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NCCN Flash Updates: NCCN Guidelines Updated for Palliative Care

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Palliative Care. These NCCN Guidelines® are currently available as Version 1.2024.

Link directly to the Updates section of the NCCN Guidelines: Palliative Care

Global Changes

  • "Anticancer" modified to "cancer"
  • "If unacceptable" modified to "if ongoing needs"
  • "Acceptable outcomes" modified to "outcomes"
  • "Psychosocial" modified to "psychosocial-spiritual"
  • "Palliative care specialist" modified to "specialty palliative care"

PAL-1

  • Definition of Palliative Care modified: Palliative care is an approach to patient-/family-/caregiver-centered health care that focuses on optimal management of distressing symptoms, while incorporating psychosocial and spiritual psychosocial-spiritual care according to patient/family/caregiver needs, values, beliefs, and cultures. The goal of palliative care is to anticipate, prevent, and reduce suffering; promote adaptive coping; and support the best possible quality of life for patients/families/caregivers, regardless of the stage of the disease or the need for other therapies. Palliative care can begin at diagnosis; be delivered concurrently with disease-directed, life-prolonging therapies; and facilitate patient autonomy, access to information, and choice. 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 provided by the primary oncology team and augmented as needed by collaboration with an interprofessional team of palliative care experts.
  • Standards of Palliative Care, bullet added: Palliative care should be provided by the primary oncology team and augmented as needed by collaboration with an interprofessional team of palliative care experts.

PAL-2

  • Indications
    • Bullet 9 modified: Advanced Cancers associated with high morbidity and or mortality
    • Bullet 11 modified: Evidence of worsening prognosis, including:(PAL-3)
    • Bullet removed: Spiritual/existential distress
    • Bullet added: Complexities related to social determinants of health
    • Sub-bullets removed:
      • Poor performance status (eg, ECOG ≥3 or KPS ≤50)
      • Cachexia
      • Persistent hypercalcemia
      • Brain or cerebrospinal fluid metastasis
      • Persistent delirium
      • Malignant bowel obstruction
      • Superior vena cava (SVC) syndrome
      • Spinal cord compression
      • Malignant effusions
      • Need for palliative stenting or venting gastrostomy
  • Assessment, present/ongoing reassessment, bullet 11 modified: CriteriaConsideration for consultation with palliative care specialistspecialty palliative care
  • Interventions
    • Bullet 13 modified: Response to requests for hastened death (physician-assisted dyingmedical aid in dying [MAID])
    • Bullet 15 modified: palliativeproportional sedation

PAL-3

  • Indications
    • Bullet removed: Spiritual/existential distress
    • Bullet 7 added: Complexities related to social determinants of health
    • Bullet 9 modified: Advanced Cancers associated with high morbidity andor mortality
    • Sub-bullets removed:
      • Persistent hypercalcemia
      • Brain or cerebrospinal fluid metastasis
      • SVC syndrome
      • Spinal cord compression
      • Malignant effusions
      • Need for palliative stenting or venting gastrostomy
    • Sub-bullet 4 modified: Malignant bowel obstruction requiring venting gastrostomy
  • Assessment, bullet 7 modified: CriteriaConsideration for consultation with a palliative care specialistspecialty palliative care. (Also for PAL-5)

PAL-6

  • Oncology Team Interventions
    • Bullet 3 added: Evaluate and treat undiagnosed mental health problems
    • Bullet 4, sub-bullets removed:
      • Mental health and social services
      • Spiritual care
      • Health care interpreters
      • Others
    • Bullet 4, sub-bullets added:
      • Mental health
      • Psychosocial-spiritual services
      • Behavioral health
      • Addiction specialist
      • Other specialists
  • Reassessment, outcomes, bullet removed: Patient satisfied with response to anticancer therapy
  • Reassessment, if ongoing needs
    • Bullet added: Assess for communication barriers and address as needed (eg, translation services, improved literacy of materials, palliative care consult)
    • Bullet removed: Evaluate and treat undiagnosed psychiatric disorders, and substance use disorders
    • Sub-bullet removed: Consult with the following
    • Sub-sub-bullets removed:
      • Mental health professional
      • Addiction specialist

PAL-7

  • Page title modified: CriteriaConsideration for Consultation with Palliative care SpecialistSpecialty Palliative Care (Also for PAL-8)
  • Assessment, bullet 2, sub-bullet 2 modified: Advanced disease processDisease refractory to cancer treatment
  • Assessment, bullet 2, sub-bullet 4 modified: Rapidly Progressive functional decline or persistently poor performance status
  • Assessment, bullet 12 modified: Communication barriersneeds
  • Assessment, bullet 12 sub-bullet removed: Physical barriers
  • Assessment, bullet added: Patient/family requests

PAL-8

  • Bullet removed: Family/caregiver challenges
  • Bullet removed: Intensely dependent relationship(s)
  • Bullet 1 modified: High risk for persistent complex bereavement disorder complicated grief
  • Bullet 3 modified: Substance use disorder impacting care
  • Bullet 6 modified: Family discordFamily/caregiver discord impacting care
  • Bullet 7 modified: Spiritual or existential crisisdistress
  • Bullet 10 added: Other complexities related to social determinants of health

PAL-9

  • Interventions, Years to months
    • Bullet 2 modified: Discuss whether anticancer therapy is palliative or curativecancer therapy is curative or noncurative
    • Bullet 3 added: Cultivate prognostic awareness
    • Bullet 7 modified: Assess for appropriateness of palliative radiation therapy (RT) or interventional procedures that are aligned with goals of care
    • Bullet removed: Consider palliative procedures that are in line with goals of care
    • Bullet 8 modified: Provide primary palliative care, including anti-cancer treatment and disease-related symptom management and encouragement of advance care planning
    • Bullet 11 added: Consider rehabilitation services and physical activity aligned with goals of care
  • Interventions, Months to weeks
    • Bullet 4 modified: Assess for appropriateness of palliative RT therapies or interventional procedures (eg, single fraction)
    • Bullet 5 modified: Consider discontinuation of cancer treatment not directly addressing a symptom complexaligned with goals of care
    • Bullet 7 modified: Offer goal-directed supportive care, including referral to specialized palliative care services or hospice
    • Bullet 8 modified: Offer education and support related to care at end of life including referral to specialized palliative care services or hospice
    • Bullet 10 added: Explore culturally/spiritually significant rituals/ceremonies important at end of life

PAL-9A

  • Reassessment if ongoing needs
    • Bullet 1 modified: Change orConsider discontinuation of anticancer therapy

PAL-10

  • Reassessment, outcomes, bullet 2 modified: Reduction of Patient/family/caregiver distress mitigated
  • Reassessment, if ongoing needs, bullet 4 added: Optimize communication
  • Footnote added: For patients with a life expectancy of multiple weeks, consider single-fraction palliative RT for painful bone metastases.

PAL-11

  • Interventions, years to weeks
    • Bullet 3 added: Consider discontinuing therapies that may be causing dyspnea
    • Bullet 4 modified: Treat potentially reversible underlying causes/comorbid conditions using:
    • Bullet 4, sub-bullet 1 modified: Radiation/chemotherapy/interventional strategies as appropriate
    • Bullet 4, sub-bullet 2 added: If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities
    • Bullet 5, sub-bullet removed: Consider benzodiazepines if coexisting anxiety

PAL-12

  • Bullet 6, sub-bullet 2
    • Sub-sub-bullet 1 modified: Oxygen if hypoxichypoxiapresent and/or subjective relief is reported
    • Sub-sub-bullet 3 modified: BenzodiazepinesConsider benzodiazepines when opioids and other non-pharmacologic measures have failed to control dyspnea
    • Sub-bullet added: Noninvasive positive-pressure ventilation (eg, CPAP, BiPAP) support if clinically indicated for severe reversible condition
  • Bullet 7 modified: Reduce excessive secretions with non-pharmacologic interventions and anti-secretory agents
  • Bullet 7, sub-bullet 1 added: Reduce IV fluids and consider repositioning

PAL-14

  • Interventions, Months to days
    • Bullet removed: Consider appetite stimulant
    • Bullet 4 added: Counsel patients and family about benefits, risks (eg, thrombosis), and options for pharmacologic management of cachexia
    • Bullet 6, sub-bullet 6 added: Consider nutritional consult
    • Bullet 6, sub-bullet 7 added: Eating for pleasure may be considered, but should not be forced upon patients with no hunger or thirst
  • Reassessment, outcomes, bullets removed
    • Decreased caregiver burden
    • Strengthened relationships
    • Optimized quality of life
    • Personal growth and enhanced meaning

PAL-15

  • Interventions
    • Bullet 1 added: Consider treatment with corticosteroids and a proton pump inhibitor, while definitive treatment is selected.
    • Bullet 3 modified: Screen for potentially reversible causes/common etiologies:
    • Bullet 3, sub-bullet 6 modified: Gastric outletGastrointestinal (GI)obstruction from intra-abdominal tumor or liver metastasis
    • Bullet 3, sub-sub-bullet 4 added: Consider interventional procedures
    • Bullet removed: NCCN Guidelines for Management of Immunotherapy-Related Toxicities
    • Bullet 9 added: If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities
  • Footnote added: Do not give metoclopramide in patients with complete gastric outlet obstruction.

PAL-16

  • If ongoing needs, bullet 3 modified: Consider palliativeproportional sedation

PAL-17

  • Interventions
    • Bullet 5 modified: Treat other causes (eg, hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus, medications, side effects of immunotherapy)
    • Bullet removed: Consider adding other laxatives
    • Bullet 11 modified: Titrate laxative agents to achieve desired frequency Consider peripherally acting mu-opioid receptor antagonist (PAMORA) or secretory agents for opioid-induced constipation
    • Bullet 12 modified: Administer tap water enema until clear Administer enema until clear: eg,tap water, soap suds, mineral oil, lactulose
    • Bullet removed: Consider use of a prokinetic agent

PAL-18

  • Screening and Assessment, bullet 1 modified: Evaluate diarrhea severity and potential causes
  • Grading modified: Determine Diarrhea Severity/Grade
    • Mild/Grade 1
    • Moderate/Grade 2
    • Severe/Grade 3
    • Severe/Grade 4
  • Interventions
    • Sub-bullet added: If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities
    • Bullet added: Consider endoscopy if diagnostic uncertainty
  • Footnotes added:
    • Euvolemic and no electrolyte abnormalities
    • Hypovolemia plus/minus electrolyte abnormalities
    • Severe hypovolemia and/or electrolyte abnormalities

PAL-19

  • Screening assessment and bullet removed: Provide immediate antidiarrheal therapy indicated by grade
  • Grade added: Any grade
  • Intervention, any grade
    • Bullet added: Treat underlying cause as appropriate
    • Bullet added: If immunotherapy-induced diarrhea, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities
    • Bullet added: Provide IV fluids and hydration if patient is unable to tolerate oral fluids
  • Mild/Grade 1
    • Bullet removed: If chemotherapy induced, decrease or delay the next dose of chemotherapy
    • Bullet removed: Provide oral hydration and electrolyte replacement
    • Bullet 1 modified: InitiateConsider antidiarrheal agents (eg, loperamide) if infection ruled out
  • Moderate/Grade 2
    • Bullet 2 modified: Initiate/continue antidiarrheal agents—as above if infection ruled out
    • Bullet removed: If chemotherapy-induced, decrease or delay the next dose of chemotherapy
    • Bullet removed: If immunotherapy-mediated diarrhea, consider
    • Sub-bullet removed: Corticosteroids
    • Sub-bullet removed: Infliximab
    • Sub-bullet removed: Probiotics
    • Sub-bullet removed: See Management of Immunotherapy-Related Toxicity Guidelines for immunotherapy-related diarrhea
  • Severe/Grades 3/4
    • Bullet removed: For GVHD diarrhea, consider limiting diet, steroids, and IV nutrition

PAL-20

  • Months to days, bullet 2 modified: Assess patient's goals for treatment to guide choice of intervention (eg, decrease NV, allow patient support the desire to eat, decrease pain, allowsupport patient to go home/to hospice)

PAL-21

  • Procedural interventions
    • Bullet 2 modified: Endoscopic management (eg, G-tube for drainage, endoscopic stent placement)
    • Sub-bullet removed: Percutaneous endoscopic G-tube for drainage
    • Sub-bullet removed: Endoscopic stent placement
    • Sub-bullet removed: G-tube for drainage

PAL-23

  • Interventions for severe delirium (agitation)
    • Bullet 3 modified: Consider addition of low-dose benzodiazepines with or without antipsychotic medications if symptomssevere agitation persists
    • Bullet removed: If agitated delirium is refractory to high doses of neuroleptics, consider adding benzodiazepine
    • Bullet 6 added: Encourage supportive caregiver presence at bedside

PAL-24

  • Interventions, weeks to days
    • Bullet 2 added: Maximize nonpharmacologic interventions (optimize sleep wake cycle; address sensory impairment; provide glasses, hearing aids)
    • Bullet removed: Provide appropriate upward dose titration of antipsychotic agents
    • Bullet 8 modified: Provide appropriate upward dose titration of benzodiazepines with or without antipsychotics for patients with refractory agitation despite high doses of neuroleptics
    • Bullet 9 added: Encourage supportive caregiver presence at bedside
    • Bullet 10 added: Support caregivers
    • Bullet removed: Consider rectal or intravenous administration of antipsychotic with or without benzodiazepine

PAL-25

  • Interventions, weeks to days
    • Sub-bullet 5 modified: Pain: treat according to NCCN Guidelines for Adult Cancer Pain; see PAL-9 and PAL-10; use non-absorbent dressing or reduce frequency if associated with dressing changes; topical opioid and/or local anesthetic; complementary therapies

PAL-26

  • Interventions, years to weeks
    • Bullet 2 added: Complexities related to social determinants of health
    • Bullet 7 modified: Assess risk for persistent complex bereavement disorderPeriodically assess and monitor family/caregiver for risk factors associated with complicated grief

PAL-27

  • Interventions, weeks to days, bullet 3 modified: ExplainEducate about the dying process and expected events to the patient/caregiver(s)/ family members

PAL-28

  • Assessment/Interventions, years to months, bullet 4 modified: Determine needIntroduce, educate, and assess need for specialized palliative care or eligibility and readiness for hospice care
  • Assessment/Interventions, months to days, sub-bullet 2 modified: Spiritual assessmentscreening

PAL-29

  • Reassessment, if ongoing needs, bullet 5 modified: Consider referral to chaplain/spiritual care counselor

PAL-31

  • Heading modified: Response to Requests for Hastened Death or Medical Aid in Dying (MAID)
  • Bullet 1 modified: We believe that a request for hastened death often has important meanings that require exploration. The most appropriate initial response to a request for hastened death is to intensify palliative care. Patients making such a request shouldmay be referred to a palliative care specialist. However, evaluating a patient's request for hastened death is an important skill, even for clinicians who feel this practice medical aid in dying (MAID) is never morally acceptable. Clarifying these meanings may enlarge the range of useful therapeutic options and might reduce the patient's wish to die.
  • Bullet 5 modified: RequestConsider a consult with a mental health professional to evaluate and treat reversible causes of psychological suffering.
  • Bullet 9 modified: Know the local legal status and local health system policies and procedures of MAID. Some patients and clinicians may be confused about legal/ethical distinctions; treatment withdrawal and aggressive treatments for symptoms, such as pain, are not requests for hastened death. MAID is currently legal in 10 U.S. jurisdictions; euthanasia is not legal anywhere in the United States.

PAL-32

  • Physical
    • Sub-bullet 9 modified: Treat unclearable terminal secretions (death rattle)
    • Sub-sub bullet added: Educate patient and caregiver
    • Sub-sub bullet modified: Avoid deep suctioning Providegentle oropharyngeal suctioning (avoid deep suctioning)
    • Sub-sub bullet added: Utilize non-pharmacologic interventions first before antisecretory agents
    • Sub-bullet 12 modified: Consider palliativeproportionalsedation for refractory restlessness and agitationsymptoms
  • Psychosocial-spiritual
    • Sub-bullet 1 modified: Educate the patient/family/caregiver about the signs and symptoms of dying and the rationale for discontinuation of treatments or medications that may not add to the patient’s comfort

PAL-33

  • Title updated: PalliativeProportional Sedation
  • Bullet 1 modified: PalliativeProportional sedation (formerly known as palliative sedation) is the intentional lowering of awareness towards, and including, unconsciousness for patients with severe and refractory symptoms with primary goal of symptom relief including alleviation of suffering.
  • Bullet 4 modified: "A patient who is suffering from a terminal illness and who is experiencing great pain has no legal barriers to obtaining medication, from qualified physicians, to alleviate suffering, even to the point of unconsciousness and hastening death.” -Justice O’Connor (see Vacco v Quill and Washington v Glucksberg, 1997). Palliative sedation is, however, controversial for existential suffering, and many providers do not ethically support the practice for patients not likely to die within 2 weeks, because at that point the absence of hydration and food an become the immediate physiologic cause of death. However, for acutely dying patients the current body of literature supports that palliative sedation does not hasten death.

PAL-34

  • Assessment, bullet 3 modified: Consistent with clinical, cultural, spiritual, and ethical standards

PAL-A 1 of 5

  • Dyspnea
    • Life expectancy modified: Years; Year to Months; and Months to Weeks; Weeks to Days (dying patient)
    • Sub-bullets removed:
      • Opioid tolerance should be taken into consideration with dosing
      • Consider alternatives to morphine in patients with known renal compromise
    • Sub-bullet added: Base dosing on patient's opioid requirement. If patient's opioid requirement is unknown, start with low doses and titrate up as appropriate.
    • Bullet removed: Anxiety: Lorazepam, 0.25–1 mg PO q1h PRN if benzodiazepine naïve
  • Row added: Dyspnea, weeks to days
  • Secretions bullet modified: Excessive secretions: Glycopyrrolate, 0.2–0.4 mg IV or SC every 4 h PRN (less sedating), scopolamine, PRN/1.5 mg patches, 1–32 2patches every 72 hOR atropine, 1% ophthalmic solution 1–2 drops SL every 2 hPRN (caution in asthma), OR hyoscyamine, 0.125–0.25 mg PO orSL every 4 hwith max dose of 1.5 mg daily
  • Anorexia/Cachexia
    • Bullet 3 modified: Low/no appetite: Megestrol acetate, 480–600 mg/d PO2 OR olanzapine, 2.5–5 mg/d PO OR corticosteroid PRN dexamethasone 3–8 mg/d OR cannabinoid PRN
    • Bullet 4 added: Clinicians may choose not to prescribe pharmacologic intervention for cancer cachexia treatment

PAL-A 2 of 5

  • Nausea and vomiting
    • Line added: Common Etiologies
    • Bullet 2 modified: Gastroparesis: Metoclopramide, 5–10 mg PO QID 30 min before meals and QHS (avoid in setting of complete bowel obstruction)
    • Bullet 5 modified: Gastric outlet obstructions: Dexamethasone, 4–8 mg/d PO; proton pump inhibitor; metoclopramide, 5–10 mg PO QID 30 min before meals and at bedtime
    • Bullet 7 added: Olanzapine, 2.5–5 mg PO 1–2 times daily starting QHS
  • Constipation
    • Bullet 1 modified: Prophylaxis: Titrate the senna and add polyethylene glycol, recommend starting with polyethylene glycol if the patient is not on opioids and can tolerate the volume of liquidStart with an osmotic laxative if patient can tolerate the volume of liquid (polyethylene glycol BID) and add stimulant laxatives (senna BID or bisacodyl daily–TID) to achieve a goal of one non-forced bowel movement every 1–2 days
    • Bullet removed: General: Add bisacodyl, titrate to 10–15 mg PO daily–TID with a goal of one non-forced bowel movement every 1–2 days
    • Bullet 3 modified: Resistant opioid-induced constipation: Consider methylnaltrexone, 8 or 12 mg/dose SC QOD; linaclotide, 72–145 mcg/d PO; naloxegol, 12.5–25 mg/d PO
    • Sub-bullet added: If oral therapy is not effective, try enema
    • Sub-bullet added: Consider methylnaltrexone, 8 or 12 mg/dose SC QOD; naloxegol 12.5–25 mg daily PO; naldemedine 0.2 mg daily PO; lubiprostone 24 mcg BID PO; linaclotide 145–290 mcg daily PO

PAL-A 3 of 5

  • Diarrhea (years to weeks)
    • Grades modified:
      • Grade 1 (mild)
      • Grade 2 (moderate)
      • Grades 3/4 (severe)
    • Grade 1, bullet 3 modified: If not on opioids: Diphenoxylate/atropine 1–2 tabs PO every 6 h PRN, maximum 8 tabs/d (Also for grades 2 and 3/4)
    • Grade 2, bullet 4 modified: C. diff-induced: Metronidazole, 500 mg PO/IV QIDTID x 10–14 days; vancomycin, 125–500 mg PO QID x 10–14 days
    • Grade 2, bullet removed: Immunotherapy-related: Dexamethasone, 4–8 mg/d; infliximab, 5 mg/kg every2–6 weeks
  • Diarrhea (weeks to days)
    • Bullet 2 modified: Initiate or increase dose of around-the-clock opioidConsider tincture of opium
    • Bullet 5 modified: Consider glycopyrrolate, 0.2–0.4 mg IV/SC every 4 h PRN

PAL-A 4 of 5

  • Page extensively modified

PAL-A 5 of 5

  • Delirium, years to weeks
    • Bullet 1 modified: UseMaximize nonpharmacologic approaches when possible
  • Delirium, weeks to days
    • Bullet 4 modified: Consider chlorpromazine, 25–10050 mg PO/PR QHSwith or without lorazepam, 0.5–2 mg SC/IV every 6 h
  • PalliativeProportional Sedation
    • Bullet 1 added: Refer to institutional guidelines and policy

 

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