadans md sitemancancercenteratbarnes jewishhospitalandwashingtonuniversityschoolofmedicinejeans kutner mduniversityofcoloradocancercenterelizabethkvale md universityofalabamaatbirminghamcomprehensivecancercentersumathimisra md vanderbilt ingramcancercenterwilliammitchell mducsandiegomoorescancercentertoddm sauer md fred pamelabuffettcancercenteratthenebraskamedicalcenterdavidspiegel mdqstanfordcancerinstitutelindasutton md dukecancerinstitutecontinue robertm taylor md ytheohiostateuniversitycomprehensivecancercenter jamescancerhospitalandsoloveresearchinstitutejennifertemel md massachusettsgeneralhospitalcancercenterromatickoo md mph memorialsloan ketteringcancercentersusang urba md universityofmichigancomprehensivecancercentercarinvanzyl md cityofhopecomprehensivecancercentersharonm weinstein md yhuntsmancancerinstituteattheuniversityofutah hematology hematologyoncology medicaloncology internalmedicine supportivecareincludingpalliativeandpainmanagementqpsychiatryandpsychology includinghealthbehavioryneurology neuro oncologyjanesthesiology geriatricmedicine pediatriconcology writingcommitteemember michaelh levy md phd chair foxchasecancercenter thomassmith md vice chairthesidneykimmelcomprehensivecancercenteratjohnshopkinsamyalvarez perez mdroswellparkcancerinstituteanthonyback md fredhutchinsoncancerresearchcenter seattlecancercarealliancejustinn baker md st judechildren sresearchhospital theuniversityoftennesseehealthsciencecentersusanblock md qdana farbercancerinstituteshirleyn codada md moffittcancercentershalinidalal md theuniversityoftexasmdandersoncancercenternccnmaryannebergmanjillianscavone phdnccnguidelinespaneldisclosures printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion nccnpalliativecarepanelmemberssummaryoftheguidelinesupdates clinicaltrials nccnbelievesthatthebestmanagementforanycancer patientisinaclinicaltrial participationinclinicaltrialsisespeciallyencouraged tofindclinicaltrialsonlineatnccnmemberinstitutions clickhere nccn org clinical trials physician html nccncategoriesofevidenceandconsensus allrecommendationsarecategory2aunlessotherwisespecified seenccncategoriesofevidenceandconsensus nccnguidelinesversion1 2014tableofcontentspalliativecare definitionandstandardsofpalliativecare pal 1 palliativecareoverview pal 2 screeningandassessmentbyoncologyteam pal 3 criteriaforconsultationwithpalliativecarespecialist pal 6 oncologyteaminterventionsandreassessment pal 8 benefits risksofanticancertherapy pal 9 symptoms pain pal 10 symptoms dyspnea pal 11 symptoms anorexia cachexia pal 13 symptoms nauseaandvomiting pal 15 symptoms constipation pal 17 symptoms malignantbowelobstruction pal 18 anyclinicianseekingtoapplyorconsultthenccnguidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinical warrantiesofanykindregardingtheircontent useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway thenccn bereproducedinanyformwithouttheexpresswrittenpermissionofnccn 2014 symptoms sleep wakedisturbancesincludinginsomniaandsedation pal 20 symptoms delirium pal 21 socialsupport resourcemanagement pal 23 goalsandexpectations educationalandinformationalneeds andculturalfactorsaffectingcareforthepatientandfamily pal 25 advancecareplanning pal 27 responsetorequestsforhasteneddeath pal 29 careoftheimminentlydyingpatient pal 30 palliativesedation pal 31 after deathinterventions pal 32 printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion 1of2 nccnguidelinesversion1 2014updatespalliativecare achievablebaseduponlikelyprognosisandlifeexpectancy 12thbulletmodifiedto considerpotentialdiscontinuationofanticancertreatment 13thbulletmodified encouragediscontinueofanticancertherapypal 11 underinterventions 2ndbullet 5thsub bulletisnewtothepage anticoagulantsforpulmonaryemboli under relievesymptoms 1stsub bulletmodified oxygentherapyforsymptomatichypoxia 5thsub bullletmodified ifdyspneaisnotrelievedbyopioidsandisassociatedwithanxiety 6thsub bulletmodifiedtoinclude temporaryventilatorynoninvasivepositive pressureventilation nppv pal 15 5thbullet 1stsub bullet changedtid qidtobid tid 6thbullet modifiedasfollows gastricoutletobstruction squashedstomachsyndrome fromintra abdominaltumororlivermetastasis 1stsub bulletmodifiedasfollows ifnotcontraindicatedbycomorbidconditions treatwithcorticosteroids aprotonpumpinhibitor and 7thbulletmodified treatmetabolicabnormalities inthe1stsub bullet modified correcthypercalcemia 2ndsub bullet modified treaturemia 8thbulletisnewtothepage gastritis gerd protonpumpinhibitor h2 blocker planningandcareplan deletedfootnote e communicationbarriersinclude language literacy 2ndsub bulletnowincludesendoscopicstentingandphysicalbarriersandinsteadincludedsub bulletsunder 3rdsub bulletisnewtothepage decompressingg tube updatesinversion1 2014ofthenccnguidelinesforpalliativecarefromversion2 2013include pal 1pal 9 continued understandardsofpalliativecare 5thbulletmodifiedtoincludesocial 10thbulletmodified redirectgoalsandhopestothosethatare thepage alsoforpal 9 lookforopportunitiestousesingleagentstotreatmultiplesymptoms 5thbullet 1stsub bullet modified addresspatientandfamilyisanewfootnoteandcorrespondstosymptoms alsoforpal 5 correspondingtopsychosocial psychiatric workers chaplains andpharmacistspal 2 bottombranch 1stsub bulletmodifiedasfollows discussanticipatesymptomsanddiscusspreventativemeasures alsoforpal 3 interventionshasreplacedeffortsthroughouttheguidelinespal 3 underlifeexpectancy 6mo palliativestentingorventinggastrostomyisnewtothepage alsoforpal 6 pal 4 4thbulletmodified goalsandmeaningofanticancertherapytoforpatientandfamily confirmthepatient sunderstandingofincurabilityofdiseaseisnewto pal 6 6thbulletmodified complexicuadmissions thoseinvolvingmulti organsystemfailureorprolongedmechanicalventilations multiplecomplicationsorthoserequiringlengthyventilatorsupport lastbulletmodified inabilityresistancetoengaginginadvancecare communicationbarriers toreplacethefootnotepal 7 childrenunder18yearsofagelivinginthehouseholdisnewtothepagepal 9 8thbulletisnewtothepage reassessunderstandingofgoalsoftherapyandprognosis printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved updates version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion nccnguidelinesversion1 2014updatespalliativecare pal 20 underinterventions 7thbullet 1stsub bullet 3rdsub sub bulletzolpidemhaschangedfrom5 10mgpoatbedtimeto5mg 5thsub sub bulletisnewtothepage olanzapine 2 5 5mgpoatbedtime 2ndsub bullet 2ndsub sub bullet seconddosenolaterthan2 00pmhasbeenmodifiedto6hoursbeforebedtime 3rdsub sub bullet seconddosenolaterthan2 00pmhasbeenmodifiedto12hoursbeforebedtimepal 21 thepageandareasfollows hyperactive hypoactive 2ndbullet 2ndsub bulletisnewtothepage unrelievedpain interventions 1stbullethasbeenmodified avoidbenzodiazepinesreduceoreliminatedelirium inducingmedicationsaspossible eg steroids anticholinergenics andbenzodiazepines pal 26 interventions 6thbullet respectgoalsandneedsofthepatientandfamilyregardingthedyingprocessisnewtothepage 7thbullethasbeenmodified promotethatpatientdoesnotdiealoneunlessdyingaloneisanestablishedpreferenceofpatientpal 27 underinterventions encouragedesignationofaskpatientifhe shehasalivingwill medicalpowerofattorney healthcareproxy orpatientsurrogateforhealthcare ifnot encouragepatienttoprepareonepal 29 vermontwasaddedtothelistofstateswherephysician assistedsuicideislegalms 1 thediscussionsectionwasupdatedtoreflectthechangesinthealgorithm ileusandmechanicalbowelobstruction 0 15mg kgsceveryotherday twosub bulletsunderassessfordelirium eg dsm ivcriteria arenewto pal 16 underinterventions olanzapineisnewtothepageanditreadsasfollows titratedopaminereceptorantagonist eg prochlorperazine haloperidol metoclopramide olanzapine tomaximumbenefitandtolerance under ifnvpersists olanzapinewasaddedasfollows addacorticosteroid eg dexamethasone olanzapine ifnotalreadytriedpal 17 underinterventions 10thbullet modifiedasfollows considermethylnaltrexoneforopioid inducedconstipation exceptforpost op nomorethanonceadaypal 18 thewordmaywasaddedtofootnote m andreadsasfollows plainfilmradiographymaybehelpfulinconfirmingtheclinicaldiagnosisofbowelobstruction consideracomputedtomographyscanifsurgicalinterventioniscontemplated asitismoresensitiveandmayhelpidentifythecauseofobstructionpal 19 3rdbullet 1stsub bullet modifiedasfollows ultrasound guidedgastrostomytubefordrainageventingtube 4thbulletnowreads pharmacologicmanagementwhenthegoalismaintaininggutfunction 2ndsub bullethasbeenremoved considerasanadjuncttoaninvasiveprocedurewheninvasiveproceduresarenotanoption 5thbullet pharmacologicmanagementwhengutfunctioncannotbemaintainedisnewtothepage 2ndsub bullet considerearlyinthediagnosisduetohighefficacyandtolerabilityhasbeenremoved footnote o hasbeenmodified riskfactorsforpoorsurgicaloutcomeprognosiscriteriaforsurgeryinclude ascites carcinomatosis palpableintraabdominalmasses multiplebowelobstructions previousabdominalradiation veryadvanceddisease andpooroverallclinicalstatus 2of2 printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved updates version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion nccnguidelinesversion1 2014palliativecare pal 1 definitionofpalliativecareapalliativecareisaspecialkindofpatient andfamily centeredhealthcarethatfocusesoneffectivemanagementofpainandotherdistressingsymptoms whileincorporatingpsychosocialandspiritualcareaccordingtopatient familyneeds values beliefs andcultures thegoalofpalliativecareistoanticipate prevent andreducesufferingandtosupportthebestpossiblequalityoflifeforpatientsandtheirfamilies regardlessofthestageofthediseaseortheneedforothertherapies palliativecarebeginsatdiagnosisandshouldbedeliveredconcurrentlywithdisease directed life prolongingtherapiesandshouldfacilitatepatientautonomy accesstoinformation andchoice palliativecarebecomesthemainfocusofcarewhendisease directed life prolongingtherapiesarenolongereffective appropriate ordesired palliativecareshouldbeinitiatedbytheprimaryoncologyteamandthenaugmentedbycollaborationwithaninterdisciplinaryteamofpalliativecareexperts standardsofpalliativecareb institutionsshoulddevelopprocessesforintegratingpalliativecareintocancercare bothaspartofusualoncologycareandforpatientswithspecialtypalliativecareneeds allcancerpatientsshouldbescreenedforpalliativecareneedsattheirinitialvisit atappropriateintervals andasclinicallyindicated patientsandfamiliesshouldbeinformedthatpalliativecareisanintegralpartoftheircomprehensivecancercare educationalprogramsshouldbeprovidedtoallhealthcareprofessionalsandtraineessothattheycandevelopeffectivepalliativecareknowledge skills andattitudes palliativecarespecialistsandinterdisciplinarypalliativecareteams includingboard certifiedpalliativecarephysicians advancedpracticenurses physicianassistants socialworkers chaplains andpharmacists shouldbereadilyavailabletoprovideconsultativeordirectcaretopatients familieswhorequestorrequiretheirexpertise qualityofpalliativecareshouldbemonitoredbyinstitutionalqualityimprovementprograms ahui d morim parsonsha etal thelackofstandarddefinitionsinsupportiveandpalliativeoncologyliterature jpainsymptommanage2012 43 582 592 bferris fd bruerae chernyn etal palliativecancercareadecadelater accomplishments theneed nextsteps fromtheamericansocietyofclinicaloncology jclinoncol2009 27 3052 3058 note allrecommendationsarecategory2aunlessotherwiseindicated clinicaltrials nccnbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrial participationinclinicaltrialsisespeciallyencouraged printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved symptommanagement monthsto consultationwith days hospicereferral responsetorequestto withdraworwithhold version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn nccnguidelinesindexpalliativecaretocdiscussion note allrecommendationsarecategory2aunlessotherwiseindicated clinicaltrials nccnbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrial participationinclinicaltrialsisespeciallyencouraged nccnguidelinesversion1 2014palliativecare overview screeningc d palliativecareinterventionsd reassessment after deathinterventions benefits risksofanticancertherapy personalgoals expectations symptoms psychosocialorspiritualdistress educationalandinformationalneeds culturalfactorsaffectingcare criteriaforconsultationwithpalliativecarespecialist acceptable patientsatisfiedwithresponsetoanticancertherapy adequatepainandsymptomcontrol reductionofpatient familydistress acceptablesenseofcontrol reliefofcaregiverburden strengthenedrelationships optimizedqualityoflife personalgrowthandenhancedmeaningunacceptable death uncontrolledsymptoms moderate to severedistressrelatedtocancerdiagnosisandcancertherapy seriouscomorbidphysicalandpsychosocialconditions lifeexpectancy 6mo metastaticsolidtumors patient familyconcernsaboutcourseofdiseaseanddecision making patient familyrequestsforpalliativecare presentnotpresent informpatientsandfamiliesaboutpalliativecareservices anticipatesymptomsanddiscusspreventativemeasures discussadvancecareplanning rescreenatnextvisit assessmentbyoncologyteam pal 3 assessmentc d ongoingreassessment anticancertherapy appropriatetreatmentofcomorbidphysicalandpsychosocialconditions coordinationofcarewithotherhealthcareprovidersyears advancecareplanningyearsto psychosocialandmonthsspiritualsupport culturallyappropriatecareweeks resourcemanagement socialsupportweekstopalliativecarespecialist dyingpatient life sustainingtreatment responsetorequestsforhasteneddeath physician assistedsuicideandeuthanasia careofimminentlydyingpatient palliativesedation pal 2 ongoingreassessment forfamilyandcaregiver s immediateafter deathcare bereavementsupport cancerriskassessmentandmodificationforhealthcareteam generalsupport after deathsupport intensifypalliativecareinterventions consultorrefertospecializedpalliativecareservicesorhospice cmanagement ofanypatientwithpositivescreeningrequiresacareplandevelopedbyaninterdisciplinaryteamofphysicians nurses socialworkers andothermentalhealthprofessionals chaplains nurse practitioners physicianassistants anddietitians doncologistsshouldintegratepalliativecareintogeneraloncologycare earlyconsultation collaborationwithapalliativecarespecialist hospiceteamshouldbeconsideredtoimprovequalityoflifeandsurvival printedbymariachenon5 27 201410 08 49pm forpersonaluseonly notapprovedfordistribution copyright 2014nationalcomprehensivecancernetwork inc allrightsreserved version1 2014 04 18 14 nationalcomprehensivecancernetwork inc 2014 allrightsreserved thenccnguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofnccn or patient familyconcernsaboutcourseofdiseaseanddecision makingor patient familyrequestsforpalliativecare diagnosisand orcancertherapyor seriouscomorbidphysical psychiatric andpsychosocialconditionsor lifeexpectancy 6mo indicatorsinclude 7metastaticsolidtumors7manystageivcancers7poorperformancestatusecog 3orkps 507hypercalcemia7brainorcerebrospinalfluidmetastasis7delirium7superiorvenacavasyndrome7spinalcordcompression7cachexia7malignanteffusions7palliativestentingorventinggastrostomy presentnotpresent seepal 4 nccnguidelinesversion1 2014palliativecarescreeningc d uncontrolledsymptomsor moderate to severedistressrelatedtocancer nccnguidelinesindexpalliativecaretocdiscussionassessmentbyoncologyteam benefits risksofanticancertherapy symptoms psychosocialdistress seepal 5seepal 6andpal 7 personalgoals expectations educationalandinformationalneeds culturalfactorsaffectingcare criteriaforconsultationwithapalliativecarespecialist informthepatientandfamilyaboutpalliativecareservices anticipatesymptomsanddiscusspreventativemeasures discussadvancecareplanning rescreenatnextvisit cmanagement ofanypatientwithpositivescreeningrequiresacareplandevelopedbyaninterdisciplinaryteamofphysicians nurses socialworkers andothermental healthprofessionals chaplains nursepractitioners physicianassistants anddietitians doncologistsshouldintegratepalliativecareintogeneraloncologycare earlyconsulta