NCCN指南：姑息治疗(.V1).ppt

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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 Preliminary

2、1.2014NCCN.orgContinue,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 TOCDiscussion,NCCN Guidel

3、ines Version 1.2014 Panel MembersPalliative Care,Maria 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 Misra

4、,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 InstituteContinue,Robert M.Taylor,MD YThe Ohio State University

5、 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 City of Hope Comprehen

6、sive 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/Neuro-oncologyj Anesthes

7、iologyGeriatric 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 Back,MD Fred Hutchinson Cancer Res

8、earchCenter/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 of TexasMD Anderson Cancer CenterNCCNMary

9、 Anne BergmanJillian Scavone,PhDNCCN Guidelines Panel Disclosures,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 Ne

10、twork,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 TOCDiscussion,NCCN Palliative Care Panel MembersSummary of the Guidelines Updates,Clinical Trials:NCCN b

11、elieves thatthe best management for any cancer,patient 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 of Evidence andConsensus:All recommendat

12、ionsare category 2A unless otherwisespecified.See NCCN Categories of Evidenceand Consensus,NCCN Guidelines Version 1.2014 Table of ContentsPalliative Care,Definition and Standards of Palliative Care(PAL-1)Palliative Care Overview(PAL-2)Screening and Assessment by OncologyTeam(PAL-3)Criteria for Cons

13、ultation 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(PAL-15)Symptoms:Constipation(PAL-17)Symptoms:Malignan

14、t 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 disclaims any responsibility for their application or

15、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)Goals and Expectations,Educationaland Informational Needs,andC

16、ultural 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 Interventions(PAL-32),Printed by Maria Chen on 5/27/2014 10:08:49 PM.For perso

17、nal 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 form without the

18、 express written permission of NCCN.,NCCN Guidelines IndexPalliative Care TOCDiscussion,1 of 2,NCCN Guidelines Version 1.2014 UpdatesPalliative Care,achievable based upon likely prognosis and life expectancy 12th bullet modified to:Consider potential discontinuation of anticancertreatment 13th bulle

19、t 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 forsymptomatic hypoxia 5th sub-bulllet modified:If dyspnea is not relieved

20、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,modified as follows:Gastric outlet obstruction(squashedstomach syndrome)from intra-

21、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 abnormalities In the 1st sub-bullet,modified:Correct Hypercalcemia 2nd sub-bullet,modified:Tr

22、eat Uremia 8th bullet is new to the page:Gastritis/GERD Proton pump inhibitor H2-blocker,planning and care plan Deleted footnote“e”Communication barriers include:language,literacy,2nd sub-bullet now includes Endoscopic stentingand physical barriers and instead included sub-bullets under 3rd sub-bull

23、et is new to the page:Decompressing G-Tube,Updates 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 bullet modified to include social 10th bullet modified:Redirect goals and hopes to those that are,t

24、he 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 Symptoms(Also for PAL-5,corresponding to Psychosocial/psychiatric),workers,chaplains,and pharmacistsPAL-2 B

25、ottom branch,1st sub-bullet modified as follows:Discuss Anticipatesymptoms and discuss preventative measures(Also for PAL-3)Interventions has replaced efforts throughout the guidelinesPAL-3 Under Life Expectancy 6 mo,Palliative stenting or venting gastrostomyis new to the page(Also for PAL-6)PAL-4 4

26、th bullet modified:Goals and meaning of anticancer therapy to forpatient and family Confirm the patients understanding of incurability of disease is new to,PAL-6 6th bullet modified:Complex ICU admissions(those involving multi-organ system failure or prolonged mechanical ventilations)multiplecomplic

27、ations or those requiring lengthy ventilator support)Last bullet modified:Inability Resistance to engaging in advance care,“Communication barriers”to replace the footnotePAL-7 Children under 18 years of age living in the household is new to thepagePAL-9 8th bullet is new to the page:Reassess underst

28、anding of goals oftherapy and prognosis,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.,UPDATES,Version 1.2014,04/18/14 National Comprehensive Cancer Network,Inc.2014,All

29、 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 TOCDiscussion,NCCN Guidelines Version 1.2014 UpdatesPalliative Care,PAL-20 Under Interventions,7th bullet,1st sub-bullet,3

30、rd 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-sub-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

31、:00PM has beenmodified to 12 hours before bedtimePAL-21,the page and are as follows:Hyperactive Hypoactive 2nd bullet,2nd sub-bullet is new to the page:Unrelieved pain Interventions,1st bullet has been modified,Avoid benzodiazepinesReduce or eliminate delirium-inducing medications as possible(eg,ste

32、roids,anticholinergenics,and benzodiazepines)PAL-26 Interventions,6th bullet,Respect goals and needs of the patient andfamily regarding the dying process is new to the page 7th bullet has been modified:Promote that patient does not die aloneunless dying alone is an established preference of patientP

33、AL-27 Under Interventions:Encourage designation of Ask patient if he/she has aliving will,medical power of attorney,health care proxy,or patientsurrogate 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

34、 The discussion section was updated to reflect the changes in thealgorithm,ileus and mechanical bowel obstruction,0.15 mg/kg SC every other day,Two sub-bullets under Assess for delirium(eg,DSM-IV criteria)are new to,PAL-16 Under Interventions,olanzapine is new to the page and it reads asfollows:Titr

35、ate dopamine receptor antagonist(eg,prochlorperazine,haloperidol,metoclopramide,olanzapine)to maximum benefit andtolerance Under“If NV Persists,olanzapine was added as follows:Add acorticosteroid(eg,dexamethasone)olanzapine,if not already triedPAL-17 Under Interventions,10th bullet,modified as follo

36、ws:Considermethylnaltrexone for opioid-induced constipation,except for post-op,no more than once a dayPAL-18 The word may was added 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

37、surgicalintervention is contemplated,as it is more sensitive and may helpidentify the cause of obstructionPAL-19 3rd bullet,1st sub-bullet,modified as follows:Ultrasound-guidedgastrostomy tube for drainage venting tube 4th bullet now reads:Pharmacologic management when the goal ismaintaining gut fun

38、ction 2nd sub-bullet has been removed:Consider as an adjunct to aninvasive procedure when invasive procedures are not an 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 tolerabi

39、lity has been removed Footnote“o”has been modified,Risk factors for poor surgical outcomeprognosis criteria for surgery include:ascites,carcinomatosis,palpableintraabdominal masses,multiple bowel obstructions,previousabdominal radiation,very advanced disease,and poor overall clinicalstatus,2 of 2,Pr

40、inted 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.,UPDATES,Version 1.2014,04/18/14 National Comprehensive Cancer Network,Inc.2014,All rights reserved.The NCCN Guidelines and t

41、his illustration may not be reproduced in any form without the express written permission of NCCN.,NCCN Guidelines IndexPalliative Care TOCDiscussion,NCCN Guidelines Version 1.2014Palliative Care,PAL-1,DEFINITION OF PALLIATIVE CAREaPalliative care is a special kind of patient-and family-centered hea

42、lth care that focuses on effective management of pain and otherdistressing symptoms,while incorporating 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 poss

43、ible quality of life for patients andtheir families,regardless of the stage of the disease or the 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 informat

44、ion,andchoice.Palliative care becomes the main focus of care when disease-directed,life-prolonging 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

45、 care experts.STANDARDS OF PALLIATIVE CAREbInstitutions should develop processes for integrating 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

46、 visit,at appropriate intervals,and as clinically indicated.Patients and families should 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 pa

47、lliative careknowledge,skills,and attitudes.Palliative care specialists and interdisciplinary palliative care teams,including board-certified palliative care physicians,advancedpractice nurses,physician assistants,social workers,chaplains,and pharmacists,should be readily available to provide consul

48、tative ordirect care to patients/families who request or require their expertise.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 Sympt

49、om Manage 2012;43:582-592.,bFerris,FD,Bruera E,Cherny N,et al.Palliative 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:N

50、CCN 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 National Comprehensive Cancer Network,Inc.,A