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Palliative care in patients with cancer

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of palliative care in patients with cancer are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2024,2021,2013), the American Society of Clinical Oncology (ASCO 2024,2023,2022,2021,2019,2014), the Multinational Association of Supportive Care in Cancer (MASCC 2024,2022), the American Academy of Family Physicians (AAFP 2023), ...
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Classification and risk stratification

Prognostic assessment: as per ESMO 2023 guidelines, use clinical experience to predict the survival of patients with advanced incurable cancer, such as a prognosis of a few months or less, recognizing potential limitations and the general tendency to overestimate survival.
B
consider supplementing personal clinical judgment with survival estimates from multiple professionals.
B
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Diagnostic investigations

Geriatric assessment: as per ASCO 2023 guidelines, include geriatric assessment-guided management in the care plan for patients with cancer aged ≥ 65 years with geriatric assessment-identified impairments. Use geriatric assessment results to inform cancer treatment decision-making and address impairments through appropriate interventions, counseling, and/or referrals. Incorporate geriatric assessment-guided management for older adults receiving systemic therapy, including chemotherapy, targeted therapy, and/or immunotherapy.
A
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Medical management

Initiation of palliative care, timing: as per ASCO 2024 guidelines, offer early specialist palliative care involvement in patients with advanced cancer, especially with uncontrolled symptoms and/or QoL concerns.
B
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  • Initiation of palliative care (components)

  • Initiation of palliative care (providers)

  • Discontinuation of cancer treatment

  • Management of pain (assessment)

  • Management of pain (general principles)

  • Management of pain (non-opioid analgesics)

  • Management of pain (opioids)

  • Management of pain (ketamine)

  • Management of pain (cannabinoids)

  • Management of pain (corticosteroids)

  • Management of pain (osteoclast inhibitors)

  • Management of pain (neuropathic pain)

  • Management of pain (intrathecal analgesia)

  • Management of pain (neurolysis)

  • Management of pain (nerve block)

  • Management of pain (percutaneous radiofrequency ablation)

  • Management of pain (radiofrequency lesioning)

  • Management of pain (spinal cord stimulation)

  • Management of pain (external beam radiation therapy)

  • Management of pain (cordotomy)

  • Management of pain (myelotomy)

  • Management of pain (DREZ-otomy)

  • Management of pain (cingulotomy)

  • Management of pain (vertebral augmentation)

  • Management of pain (alternative and complementary therapies)

  • Management of nausea and vomiting

  • Management of esophageal dysphagia

  • Management of gastric outlet obstruction

  • Management of malignant biliary obstruction

  • Management of bowel obstruction (antiemetics)

  • Management of bowel obstruction (laxatives)

  • Management of bowel obstruction (corticosteroids)

  • Management of bowel obstruction (opioids)

  • Management of bowel obstruction (anticholinergics)

  • Management of bowel obstruction (water-soluble contrast agents)

  • Management of bowel obstruction (nutritional support)

  • Management of bowel obstruction (palliative surgery)

  • Management of bowel obstruction (bowel decompression)

  • Management of bowel obstruction (self-expanding metallic stents)

  • Management of dyspnea (evaluation)

  • Management of dyspnea (general principles)

  • Management of dyspnea (opioids)

  • Management of dyspnea (benzodiazepines)

  • Management of dyspnea (antidepressants)

  • Management of dyspnea (bronchodilators)

  • Management of dyspnea (corticosteroids)

  • Management of dyspnea (sedation)

  • Management of dyspnea (airflow interventions)

  • Management of dyspnea (supplemental oxygen)

  • Management of dyspnea (noninvasive ventilation)

  • Management of dyspnea (other measures)

  • Management of noisy breathing

  • Management of delirium

  • Management of fatigue (indications for screening)

  • Management of fatigue (choice of screening tool)

  • Management of fatigue (clinical assessment)

  • Management of fatigue (laboratory evaluation)

  • Management of fatigue (general counseling)

  • Management of fatigue (indications for referral)

  • Management of fatigue (general principles of management)

  • Management of fatigue (physical activity)

  • Management of fatigue (eugeroics)

  • Management of fatigue (psychostimulants)

  • Management of fatigue (antidepressants)

  • Management of fatigue (corticosteroids)

  • Management of fatigue (minocycline)

  • Management of fatigue (psychosocial interventions)

  • Management of fatigue (alternative treatments)

  • Management of fatigue (dietary supplements)

  • Management of fatigue (assessment of treatment response)

  • Management of osteoporosis (screening)

  • Management of osteoporosis (prevention)

  • Management of osteoporosis (treatment)

Nonpharmacologic interventions

Physical activity: as per ASCO 2022 guidelines, offer aerobic and resistance exercise during active treatment of adult patients with curative intent to mitigate side effects of cancer treatment.
B
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  • Nutritional support

  • Hydration

  • Oral care

  • Psychological support

  • Spiritual support

  • Bereavement care

Therapeutic procedures

Blood transfusion: as per ESMO 2021 guidelines, recognize that RBC and platelet transfusions may have limited benefits in the last weeks of life.
B
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Patient education

Shared decision-making
As per ESMO 2021 guidelines:
Ensure effective communication and shared decision-making at the end of life.
B
Prepare patients and families strategically, respecting personal wishes and beliefs, to reduce adverse bereavement outcomes.
B
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Preventative measures

Thromboprophylaxis: as per ESMO 2021 guidelines, do not administer prophylactic anticoagulation at end of life.
D
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