（2026.V1）NCCN临床实践指南：姑息治疗

指南肿瘤内科· 肿瘤治疗与综合管理 · 2026

NCCN Guidelines Version 1.2026 Palliative Care

*Anne M. Walling, MD, PhD/Chair £ UCLA Jonsson Comprehensive Cancer Center

*Toby Campbell,MD,MS/Vice-Chair t$\vDash$

University of Wisconsin Carbone Cancer Center

*Rajiv Agarwal, MD t£‡

Vanderbilt-Ingram Cancer Center

Ariana Bauer, MD £

Fred & Pamela Buffett Cardiff Center

Anna C.Beck,MD†

Huntsman Cancer Institute

James Brehany,MD£

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

David Buxton, MD £ 0 Moffitt Cancer Center

Elise C. Carey, MD E p

Mayo Clinic Comprehensive Cancer Center

Amy A. Case, MD $

Roswell Park Comprehensive Cancer Center

Shalini Dalal, MD £

The University of Texas

MD Anderson Cancer Center

Andrew S. Epstein, MD+£

Memorial Sloan Kettering Cancer Center

*Nathan Paul Fairman, MD, MPH $£ 0$ UC Davis Comprehensive Cancer Center

Leslie Fecher, MD t

University of Michigan Rogel Cancer Center

Stacy Fischer, MD £ m

University of Colorado Cancer Center

Nathan Gray,MD£

Johns Hopkins-Zimmel Cancer Center

Christine Hong, PharmD, MBA $\Sigma$

UT Southwestern Simmons

Comprehensive Cancer Center

Jennifer Kapo, MD E

Yale Cancer Center/Smilow Cancer Hospital

Pallavi Kumar, MD, MPH+ $\varepsilon$

Abramson Cancer Center at the University of Pennsylvania

Heather Leeper, MD, MS£ 4

The UChicago Medicine

Comprehensive Cancer Center

Deena Levine, MD££

St. Jude Children's Research Hospital/The University of Tennessee Health Science Center

*Elizabeth T. Loggers, MD PhD£t

Fred Hutchinson Cancer Center

Susan McCammon, MD £p

O'Neal Comprehensive Cancer Center at UAB

Erin Newton,MD+£

Indiana University Melvin and Bren Simon Comprehensive Cancer Center

Adeboye Ogunseitan, MD P £

City of Hope National Medical Center

Kavitha Ramchandran, MD t

Stanford Cancer Institute

*Dylan Sherry,MD£

Fox Chase Cancer Center

*Kira Skavinski,DO£

UC San Diego Moores Cancer Center

Linda Sutton, MD $+ £

Duke Cancer Institute

Eytan Szmuilowicz, MD £

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

*Jennifer Temel, MD $\dagger$

Dana-Farber/Brigham and Women's Cancer Center| Mass General Cancer Center

Patrick White, MD, PhD p $\ $ $

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

Nicholas G. Zaorsky, MD, MS §

Case Comprehensive Cancer Center/University Hospitals Seldman Cancer Center and Cleveland Clinic Taussig Cancer Institute

NCCN

Carly J. Cassara, MSc Richard Howley,PhD Vaishnavi Sambandam,PhD

£ Supportive care including

Griiatric medicine

Hematology/Hematology oncology

B Internal medicine

€ Pediatric oncology

θ Psychiatry, psychology,

including health behaviorS/Radiation oncology

£ Supportive care including hospice and palliative care medicine, pain management

+Medical oncology

No Neurology/Neuro-oncology

$\Sigma$ Oncology pharmacy

* Discussion Section Writing Committee

NCCN Guidelines Version 1.2026 Palliative Care

Version 1.2026, 10/27/2025 © 2025 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

NCCN Guidelines Index Table of Contents Discussion

NCCN Palliative Care Panel Members Summary of the Guidelines Updates

Definition and Standards of Palliative Care (PAL-1)

Palliative Care General Overview (PAL-2)

Assessment by Oncology Team (PAL-3)

Oncology Team Interventions and Reassessment (PAL-5)

Consideration for Consultation with Specialty Palliative Care Team (PAL-6)

Shared Decision-Making Considerations About the Benefits/Burdens of Cancer Therapy (PAL-8)Symptoms: Pain (PAL-10)

Symptoms: Dyspnea (PAL-11)

Symptoms: Anorexia/Cachexia (PAL-13)

Symptoms: Nausea and Vomiting (PAL-15)

Symptoms: Constipation (PAL-17)

Symptoms: Diarrhea (PAL-18)

Symptoms: Malignant Bowel Obstruction (PAL-20)

Symptoms: Sleep/Wake Disturbances Including Insomnia and Sedation (PAL-22)

Symptoms: Delirium (PAL-23)

Symptoms: Malignant Wounds (PAL-25)

Social Support/Resource Management (PAL-26)

Preparing Patients/Families/Caregivers for End of Life and Transition to Hospice Care (PAL-28)Advance Care Planning (PAL-29)

Response to Requests for Hastened Death (PAL-31)

Shared Decision-Making in the Care of the Imminently Dying Patient (PAL-32)

Proportional Sedation (PAL-33)

After-Death Interventions (PAL-34)

Palliative Care Drug Appendix (PAL-A)

Abbreviations (ABBR-1)

Please see NCCN Guidelines for Distress Management

Find an NCCN Member Institution:

https://www.nccn.org/home/memberinstitutions.

NCCN Categories of Evidence and Consensus: All recommendations are category 2A unless otherwise

indicated.

See NCCN Categories of Evidence and Consensus.

The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to

treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2025.

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

UPDATES

Updates in Version 1.2026 of the NCCN Guidelines for Palliative Care from Version 2.2025 include:

Continued

PAL-1

• Definition of Palliative Care: Palliative care is an approach to patient-/family-/caregiver-centered health care that focuses on optimal management of distressing symptoms, while incorporating psychosocial, spiritual support according to patient/family/caregiver needs, values, beliefs, and cultures.

Unless otherwise stated, these guidelines encourage the involvement of each patient’s support network, as determined by the patient and abbreviated here as patient/family/caregiver, in all aspects of care as needed and appropriate...

• Standards of Palliative Care

Bullet 1 modified: Palliative care should be provided by the primary oncology team and augmented as needed by collaboration with an

interprofessional team of palliative care experts including but not limited to board-certified palliative care physicians, advanced practice providers,

nurses, social workers, spiritual care providers, mental health professionals, and pharmacists. These team members are referred to as “specialty palliative care team” throughout the guideline and should be available to provide consultative or direct care to patients/families/caregivers and/or health care professionals who request or require their expertise.

Bullet removed: Interprofessional palliative care teams, including but not limited to board-certified palliative care physicians, advanced practice

providers, nurses, social workers, chaplains, and pharmacists, should be readily available to provide consultative or direct care to patients/families/ caregivers and/or health care professionals who request or require their expertise.

PAL-2

• Assessment by oncology team, bullet 1: Consideration for consultation with specialty palliative care team

• Footnote e: Patients with one or more positive indicators may benefit from a care plan developed by an interprofessional team of physicians, nurses,social workers, mental health professionals, chaplains, advanced practice clinicians, and other health care professionals specialty palliative care team.

(Also for PAL-5)

PAL-3

• Symptom management, bullet added: fertility and intimacy concerns

• Footnote added: Every time the patient is mentioned, consider patient's family/caregiver as defined on PAL-1.

PAL-4

• Column 1, row 1: Existential, psychosocial, spiritual distress

• Column 1, row 3: Consideration for consultation with specialty palliative care team (made throughout Guidelines)

• Column 3, row 2: Consider consultation with specialty palliative care team and/or spiritual or psychosocial, mental health professionals, spiritual

resources (eg, chaplains spiritual care providers, clinical psychologists, community resources, social workers)

• Footnote added: See PAL-1 for list of specialty palliative care team.

PAL-5

• Oncology team interventions, sub-bullet 1: Mental/behavioral health

• Reassessment, bullet 3: Reduction of patient/family/caregiver distress if needed

PAL-6

• Column 1: Patient characteristics Consider consultation with specialty palliative care team

• Assessment

Bullet 5: Complexity of care needs (including physical and/or psychosocial, spiritual, existential needs)

Bullet 21 added: Substance use disorder

• Footnote added: Refer to the NCCN Distress Thermometer and Problem List, which includes social determinants of health. See NCCN Guidelines for Distress Management (DIS-A). (Also for PAL-7, PAL-13, PAL-26)

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

UPDATES Continued

PAL-8

• Months to years, interventions

Bullet 1: Assess understanding of prognosis, and goals of therapy, and implications of disease and/or treatment on their physical and cognitive

function

Bullet 12 added: Fertility and intimacy concerns (See NCCN Guidelines for Survivorship)

• If ongoing needs, bullet 6: Consider hospice referral as appropriate (Also for PAL-9, PAL-10)

PAL-9

• Interventions, bullet 5: Consider psychosocial, spiritual support regarding anticipatory grief for patients/families/caregivers

PAL-10

• Interventions

Bullet 2: Educate patient/family/caregiver on the patient's condition and the role of pain medication the importance of pain control in the dying process

at the end of life

Bullet 4: Consider nonpharmacologic and/or integrative interventions (eg, massage, art or music therapy, acupuncture, relaxation, mindfulness, guided

imagery) See NCCN Guidelines for Adult Cancer Pain (PAIN-D).

Bullet 5 added: Consider interventional strategies. See NCCN Guidelines for Adult Cancer Pain (PAIN-M)

Bullet 6 added: Consider hypofractionated palliative RT as indicated

Sub-bullet 1 added: Use ongoing shared decision making to balance desired pain control with acceptable toxicities

Sub-bullet 3: Avoid opioid dose reduction solely for decreased blood pressure or respiration rate. If opioid reduction is indicated, consider 10% daily or

25% every 3 days as per national tapering recommendations to avoid acute opioid withdrawal or pain crisis. Avoid opioid antagonists.

Sub-bullet 5: Recognize and treat opioid-induced neurotoxicity, including myoclonus and hyperalgesia; consider opioid rotation if needed.

PAL-11

• Interventions

Sub-bullet 8: Pharmacologic therapy (if nonpharmacologic and nonopioid interventions are ineffective)

Sub-sub-bullet 1: Low-dose opioids Trial of low-dose opioids with close monitoring of adverse events

PAL-12

• Interventions

Sub-bullet removed: Consider time-limited trial of mechanical ventilation if indicated

Sub-bullet removed: Consider therapy with high-flow nasal cannula

Sub-bullet 4 added: Consider therapy with high-flow nasal cannula

Sub-bullet 8 added: Gentle suction of oral pharynx, avoiding deep suctioning

PAL-13

• Assessment and interventions

Sub-bullet 4 added: Gastrointestinal

Sub-sub bullet 1 added: Constipation

Sub-sub bullet 2 added: Nausea/Vomiting (NV)

Sub-bullet 6 added: Oral health

Sub-sub bullet 5 added: Mucositis

Sub-bullet 9 added: Psychiatric

Sub-sub bullet 8 added: Anxiety

Sub-bullet removed: Mucositis

Updates in Version 1.2026 of the NCCN Guidelines for Palliative Care from Version 2.2025 include:

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

UPDATES Continued

PAL-13 (continued)

Bullet 5: Consider evaluating for endocrine abnormalities (eg, thyroid dysfunction)

Sub-bullet removed: Hypogonadism

Sub-bullet removed: Thyroid dysfunction

Sub-bullet removed: Metabolic abnormalities (eg, increased calcium)

Bullet removed: Consider registered dietitian consult

Bullet 7 added: Encourage, if able, high protein, high nutrition food

Bullet 11 added: Consider enrolling patient in a clinical trial with novel cachexia medication

• Reassessment, if ongoing needs, bullet 2: Provide dietary nutritional consultation

PAL-14

• Interventions, bullet 4: Counsel patient and family about benefits, risks (eg, thrombosis), and options for pharmacologic management of cachexia

PAL-15

• Sub-bullet 15: If anxiety (or anticipatory nausea) contributes to NV, consider adding benzodiazepine

PAL-17

• Column 1, bullets removed:

Increase fluids

Increase dietary fiber if patient has adequate fluid intake and physical activity

Exercise, if appropriate

• Column 1, bullet 1 added: Optimize food intake and physical activity as appropriate

PAL-19

• Sever/Grades 3/4, bullet 2: Provide IV fluids and use antidiarrheal agents and anticholinergics as mentioned above

PAL-21

• Procedural interventions

Bullet 7 added: Consider bowel rest as appropriate

Sub-bullet removed: Consider if there is expected improvement in quality of life and life expectancy of months to years

Sub-bullet 9 added: In patients with a life expectancy of months to years, consider in limited cases when aligned with patient-specific goals for

maintaining quality of life and after consideration of the risks and benefits

PAL-23

• Assessment

Bullet 3: Screen for and treat underlying reversible causes, such as

Sub-bullet 10: Bladder outlet obstruction Urinary retention

• Interventions, bullet 2: Maximize nonpharmacologic interventions (optimize sleep-wake cycle; address sensory impairment; provide glasses, hearing aids; consider role of exercise and activity)

PAL-24

• Footnote added: Consider patient's family/caregiver as defined on PAL-1.

PAL-25

• Days to weeks, interventions, sub-bullet 7: Body image: maintain symmetry in dressings; manage wound odor and exudate; screen for depression,anxiety; address intimacy concerns

Updates in Version 1.2026 of the NCCN Guidelines for Palliative Care from Version 2.2025 include:

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

UPDATES

PAL-26

• Interventions, sub-bullet 6 added: Assess for substance use disorder (See NCCN Guidelines for Adult Cancer Pain)

PAL-29

• Reassessment, if ongoing needs, bullet 4: Consider referral to a mental health clinician to explore mental well-being

PAL-30

• Weeks to months, interventions, bullet 8 added: Offer anticipatory guidance

PAL-31

• Sub-bullet 1: Reassess symptom concerns and/or management.

• Sub-bullet 2 added: Assess patient concerns regarding symptoms.

• Bullet 11: Clarify the care plan. Requests for hastened death should prompt ongoing discussion and active attempts to ameliorate physical and

psychosocial, spiritual distress. Re-emphasize your own commitment to providing continuing care for the patient. Re-evaluate and maintain medications for symptom management.

PAL-32

• Heading: Shared decision-making in the care of the imminently dying hospitalized patient

• Paragraph 1: For an imminently dying patient whose goals have transitioned to comfort, consider the following physical, psychosocial, existential,

spiritual, and practical interventions

• Bullet 2: Psychosocial, spiritual, existential

• Sub-bullet 15: Consider consults to psychosocial, spiritual providers, including but not limited to social workers, child life specialists, and psychologists specialty palliative care team...

• Sub-bullet 16: Offer anticipatory bereavement support and assess for complicated bereavement risk

PAL-33

• Bullet 3 added: Consider interdisciplinary discussion prior to inception of sedation and throughout the process, to support the care team (including both the caregivers and family and support of the patient, and the medical staff taking care of the patient).

• Bullet 4 added: Consider periodic reassessment of symptoms to ensure level of sedation is proportional to need for symptom relief.

PAL-34

• After-death interventions

Sub-bullet 4: Involve chaplain spiritual care provider to assess family's desire for religious ritual or spiritual support

Sub-sub bullet 3: Identify any health care professionals at risk for complicated grief, moral distress, or compassion fatigue

PAL-A

• Section extensively modified.

Updates in Version 1.2026 of the NCCN Guidelines for Palliative Care from Version 2.2025 include:

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

Note: All recommendations are category 2A unless otherwise indicated.

PAL-1

a Hui D, et al. J Pain Symptom Manage 2012;43:582-592.b Seaman JB, et al. J Palliat Med 2020;23:1157-1158. c Ferris FD, et al. J Clin Oncol 2009;27:3052-3058. d IOM (Institute of Medicine). 2014 Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. Available at:www.nap.edu/read/18748/chapter/1.

Definition of Palliative Carea,b

Palliative care is an approach to patient-/family-/caregiver-centered health care that focuses on optimal management of distressing

symptoms, while incorporating psychosocial, spiritual support according to patient/family/caregiver needs, values, beliefs, and cultures.

Unless otherwise stated, these guidelines encourage the involvement of each patient’s support network, as determined by the patient and

abbreviated here as patient/family/caregiver, in all aspects of care as needed and appropriate. 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 only becomes the main focus of care when disease-directed, life-prolonging therapies are no longer effective, appropriate, or desired.

Standards of Palliative Carec,d

• Palliative care should be provided by the primary oncology team and augmented as needed by collaboration with an interprofessional team of palliative care experts including but not limited to board-certified palliative care physicians, advanced practice providers, nurses, social workers, spiritual care providers, mental health professionals, and pharmacists. These team members are referred to as “specialty palliative care team” throughout the guideline and should be available to provide consultative or direct care to patients/families/caregivers and/or

health care professionals who request or require their expertise.

• Institutions should develop processes for integrating palliative care into cancer care, both as part of usual oncology care and for patients

with specialty palliative care needs.

• All patients with cancershould be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically indicated(see PAL-2 and PAL-3).

• Patients/families/caregivers 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 palliative care

knowledge, skills, and attitudes.

• Quality of palliative care should be monitored by institutional quality improvement programs.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ASSESSMENT BY ONCOLOGY TEAM\n-Benefits/burdens of cancer therapy\n-Apprompative treatment of comorbid physical and psychosocial, spiritual conditions\n● Consideration for consultation with specialty palliative care team (PAL-6)\n●Coping strategies\n●Cultural factors affecting care (PAL-4)\n●Cultural factors affecting capacity\n●Coordination of care with other health care providers\n●Consultation with specialty palliative care team (PAL-4)\n●Ongoing reassessment\n●Outcomes:\n●Acceptable sense of control\n●Adequate symptom management\n●Decision-making patient\n●Decination of care with other health care providers\n●Decreased caregiver stress and burden\n●Optimized quality of life\n●Patient satisfied with response to cancer therapy\n●Personal growth and enhanced meaning\n●Reduction of patient/family/caregiver distress\n●Strengthened relationships\n●Strengthening needs conditions\n●Personal public life\n●Effect of death\n●Death→\n→Doth→\n●Psychological bereavement support\n●Psychological bereavement support\n●Personal growth and enhanced meaning\n●Reduction of patient/family/caregiver distress\n●Strengthened relationships\n](2/aj0YEe4oUhYkBdfpda0fYP/figuref0ed321dc312467c9b2c42e669e0a7a7_0_4.png) e Patients with one or more positive indicators may benefit from a care plan developed by an interprofessional specialty palliative care team.

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

9 See FEV-D in the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections for an approach to assess for the risk of serious complications in patients with neutropenic fever.

h For an approach to decision-making in older adults and geriatric screening tools, see the NCCN Guidelines for Older Adult Oncology.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

|ASSESSMENT BY ONCOLOGY TEAM|| |---|---| |·Natural history of specific tumor|●Natural history of specific tumor| |·Potential for response to further treatment|| |·Potential for treatment-related toxicities|| |·Patient's understanding of disease prognosis|PAL-89,h| |·Hopes for and understanding of cancer therapy|●Hopes for and understanding of cancer therapy| |·Impairment of vital organs|●Impairment of vital organs| |·Performance status|| |·Serious comorbid conditions|| |·Shared decision-making with patient/family/caregiver(s)|| |·Document surrogate and discuss advance care planning|PAL-89,h| |·Patient/family/caregiver values and preferences about information|Advance Care Planning (PAL-29)| |·Patient/family/caregiver values and communication|Preparing Patients/Families/Caregiver(s) for End| |·Hopes for and understanding of cancer therapy|of Life and Transition to Hospice Care| |·Quality of life|(PAL-28)| |·Dyspnea|Pain (PAL-10)| |·Dyspnea/cachexia|Dyspnea (PAL-11)| |·Anorexia/cachexia|Anorexia/Cachexia (PAL-13)| |·Nausea/vomiting (NV)|Nausea/Vomiting (PAL-15)| |·Constipation|Constipation (PAL-17)| |·Diarrhea|Diarrhea (PAL-18)| |·Malignant bowel obstruction|Malignant Bowel Obstruction (PAL-20)| |·Fatigue/weakness/asthenia|NCCN Guidelines for Cancer-Related Fatigue| |·Insomnia/sedation|Insomnia/Sedation (PAL-22)| |·Delirium|Delirium (PAL-23)| |·Malignant wounds|Malignant Wounds (PAL-25)| |● Lymphedema|NCCN Guidelines for Survivorship| |● Hormone-related symptoms|NCCN Guidelines for Distress Management| |● Distress|NCCN Guidelines for Distress Management| |● Immunotherapy-related toxicities|NCCN Guidelines for Management of Immunotherapy-Related Toxicities| |●Fertility and intimacy concerns|NCCN Guidelines for Survivorship|

g See FEV-D in the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections for an approach to assess for the risk of serious complications in patients with neutropenic fever.

h For an approach to decision-making in older adults and geriatric screening tools, see the NCCN Guidelines for Older Adult Oncology.

${}^{i}$ Every time the patient is mentioned, consider patient's family/caregiver as defined on PAL-1.Look for opportunities to use single agents to treat multiple symptoms.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ASSESSMENT BY ONCOLOGY TEAM\nPsychosocial, spiritual/psychiatric\nPsychiatric\nDepression/anxiety\nDistress\nSpiritual or existential needs\nSocial/practical challenges or concerns\nSocial support\nHome\nFamily\nFinancial toxicity\nAccess barriers, including geography/transportation\nCommunity\n• Resource needs\nProvide age-appropriate social support services\nSocial isolation and/or loneliness\n·Social support/ajouschocatalytic professional photosocial\n·eg, spiritual care providers, clinical psychologists, community resources\n·social workers) (PAL-7)\n](2/aj0YEe4oUhYkBdfpda0fYP/figuredbc619fafce64aa38f4872948afa9bc1_0_4.png) |● Educational and informational needs|● Patient/family/caregiver values and preferences about information and communication ● Cultural factors ● Patient/family/caregiver perceptions of disease status|Preparing Patients/Families/Caregivers for End of Life and Transition to Hospice Care (PAL-28)| |---|---|---| |● Cultural factors|● Patient/family/caregiver perceptions of disease status|● Property of Life and Transition to Hospice Care (PAL-28)| |● affecting care|● Patient/family/caregiver perceptions of disease status|● Property of Life and Transition to Hospice Care (PAL-28)|

g See FEV-D in the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections for an approach to assess for the risk of serious complications in patients with neutropenic fever.

j Look for opportunities to use single agents to treat multiple symptoms.

k See PAL-1 for list of specialty palliative care team.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

ONCOLOGY TEAM INTERVENTIONS

REASSESSMENT

![•Collaborate with palliative care specialist/team,e,f - Collaborate with other health care professionals treating the patient\n•恢复ate with other health care professionals treating the patient. Evaluate and treat undiagnosed physical and mental health issues. Consider additional referrals: Mental/behavioral health Psychosocial, spiritual services - Behavioral health. Other specialists - Substance use disorders - See NCCN Guidelines for Adult Cancer Pain - 摩动cell community support - Religious/Spiritual - School Community agencies - Introduce needs- ● Introduce advance care planning conversations - Expedite referral to hospice services when appropriate|\`l ongoing needs\→ post.Rone NCCN Guidelines 108\→ supportate intervention options and intensify as possible.\` See NCCN Guidelines for Distress Management\|\n Ongoing re-evaluation and communication between the patient and health care team\n Optimized quality of life\n Personal growth and enhanced meaning\nBehavioral health and Other specialists - Advance care planning in progress\n·Collaborate with palliative care in adult Religious/Spiritual - School community agencies - Introduce needs- ● Introduce advance care planning conversations - Expedite referral to hospice services when appropriate\n](2/aj0YEe4oUhYkBdfpda0fYP/figureab346905fb2b4ccda1e130cccd6b81b1_0_6.png) e Patients with one or more positive indicators may benefit from a care plan developed by an interprofessional specialty palliative care team.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

CONSIDERATION FOR CONSULTATION WITH SPECIALTY PALLIATIVE CARE TEAM

ASSESSMENT

|Consider consultation with specialty palliative care team|●Address patient/family/caregiver concerns about course of disease and decision-making ●Advanced cancer ●Assessment by Oncology Team (PAL-2) ●Communication needs (ie, language, literacy, culture, cognitive impairment) ●Complexity of care needs(including physical and/or psychosocial, spiritual, existential needs) ●Complexities related to social determinants of health|●High level of psychological distress based on standardized distress screening (NCCN Guidelines for Distress Management) ●High risk of poor pain management or pain that remains resistant to conventional interventions ●See NCCN Guidelines for Adult Cancer Pain (PAIN-K, PAIN-L, PAIN-M) ●Limited cancer treatment options due to: ●Limited access to cancer treatment ●Disease refractory to cancer treatment ●Multiple and/or severe comorbid conditions ●Progressive functional decline or persistently poor performance status ●Need for intensive care unit (ICU)-level care ●especially involving multi-organ system failure or prolonged mechanical support) ●Need for invasive procedures (eg, palliative stenting or venting gastrostomy) ●Patient/family requests consultation ●Poor prognostic awareness and/or need for advance care planning/clarification of goals of care ●Poor proposed hastened death ●Substance use disorder ●Uncontrolled symptoms| |---|---|---|

| Advanced solid tumors and hematologic malignancies.

m Refer to the NCCN Distress Thermometer and Problem List, which includes social determinants of health. See NCCN Guidelines for Distress Management(DIS-A)

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

CONSIDERATION FOR CONSULTATION WITH SPECIALTY PALLIATIVE CARE TEAM

ASSESSMENT

![## Complex patient/family/ caregiver\nComplex patient/family/ caregiver\nCancer circumstances\n×\n▶▶\nDither\nNCCN\nNoncal思维 lines Version 1.2026\nNCCN\nNoty 2.06 1.0554-2019\nPalliative Care\nTatal\ncare giving 2\n● Patient's concerns regarding family/caregiver well-being\nDependent children and/or older relatives requiring care living in the household\nCare planning for children of parent with poor prognosis 2\nSupport for active caregivers\n- Substance use disorder impacting care "Spiritual or existential distress ● Unresolved or multiple prior losses \n](2/aj0YEe4oUhYkBdfpda0fYP/figureac612b0852094e82b08ac7faf4844a88_0_6.png) ![Oncology care\,team\,staff\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,chologuations\,challenges\,chologuants\,chologuants\,chologu$\in$ C.ncon n 1.2026, 10/27/2025©2025 National Comprehensive Cancer Network®(NCCN®),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.\n](2/aj0YEe4oUhYkBdfpda0fYP/figure0ddc860ff0bf4c58bd676d0b953d216e_0_7.png) m Refer to the NCCN Distress Thermometer and Problem List, which includes social determinants of health. See NCCN Guidelines for Distress Management(DIS-A)

Note: All recommendations are category 2A unless otherwise indicated.

NCCN

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SHARED DECISION-MAKING CONSIDERATIONSABOUT THE BENEFITS/BURDENS OF CANCER THERAPY

![####ESTIMATED INTERVAL FIREPANSORY LIFE EXPECTANCY\nAssess understanding of prognosis, goals of therapy, and implications of disease and/or treatment on their physical and cognitive function\n●Discuss whether cancer therapy is curative or noncurative\n● Discuss whether cancer therapy is curative or recurrence\n● Offer goal-directed supportive care, including referral to specialized palliative care services, if indicated\n● Provide appropriate cancer therapy that is aligned with stated patient\nMonths to years\n●Assess for appropriateness of palliative radiation therapy (RT) or interventional procedures that are aligned with goals of care\n●Provide cancer treatment and disease-related symptom management\n●Observe a discrentation of applications of disease and/or integrative interventions (eg, cognitive behavioral, massage, art, or music therapy)\n●Consider rehabilitation services and physical activity aligned with goals\n●Reassess prognostic awareness and goals of therapy\n●Redirect goals and hopes to those that are achievable based on likely prognosis and life expectancy\n●Provide guidance regarding anticipated course of disease\n●Assess for appropriateness of palliative RT and/or interventional weeks\n●Procedures (eg, single fraction)\n●Consider discontinuation of cancer treatment not aligned with goals of care\n●In this level\n●If ongoing care planning\n●Systematically review advance care plans to ensure ongoing accuracy as illness or situation evolves\n●Offer goal-directed supportive care\n●Offer education and support related to care at end of life, including referral to specialized palliative care services or hospice\n●Assess and document preferred location of death\n●Explore culturally/spiritually significant rituals/ceremonies important at\n●ying d of life\npalant)\n](2/aj0YEe4oUhYkBdfpda0fYP/figurea783851fca1142d7aa3922a3dd72834a_0_5.png) NCCN 授权医脉通提供NCCN指南全文下载。wmIsyy于2025/10/28,19:10在脉通平台下载，仅供个人使用，严禁分发。2025 美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SHARED DECISION-MAKING CONSIDERATIONS ESTIMATED INTERVENTIONS ABOUT THE BENEFITS/BURDENS OF CANCER THERAPY EXPECTANCY REASSESSMENT

![Days to weeks\nContributionor\n●Discontinue all treatments not directly contributing to\npatient comfort\n●Intensify palliative care in preparationor death\n●Providece guidance\n●Intensify palliative care in preparationor death\n●Provide guidance regarding anticipated dying process\n●Consider psychological support and education\n●Consider psychosocial, spiritual support regarding anticipatory grief for patients/families/caregivers\n●Focus on symptom management and comfort\n●Refer to hospice team\n●Assist with completion of legal documents, if appropriate\n●Assess and document preferred location of death\n●Consider nonpharmacologic and/or integrative interventions (eg, heat or ice, positioning or support)\n●Consider nonpharmacologic and/or integrative interventions (eg, heat or ice, positioning or support)\n●Offer education and support related to care at end of life\n●Ordering culturally/spiritually significant rituals/ceremonies important at end of life\n●Explore culturally/spiritually significant rituals/needs ①ing needs\n●Annected for the future of future generations, this may be difficult to continue and give a care plan\n●Review advance care planning\n●Review advance care planning\nneeds ①cere$\bullet$Re-evaluate palliative care interventions and②Consult or refer to specialized palliative care services or hospital\n●Consult or refer to specialized pathiative care services or hospital\n●Consider hospice\n●Consider hospice\n①Report\n●Review hospital\n●Consider planning\n①Re-evaluate palliative care interventions and②Consult or refer to specialized pathiative care services or hospital\n●Simplicie\n●Consult or refer to specialized pathiative\n●Consider hospice referral\n](2/aj0YEe4oUhYkBdfpda0fYP/figure7a19961cdc0e4c34820bd28ba3e05944_0_5.png) NCCN 授权医脉通提供NCCN指南全文下载。wmIsyy于2025/10/28,19:10在医脉通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![####ESTIMATED LIFE EXPECTANCY\nTreat according to NCCN Guidelines for Adult Cancer Pain years\n●Treat according to NCCN Guidelines for Adult Cancer Pain\n●Pain In addition:\n●Educate patient/family/caregiver on the importance of pain control at the end of life\n●Optimize psychosocial, spiritual support for patient and family/caregivers\n●Consider integrative interventions. See NCCN\n●Guidelines for Adult Cancer Pain (PAIN-D).\n●Consider interventional strategies. See NCCN Guidelines for Adult Cancer Pain (PAIN-M)\n●Use ongoing shared decision making to balance desired pain control with acceptable toxicities\nDays to weeks\npairant patients\n●Maintain analgesic therapy; titrate to optimal comfort\n●Balance analgesia against reduced level of consciousness as possible or desired\nIf ongoing conversions. Intertransderly administered medications have longer times to onset than other routes. IV bolus dosing combined with drip titration may be the effective method of rapid titration; drip titration alone\n●Recognize and treat opioid-induced neurotoxicity,including myoclonus and hyperalgesia; consider opioid rotation if needed.\n●Consider single-fraction palliative RT for painful bone metastases for patients with a life expectancy of multiple weeks\n●Optimized generally of life\n●Personal growth and enhanced meaning\nIf ongoing needs\nPain NCCN Guidelines\n●Consider for Adult Cancer\nPain\nOngoing\nIn</td>\n</tr>\n](2/aj0YEe4oUhYkBdfpda0fYP/figure475e9e22aa9f48d9982f2ea773708812_0_4.png) NCCN 授权医脉通提供NCCN指南全文下载。wmIyys于2025/10/28,19:10在医脉通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![####ESTIMATED INTERVAL 1INTERVENTIONS\nDYPSPNEA REASSESSMENT\nLIFE EXPECTANCY\n●Assess symptoms comprehensively\n●Educate patient/family/caregiver on patient's condition and risk/benefit of treatment options\n●Consider discontinuing therapies that may be causing dyspnea\n●Treat potentially reversible underlying causes/comorbid conditions using:Radiation/chemotherapy/interventional strategies as appropriate\n●Inmunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy\n●Optimized quality of life\n●Decreased caregiver burden\n●Relieve symptoms\nOxygen therapy for symptomatic hypoxia\nEducational, psychosocial, spiritual, and emotional support for the patient/family/caregiver caregiver\nNonpharmacologic therapies, including fans,cooler temperatures, stress management,relaxation therapy, and physical comfort\n●Pharmacologic therapy (if nonpharmacologic and nonopioid interventions are ineffective)◆Trial of low-dose opioids with close monitoring of adverse events\n●Noninvasive positive-pressure ventilation(eg, CPAP, BiPAP) support if clinically indicated for severe reversible condition\nDays to weeks of dying-pylying (PAL-12)\nEvents\n●Interventions (PAL-12)\n●Proving reassess (o)\nInerventions (PAL-12)\nYPS\n●Re-evaluate palliative care interventions and initiatives and possible instructions\n●Consult or refer to needs (If needs\n●Consulted palliative care services or hospice\n●Re-evaluate palliative care interventions and ongoing:1.2026,10/27/2025©2025 National Comprehensive Cancer Network (NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.\n](2/aj0YEe4oUhYkBdfpda0fYP/figure63e28b27b7164fc089042a697002904d_0_4.png) n See Palliative Care Drug Appendix (PAL-A) for specific recommendations for medical management of symptoms.

° For acute progressive dyspnea or for patients who are opioid tolerant, titration may be required.

Note: All recommendations are category 2A unless otherwise indicated.

![NCCN\nNational Comprehensive Cancer Network®\n](2/aj0YEe4oUhYkBdfpda0fYP/figure456980179b5744c1a0ff1b9a44787d0f_0_1.png)

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS${}^{n}$ \nAssess symptoms comprehensively \nUse labored breathing or other physical signs of dyspnea in patients who are noncommunicative \nApsema patient and family/caregiver preferences\nMonths to year\nInterventions (PAL-11)\nWeekss to $\times$ Days to weeks (dying patient) \nYears\n\nSuppression options\n\n Of people\nProvide anticipatory guidance for patient/family/ caregiver \nCaregiver regarding dying or respiratory failure\nProvide emotional and spiritual/ family/ \nFocus on comfort \nContinue to treat underlying condition as appropriate\n● Provide emotional and spiritual support \n● Focus on comfort \nContinue to treat patient/ family/caregiver \nDysmpnea\nWeekss to \nEmotional, psychosocial, spiritual, and emotional support (PAL-11)\nDysmpacologic therapies\nFox, cooler temperatures\nPharmacologic therapies\nYears\nDays to weeks (dying patient) \nOxygen if hypoxia present and/or subjective relief is reported\nIf opioid naive, low-dose opioid '-If on chronic opioids, consider increasing dose by 25% for unrelied dyspnea; see NCCN \nGuidelines for Adult Cancer Pain for additional \ninformation on opioid titration \nConsider benzodiazepines when opioids and other non-pharmacologic measures have failed to control dyspnea\nConsider therapy with high-flow nasal cannula \nNoninvasive positive-pressure ventilation (eg,CPAP,BiPAP) support if clinically indicated for severe reversible condition \nIf fluid overload is a contributing factor: \nDecrease/discontinue enteral or parenteral fluid \nConsider low-dose diuretics\n● Consider excessive secretions with nonpharmacologic interventions and anti-secretory agents \nReduce IV fluids and consider repositioning \nGentle suction of oral harynx, avoiding deep suctioning\n](2/aj0YEe4oUhYkBdfpda0fYP/figure83c6b88ae82b4b08b90429aeb34a4c60_0_4.png) n See Palliative Care Drug Appendix(PAL-A) for specific recommendations for medical management of symptoms.

°For acute progressive dyspnea or for patients who are opioid tolerant, titration may be required.

P The addition of benzodiazepines to opioids can increase the risk of respiratory depression.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Palliative Care 1.2026 NCCN Cancer Cancer Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![####ESTIMATED LIFE EXPECTANCY\nASSESSMENT AND INTERVENTIONS\nOutcomes:●Outcomes:●Weight stabilization or gain\n● Improvement in symptoms that interfere with intake dyspnea(PAL-11)\n·Educate patient/family/caregiver on patient's condition and risk/benefits of treatment options\n●Screen for conditions/symptoms that interfere with intake Dyspnea(PAL-11)\n·Screen for intense with intake ·Improved energy with Fatigue (See NCCN Guidelines for Cancer-Related Fatigue\nYears\nMonths to year\nMemory to year\nIntractable hiccups\nDental and/or jaw issues\nDysgeusia\nMucositis\nOropharyngeal candidiasis\nXerostomia\nPain (See NCCN Guidelines for Adult Cancer Pain)\nPancreatic exocrine enzyme insufficiency\nPsychiatric Anxiety\nDysperian & Depression\nEating disorders/distortedbody image\n●Review/modify medications that interfere with intake\n·Equity evaluating for endocrine abnormalities\n·Supervised energy needs\n·Consider evaluating for endocrine abnormalities of health\n·Consider appetite stimulant\nANIOX\n●Assess complexities related to social determinants of healthm\n●Encourage, if able, high protein, high nutrition food\n●Consider swallowing evaluation\n●Consider psychiatric consultation if patient has an eating disorder or phobia/anxiety related to eating/swallowing\nweeks to Consider nutrition support, enteral and parenteral feeding (as appropriate)\nDental and/or jaw issues\nDysgeusia\nMucositis\nOropharyngeal candidiasis\nXerostomia\nPain (See NCCN Guidelines for Adult Cancer Pain)\nPancreatic exocrine enzyme insufficiency\nPsychiatric Anxiety\nDysperian & Depression\nEating disorders/distortedbody image\n●Review/modify medications that interfere with intake\n·Equity evaluating for endocrine abnormalities\n·Assess complexities related to social determinants of healthm\n●Consider adversarial\n·Equage or ability\n·Conserve, if able, high protein, high nutrition food\n●Consider swallowing evaluation\n·Consideor psychiatric consultation if patient has an eating disorder or phobia/anxiety related to eating/swallowing\n$\cdot$Consider答题\nDays to weeks (dying years of patient)\n·Consider enrolling patient in a clinical trial with novel cachexia medication\n`Invertions (PAL-14)\nPatient)\nInterventions (PAL-14)\nNote: All recommendations are category 2A unless otherwise indicated.\n](2/aj0YEe4oUhYkBdfpda0fYP/figure41647de1f1484a699a06e1b80bd846e6_0_3.png) m Refer to the NCCN Distress Thermometer and Problem List, which includes social determinants of health. See NCCN Guidelines for Distress Management (DIS-A)See Palliative Care Drug Appendix (PAL-A) for specific recommendations for medical management of symptoms.

National Comprehensive Cancer Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![### 2 ESTIMATED LIFE EXPECTANCY Years Months to year\nInterventions (PAL-13)\nMonths to year\nTreat reversible causes of anorexia (PAL-13)\nAssess anorexia/cachexia severity and associated symptoms\n● Educate patient/family/caregiver on patient's condition and risk/benefit of treatment options\n● Counsel patient and family about benefits, risks, and options for pharmacologic management of cachexia\n● Focus on patient goals and preferences\n● Provide education and emotional support to patient/ family/caregiver regarding natural history of disease, including the following points:\nAbsence of hunger and thirst is normal in the dying patient\n● Uncortical support may not reverse weight loss in patients with advanced cancer\n● Artificial nutrition and hydration may increase risk of fluid overload, aspiration, infection, and hastened death\n● Symptoms like dry mouth should be treated with local measures (eg, mouth care, small amounts of liquids)\n● Discontinuing previously initiated enteral or parenteral nutrition near the end of life is appropriate, ethically permissible, and may improve some symptoms\n● Counsel patient and family about benefits, risks, and options for pharmacologic management of cachexia\n● Acceptable sense of control\n● Focus on patient goals and preferences\n● ● Provide Education and emotional support to patient/ family/caregiver regarding natural history of disease, including the following points:\n● Absence of hunger and thirst is normal in the dying patient\n● Nutritional support may not reverse weight loss in patients with advanced cancer\n● Artificial nutrition and hydration may increase risk of fluid overload, aspiration, infection, and hastened death\n● Symptoms like dry mouth should be treated with local measures (eg, mouth care, small amounts of liquids)\n● Discontinuing previously initiated enteral or parenteral nutrition near the end of life is appropriate, ethically permissible, and may improve some symptoms\n● Discuel patient and family about benefits, risks, and options for pharmacologic management of cachexia\n● Acceptable sense of control\n● Focus on patient goals and preferences\n● ● Dieveare palliative care (needs)\n](2/aj0YEe4oUhYkBdfpda0fYP/figure1143b86a1fd34357bbc704aa138fffe7_0_3.png) Note: All recommendations are category 2A unless otherwise indicated.

National NCCN Guidelines Version 1.2026 Comprehensive Palliative Care

NCCN Guidelines Index Table of Contents Discussion

INTERVENTIONS${}^{n}$

●Assess NV severity and associated symptoms

●Educate patient/family/caregivers on patient's condition and treatment options

●Screen for potentially reversible causes/common etiologies:

Chemotherapy/RT-induced(See NCCN Guidelines for Antemiesis)

Acupressure

Severe constipation/fecal impaction(PAL-17)

Gastroparesis

Prokinetic agent

Bowel obstruction(PAL-20)

Central nervous system (CNS) involvement

Corticosteroids

Palliative RT

Gastrointestinal (GI) obstruction from intra-abdominal tumor or liver metastasis

Consider treatment with corticosteroids, a proton pump inhibitor, and metoclopramideq

Endoscopic stenting

Decompressing gastrostomy tube (G-tube)

Consider interventional procedures

Gastritis/gastroesophageal reflux disease(GERD)

Proton pump inhibitor

$\diamond$ H2-blocker

●Treat other causes/symptoms(eg, dehydration, uremia,hypercalcemia)

NAUSEA AND VOMITING

●Medication/substance-induced

Review medication list, including non-prescribed supplements and herbs, and discontinue any unnecessary medications

Review use of cannabis for possible cannabis-associated hyperemesis syndrome and counsel regarding cessation if indicated

Check blood levels of relevant medications(eg, digoxin,phenytoin, carbamazepine, tricyclic antidepressants)[TCAs]

Treat medication-induced gastropathy(eg, proton pump inhibitor, prokinetic agent)

Consider rotating and/or reducing opioid requirement with non-nauseating coanalgesics or procedural interventions

●Psychogenic

Consider psychiatric consultation if patient has an eating disorder, somatization, phobia, or panic disorder causing NV(See NCCN Guidelines for Distress Management)

•Non-specific NV

Initiate pharmacologic management with dopamine receptor antagonists or 5-HT3 receptor antagonists

If anxiety (or anticipatory nausea) contributes to NV,consider adding benzodiazepine

If vertiginous component, consider anticholinergic/antihistamine

●Consider nonpharmacologic therapies and integrative therapies(eg,acupuncture, hypnosis, cognitive behavioral therapy)

●If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities

If NV stops:see Reassessment (PAL-16)If NV stops:see Reassessment (PAL-16)

n See Palliative Care Drug Appendix(PAL-A) for specific recommendations for medical management of symptoms.

9Do not give metoclopramide in patients with complete gastric outlet obstruction.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

PERSISTENT NAUSEA AND VOMITING

INTERVENTIONSn,r,s

●Titrate dopamine antagonist to maximum benefit and tolerance

●For continued NV, consider additional drug classes with potential antiemetic properties: See Drug Appendix(PAL-A)

Corticosteroid

5-HT3 antagonist

Antipsychotic

Anticholinergic

Antihistamine

● Oral cannabinoid

●Consider appropriate route and frequency of administration

Provide PRN (as needed) and scheduled dosing;consider altering timing of agents to optimize NV control

Prescribe oral, sublingual, or rectal agent and titrate to maximum benefit

If NV persists, provide PRN (as needed), consider subcutaneous or parenteral infusion

●Opioid rotation when opioid may be causing or exacerbating NV

REASESSMENT

![\nOutcomes:\n\nDequate symptom management\nReduction of patient/family/caregiver distress\n\nAcceptable sense of control\n● Decreased caregiver burden\n● Optimized quality of life\nOngoing reassess\nContinue to treat and monitor symptoms and quality of life\nIf needs\nRe-evaluate palliative care interventions and intensify as possible\n● Consult or refer to specialized palliative care services or hospice\n\nIf nceeds\n● Re-evaluate palliative care interventions and intensify as possible\n\n\n● Consult or refer to specialized palliative care services or hospice\n\nIn stage or persisting what for you? \nPooi rotation when opioid may be causing or exacerbating NV\n\nneedsing\n\nRe-evaluate all palliative care services or hospice\n\nNo\nIonging has a three-nterstest \nInventories, interventions for online\nneedsing\n\nRe-evaluate all palliative care services or hospice\n](2/aj0YEe4oUhYkBdfpda0fYP/figure8c7e31b7914f4dabbcbbf2bd8a9c8310_0_20.png) NCCN 授权脉医通提供NCCN指南全文下载。wmsyy于2025/10/28,19:10在脉医通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![##############0\n·Optimize food intake\n●Optimize through my\nof physical activity as appropriate\n#####·Administer prophylactic medications\n#####·Stimulant laxative±osmotic laxative dose with goal of one non-forced bowel movement every 1-2 days\nIncrease laxative damage\n#############dows in no-forced bowel day\nIncrease Laxative damage\n############days\nIncrease Laxative movement every 1-2 days\n###########\n\nNCCN\nNational Comprehensive Version 2020\nNCCN\nComprehensive Version 2020\nPalliative Care\nCONSTYPATION\n###################################################################\n\n##########\n\n#########\n\n########\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n######\n\n######\n\n#####\n\n}\#\n#############\n\n#########\n\n########\n\n########\n\n########\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n#######\n\n######\n\n#####"\n](2/aj0YEe4oUhYkBdfpda0fYP/figure3cebd117e6d84e4ab9c115d05600b6cd_0_4.png) n See Palliative Care Drug Appendix(PAL-A) for specific recommendations for medical management of symptoms.

t Use suppository and enema with caution in patients receiving chemotherapy due to risk of cytopenia.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SCREENING AND ASSESSMENT

DIARHEA

INTERVENTIONS

●Evaluate diarrhea severity and potential causes

●Educate patient/family/caregiver on condition and treatment options

Determine Diarrhea Severity/Gradeu

●Mild/Grade 1: Increase of<4 stools/day over baseline; mild increase in ostomy output

●Moderate/Grade 2: Increase of 4-6 stools/day over baseline; moderate increase in ostomy output

●Severe/Grade 3: Increase of>7 stools/day over baseline; incontinence;hospitalization indicated; severe increase in ostomy output; limiting self-care;interferences with activities of daily living(ADL)x

●Severe/Grade 4: Life-threatening consequences; urgent intervention indicated ${ }^{U}^{U}$

![● Tailor treatment to potential causes If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities\nGraft-versus-host disease (GVHD) and/or\nimmunotherapy-related colitis\nChemotherapy regimen\nRadiation-induced enteritis or other RT side\neffects\nInfection\n $\diamond$ Screen for Clostridioides difficile, human\nimmunodeficiency virus (HIV), and other\ncomorbid infections(ie, ova/parasites)\nDrugs that frequently induce diarrhea\nDietary changes\nPost-surgical/atomic changes (ie, short\nbowel syndrome)\nPrancreatic insufficiency in pancreatic cancer\nIrritable bowel syndrome (IBS)/Crohn's\ndisease\n● Recent antibiotic use\n● If fecal impaction is suspected, see PAL-17\nindicated by grade\n● If chemotherapy induced, decrease or delay\nthe next dose of chemotherapy\n● Consider endoscopy if diagnostic uncertainty\n](2/aj0YEe4oUhYkBdfpda0fYP/figure650c4e6cfe6b4935ac8243bb53a43876_0_14.png) National Cancer Institute's Common Terminology Criteria for Adverse Events: Diarrhea.

vEuvolemic and no electrolyte abnormalities.

W Hypovolemia plus/minus electrolyte abnormalities.

× Severe hypovolemia and/or electrolyte abnormalities.

Note: All recommendations are category 2A unless otherwise indicated.

![NCCN\n](2/aj0YEe4oUhYkBdfpda0fYP/figurece235fda96fd44418acc22d0e0a8ed86_0_1.png) National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

|ASSESSMENT|ASSESSMENT|INTERVENTION| |---|---|---| |Any Grade||● Treat underlying cause as appropriate ● If chemotherapy induced, decrease or delay the next dose of chemotherapy ● If immunotherapy-induced diarrhea, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities ● For GVHD diarrhea, consider limiting diet, steroids, and IV nutrition ● Provide oral hydration and electrolyte replacement ● Provide IV fluids and hydration if patient is unable to tolerate oral fluids| |Mild/Grade 1||● Consider antidiarrheal agents (eg, loperamide) and/or dietary changes if infection ruled out ● If IBS-related, utilize cognitive behavioral interventions complementary to medication interventions| |Moderate/Grade 2||● Provide IV fluids if patient is unable to tolerate oral fluids ● Initiate/continue antidiarrheal agents-as above if infection ruled out ● Consider anticholinergic agents ● If non-C. diff infection-related, treat with appropriate antibiotics ● If C. diff infection-related, administer antibiotics and probiotics as appropriate| |Severe/Grades 3/4||• Inpatient hospitalization (intensive care for Grade 4) if consistent with goals ● Provide IV fluids and use antidiarrheal agents and anticholinergics ● Consider somatostatin analog|

n See Palliative Care Drug Appendix (PAL-A) for specific recommendations for medical management of symptoms.

Note: All recommendations are category 2A unless otherwise indicated.

NCCN

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

MALIGNANT BOWEL OBSTRUCTIONY

![ESTIMATED LIFE EXPECTANCY\nASSESSMENT\n● Evaluate severity and cause(s) of malignant bowel obstruction\n● Educate patient/family/caregivers on patient's condition and treatment options\n● Screen for and treat underlying potentially reversible causes\n Adhesions\n Radiation-induced strictures\n● Surgical and strictures\n● Internal hernias\n● Assess for malignant causes\n● Tumor mass\n● Carcinomatosis\n● Consider patient goals, prognosis(including life span post procedure), and relative invasiveness of proposed intervention\n● Consider medical management is got for treatment to guide choice(s) of intervention2(eg, decrease in intervention3)\n\nProcedural Interventions(PAL-21)\n](2/aj0YEe4oUhYkBdfpda0fYP/figuread7d624351c8445aa4f634e477c82ced_0_6.png) ![Weeks to months\n● Consider medical management rather than surgical management\n●Assess patient's goals for treatment to guide choice of intervention\n●Intravenous or subcutaneous fluids\n●Enteral tube drainage\n●Consider only if other measures\n●fail to reduce vomiting\n●Endoscopic management\n●Endoscopic management\n●PAL-21\n](2/aj0YEe4oUhYkBdfpda0fYP/figure297e3d09edb74e8bafee2e0bba0d74d2_0_7.png) yPlain film radiography may be helpful in confirming the clinical diagnosis of bowel obstruction. Consider a CT scan if surgical intervention is contemplated, as it is more sensitive and may help identify the cause of obstruction.

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

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

MALIGNANT BOWEL OBSTRUCTION

PROCEDURAL INTERVENTIONS

REASSESSMENT

•Operative management (eg, resection, bypass, diverting ostomy)

Discuss treatment options with patient/family/caregiver

◆Risk of mortality, morbidity, and re-obstruction

◇Overall prognosis

◇ Invasiveness of the proposed intervention

Risk factors for poor surgical outcome include ascites,carcinomatosis, palpable intra-abdominal masses, multifocal bowel obstructions, previous abdominal radiation, very advanced disease,and poor overall clinical status

●Endoscopic management (eg, G-tube for drainage, endoscopic stent placement)

●Interventional radiology management

●Pharmacologic management when the goal is maintaining gut function:

Use rectal, transdermal, subcutaneous, or intravenous routes of administration

○ Opioids

Antiemetics: Do not use antiemetics that increase Gl motility such as metoclopramide; however, these may be beneficial in incomplete bowel obstruction.

Corticosteroids

•Pharmacologic management when gut function cannot be maintained:

▶Administer antisecretory agents

▶Administer intravenous or subcutaneous fluids

●Nasogastric or gastric tube drainage

●Consider bowel rest as appropriate

•Total parenteral nutrition(TPN)

In patients with a life expectancy of months to years, consider in limited cases when aligned with patient-specific goals for maintaining quality of life and after consideration of the risks and benefits

●Outcomes:

●Adequate symptom management

● Reduction of patient/family/caregiver distress

● Decreased caregiver burden

Continue to treat and monitor symptoms and quality of life

If ongoing needs

ongoing needs

●Consult or refer to specialized palliative care services or hospice

• Consider referral to GI specialist

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SLEEP/WAKE DISTURBANCES INCLUDING INSUDING INSOMNIA AND SEDATION

|ESTIMATED LIFE EXPECTANCY|ASSESSMENT AND INTERVENTIONS●Assess patient's desire to have insomnia and sedation treated and provide cognitive behavioral interventions ●Ueducate patient/family/caregivers on patient's condition and treatment options ●Evaluate type/severity of sleep-wake disturbance, including daytime impairments and co-sleeper observations ●Explore worries and anxiety regarding cancer-related stressors ●Provide sleep hygiene education ●Refer to cognitive behavioral therapy for insomnia (CBT-I)aa,bb Sleep restriction and stimulus control ●Assess for and treat contributing factors ●Pain,depression,anxiety,delirium,and nausea ●Medication side effects or withdrawal syndromes ●(eg,corticosteroids,opioids,anticonvulsants,caffeine, hormones, herbals,barbiturates, benzodiazepines, alcohol, TCAs) ●Primary sleep disorders such as obstructive sleep apnea,restless legs syndrome, and periodic limb movement disorder ●Continuous positive airway pressure (CPAP)/Bilevel positive airway pressure (BiPAP) ●Obtain sleep study (if prognosis allows) ●Consider addition of pharmacologic therapies for refractory|Outcomes●Adequate management of symptoms ●Reduction of patient/family/caregiver distress ●Re-evaluate contributing etiologies ●Change insomnia or antisedation therapy ●Re-evaluate palliative care interventions and is possible ●Consult or refer to specialized palliative care services or hospice| |---|---|---| |(dying patient)|sleep/wake disturbance ●Insomnia: ●Antipsychotics ●Sedative/hypnotics ●Antidepressants ●Daytime sedation: ●CNS stimulant/wakefulness-promoting agents ●Consider consult to physiatrist for tailored exercise therapy program|※es could give distress on the problem. ●Relangeessment ●Re-evaluate contributing etiologies ●Change insomnia or antisedation therapy ●Re-evaluate palliative care interventions and is possible ●Consult or refer to specialized palliative care services or hospice|

n See Palliative Care Drug Appendix (PAL-A) for specific recommendations for medical management of symptoms.

aa Edinger J,et al.J Clin Sleep Med 2021;17:255-262.

bb CBT-I is preferred over pharmacologic interventions as first-line therapy.

NCCN Guidelines Index Table of Contents Discussion

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

![####ESTIMATED LIFE EXPECTANCY ASSESSMENT\n●Evaluate delirium severity and cause(eg, DSM criteriacc)See also NCCN Guidelines for Distress Management and NCCN Guidelines for Older Adult Oncology Hyperactive Hypoactive ·Ueducate patient/family/ caregivers; provide变异 patient's conditions and treatment options ·Screen for and treat underlying reversible causes, such as ·Metabolic causes ·Dehydration + deposits or failure is disrupting year\n●Unrelieved pain\n●Hypoxia - Brain metastases (consider palliative RT) or other CNS events ·Urinary retention .Medication or substance effect or withdrawal (eg, benzodiazepines, opioids, anticholinergics, non-prescribed substances)\n●Reduce or eliminate delirium-OR\n●Supercive distress\n●Decreased caregiver burden\n●Outcomes:●Adequate symptom management to treat and monitor symptoms ●Reduction of patient/family/ caregiver distress ● Decreased caregiver burden\n●Adequate symptom management\n●Reduction of patient/family/ caregiver distress\n●Reduction of healthy of life\nWeeks to months\n2033\n●Undering months\n●Infection\n●Consider opinion dose 截opic dose reduction or rotation bedside \n●Encourage supportive caregiver presence at bedside for withdrawal (eg, basedide caregivers\n●Support caregivers\n●Support medications as possible moderate interventions .●Orient patient with family/ interventions ●Cargiver nonpharmacologic interventions\nDays to weeks (dying patient) \nInterventions (PAL-24)\nNote:All recommendations are category 2A unless otherwise indicated.\n](2/aj0YEe4oUhYkBdfpda0fYP/figurebf92566caa68417bbdb858b4d70d6c7d_0_4.png) NCCN 授权医脉通提供NCCN指南全文下载。wmIsyy于2025/10/28,19:10在医脉通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS\nYears\nInterventions\n● Educate family and caregiver(s) about delirium and how to support patient\n● Maximize nonpharmacologic interventions (optimize sleep-wake cycle; address sensory impairment; provide unnecessary medications, tubes, etc.\n● Review treatment plan and discontinue unnecessary medications, tubes, etc.\n● Decrease doses of medications dependent upon hepatic or renal function\n● Consider that under- or overtreatment of pain may exacerbate delirium\n● Examine for fecal impaction, urinary tract infection (UTI), or distended bladder as potential causes of delirium\n● Examine for fecal impaction, urinary tract infection (UTI), or distended bladder as potential causes of delirium\n● Reg-evaluate palliative care interventions\n● Outcomes: ● Adequate symptom management\n● Reduction of patient/family/ caregiver distress\n● Reduction to treat and monitor caregivers and dilutive quality of life\n● Outcomes: ● Adequate symptom management\n● Re-evaluate palliative care interventions\n● Consultages: ● Under to treat and symptom/family/ caregiver distress\n● Reduction of patient/family/ caregiver distress\n● Consultages: ● To treat and symptoms and quality of life\n\n● Consultages: ● Consult with specialty care team\n● Consult with specialty care team\n● Consider proportional sedation (PAL-33)\n](2/aj0YEe4oUhYkBdfpda0fYP/figure12890057cba7482ea090c7cf45471ba2_0_4.png) ⅡSee Palliative Care Drug Appendix(PAL-A) for specific recommendations for medical management of symptoms.

dd Consider patient's family/caregiver as defined on PAL-1.

NCCN

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS\nTESTAM\nINTERVENTIONS\nREASSESSMENT\nYears\nAssess wound comprehensively\nEducative symptom atpatient's conditions and risk/benefit of treatment options\nTreat if potentially reversible: Surgical debridement; consideration of skin grafting\nRadiation/chemotherapy/hormonal therapy\nWound cleansing and irrigation\nDressing changes\nWeeks to months\nYear\nYears\n�着要济ment\nProting infection\nOptimize nutrition and mobilization\nReduce or prevent odor from wounds\nor exudates\nrent wound spread-keep patient dry and clean; position to avoid pressure on bony prominences; avoid shearing force on fragile skin when repositioning\n\nResolve symptoms: Odor: wound cleansing and debridement; topical antibiotic gel; activated charcoal or silver sulfadiazine dressings; external odor absorbers. Avoid strong "cover" odors.\nInfection: topical or systemic antibiotics; irradiated honey applications\nExudate: absorbent alginate, foam dressings; drainage stoma appliance if high volume\nBleeding: hemostatic dressings (alginate, collagen, non-adherent gauze, gelfoams, suscalfate paste; oral antifibrinolytics;consider radiotherapy or embolization if brisk bleeding; dark-colored linens, anxiolytics, and pain management)\nPurritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\nProportions: Not aume: maintain symmetry in dressings; manage wound odor and exudate; screen for depression; anxiety; address intimacy concerns\nPAL-2507/2025\n10/27/2025© 2025 National Comprehensive Cancer Network®(NCCN),All rights reserved. NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN\nDying: treat according to NCCN Guidelines for Adult Cancer Pain; see PAL-8 and PAL-10; use non-absorbent dressing or reduce frequency if associated with dressing changes; topical opioid and/or local anesthetic; complementary therapies\nPruritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#onging needs\nIf needs\nContinue to treat and continue to lead to medical injury and disease and surgery\n#8. Re-evaluate palliative care interventions and intensify as possible\n#9. Consult or refer to specialized palliative care services or hospice\n● Consult or refer to specialized paliative care services or hospice\n\nDays to weeks to fit the topical osterical gauge, foam dressings; drainage stoma appliance if high volume\nBleeding: hemostatic dressings (alginate, collagen, non-adherent gauze, gelfoams, suscalfate paste; oral antifibrinolytics;consider radiotherapy or embolization if brisk bleeding; dark-colored linens, anxiolytics, and pain management)\nPain: treat according to NCCN Guidelines for Adult Cancer Pain; see PAL-8 and PAL-10; use non-absorbent dressing or reduce frequency if associated with dressing changes; topical opioid and/or local anesthetic; complementary therapies\nPruritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8. Overall we have a positive effect, long-term alcohol mice\nPuritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial\n#8.851/2025/2025\n#8.506/2025\n3010/2025/2025\n1000/2025/2025/2025\n3010/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/\n](2/aj0YEe4oUhYkBdfpda0fYP/figurea1fd35960e4e4f058c42980766e49b56_0_5.png) NCCN授权脉医通提供NCCN指南全文下载。wmsyy于2025/10/28,19:10在脉医通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

![NCCN\nNational Comprehensive Cancer Network®\n](2/aj0YEe4oUhYkBdfpda0fYP/figure0f7d79d934cd43e682ecb677cc09867b_0_1.png)

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SOCIAL SUPPORT/RESOURCE MANAGEMENT

![ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS\n●Assess:\nCoping and adjustment to illness by patient/family/caregivers Caregiver(s) availability\nSafe home environment\nAdequate access to transportation\nSufficient financial resources\nAssess for substance use disorder\n(See NCCN Guidelines for Adult Cancer Pain)\nCulture-specific needs\nAssess complexities related to social determinants of healthm\nObtain medical interpreters/translators as needed who are not related to the patient\n●Obtain medical interpreters/translators as needed who are not related to the patient\n●Mobilize family and community financial resources\nEnsure support and education to caregiver(s) and family members\n●Ensure support and education to child life services\nArt and music therapy, if available\nFor and music therapy, if available\npropositioning\nPhysical medicine and rehabilitation training for transfers and repositioning\nPsychosocial, spiritual support\n●Respond to caregiver-specific burdens and stresses\n●Periodically assess and monitor family/ caregiver for risk factors associated with complicated grief\n●Consider repsite care for families and caregivers (dying patients)\nInterventions(PAL-27)\nWeeks (dying patient)\n](2/aj0YEe4oUhYkBdfpda0fYP/figure7d5622f0b43c459d8242659b98febaed_0_5.png) m Refer to the NCCN Distress Thermometer and Problem List, which includes social determinants of health. See NCCN Guidelines for Distress Management (DIS-A)

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

ESTIMATED COSIAL SUPPORT/RESOURCE MANAGEMENT LIFE EXPECTANCY REASSESSMENT

![Years\nInterventions (PAL-26)\nDays to weeks (dying days for patient)'\nWeeks (years\n10\n0\nor\n20\n\nInterventions\nPalliative Care\nNCCN Guidelines Version 1.2026\nNCCN Guidelines 1.026\nPongoing 2\nOngoing modelling 1\nFli needs\nLingong ongoing 3\nOlying long ongoing 3\nRe-evaluation and 1\npatient/family/caregiver between the patient and health care team\n- Acceptable sense of control Personal growth and enhanced meaning\nI\ngoining 3\nLingong ongoing 3\nRe-evaluate palliative care interventions and intensify as possible\n- Consult and 1\nConstructions (PAL-26)\nOngoing possible\nLingong ongoing 3\nOngoing care services, hospitals (or ethics committee\n burden\n● Reduction of patient/family/caregiver communication distress\n● Acceptable sense of control\n● Personal growth and enhanced meaning\n\nIf\n\nneeds\n$Ongoing\nInversion\nLingong ongoing 3\nRe-evaluate all potential care and 3\nlonging ongoing 3\nOngoing possible\nhospice, or ethics committee\nInd秀ing\nNCCN Guidelines for 3\nConsider referral to social worker, psychologist, and/or psychiatrist\n● See NCCN Guidelines for Distress Management\n](2/aj0YEe4oUhYkBdfpda0fYP/figurec50482a58d1a44bb950c639a3c86741e_0_5.png) NCCN 授权医脉通提供NCCN指南全文下载。wmIsyy于2025/10/28,19:10在医脉通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

PREPARING PATIENTS/FAMILIES/CAREGIVERS FOR END OF LIFE AND TRANSITION TO HOSPICE CARE

![ESTIMATED LIFE EXPECTANCY\nASSESSMENT/INTERVENTIONS\nOutcomes:● Reduction of patient/family/caregiver distress\n●Reduction of patient/family/caregiver distress\n●Acceptable sense of control\nfamily/caregiver about prognosis and anticipated care\n●Increaseded family and caregiver resilience\nStromstened\nSSESSMENT/INTERVENTIONS\nPalliative decision maker\nYears\n●Assess for decision-making capacity and need for a surrogate decision maker\n●If ongoing needs: Re-evaluate palliative care interventions and intensify as possible\n●Introduce,educate,and assess need for specialized palliative care/or eligibility and readiness for hospice care\n●Induceate patient/family/caregiver on dying process\n●Address potential need for transitions in care while ensuring continued involvement of primary care physician and primary oncology team\nWeeks to months\n●Refer to hospice care agencies\n●Provide information and additional referrals, as necessary, for:\n●Psychosocial assessment\n●Legacy work\n●Grief counseling\nwelsys\nSpiritual screening\n◆Spiritual support if needed\n◆Funeral/memorial service planning\n●Respect goals and needs of the patient/family/ caregiver regarding the dying process\n●Inform other involved health care professionals of the patient's death\n●Inform other involved health care professionals of\n●Inform other involved health care professionals of\n\n](2/aj0YEe4oUhYkBdfpda0fYP/figureb60ad3f35adb4d6eb76460dbd4fc2480_0_5.png) NCCN授权脉医通提供NCCN指南全文下载。wmIsyy于2025/10/28,19:10在医脉通平台下载，仅供个人使用，严禁分发。2025美国国家综合癌症网络版权所有。

NCCN

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![# 2 ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS\nAssess decision-making capacity and identify surrogate decision maker if necessary\n● Ask if patient has completed any advance care planning documents (eg, a living will, medical power of attorney, health care proxy, patient surrogate for health care)\n#\nFor not, encourage patient to prepare one refer to social worker\n● Explore hopes, worries, and fears about the future\nInitiate discussion of personal values and preferences\n● Make recommendation about future care if patient values and goals lead to a clear recommendation regarding future treatment\nDocumenting values (eg, a living will, medical power of attorney, health care proxy, patient surrogate for health care)\n● Approximate advance care planning documentation \n● Adequate advance care planning documentation \n● Reduction of patient/family/\n● Paying customer distress\n● Acceptable sense of control \n● Decreased caregiver burden \n● Optimized quality of life\nOutcomes:\Odequate advance care planning \n● Acceptable sense of control \n● Decreased caregiver burden \n● Optimized quality of life\nOngoing reassessment Ongoing\n](2/aj0YEe4oUhYkBdfpda0fYP/figure8b696f859d0c49b9917df775e9d804f8_0_5.png) ee Patient's values and preferences and any decisions should be documented in the medical record, including MOLST/POLST.

Note: All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

![ESTIMATED LIFE EXPECTANCY\nINTERVENTIONS\nYears\nInterventions (PAL-29)\nMonths\n● Address months-to-years interventions (PAL-29)\n● Determine patient/family/caregiver preferences for the location of the patient's death\n● Confirm the patient's values and decisions in light of changes in status\n● Avoidance of goal-inconsistent interventions\nall�\nDays to be months\n●Acceptable sense of control\n●Decreased caregiver burden\n● Optimized quality of life\n● Explore patient reluctance cable to engage in advance care plan\n● Avoidance of goal-inconsistent interventions\n● Exploreing also the following decision's values\n●Acceptable sense of control\n● Decreased caregiver burden\n●Optimized quality of life\n● Explore patient reluctance)\nWeeks (dying patient)\n● Explore destination for personal and/or autopsy\n● Educate patient/family/caregiver on benefits and limitation of CPR\n● Document resuscitation orders per patient/family/caregiver in the medical record, including MOLST/POLSTee\n● Optimized quality of life\n● Explore patient reluctance)\n● Acknowledge of goal-inconsistent interventions\n● Avoidance of goal-inconsistent interventions\n● Explore more for organ donation and/or autopsy\n● Educate patient/family/caregiver on benefits and limitations of CPR\n● Document resuscitation orders per patient/family/caregiver in the medical record, including MOLST/POLSTE\n● Optized quality of life\n● Explore patient reluctance)\n](2/aj0YEe4oUhYkBdfpda0fYP/figure8eeee8c15c2a4b769d235b977d8e0f4b_0_4.png) ee Patient's values and preferences and any decisions should be documented in the medical record, including MOLST/POLST.

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

Note: All recommendations are category 2A unless otherwise indicated.

PAL-31

RESPONSE TO REQUESTS FOR HASTENED DEATH

• 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 ensure palliative care needs are being met. Patients making such a request may be referred to specialty palliative care team. However, evaluating a patient's request for hastened death is an important skill, even for clinicians who feel 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.

• Explore the reasons for the request for a hastened death, and find out "why now” in a joint discussion with the patient, family, and

caregivers.

Reassess concerns and/or symptom management.

Assess patient concerns regarding symptoms.

Reassess psychological/psychiatric issues, especially depression, anxiety, grief, psychosis, delirium, and dementia.

Ask about the patient's relationship to family or other important people.

Ask about individual values, purpose and meaning, and personal views of spiritual/existential suffering and consider spiritual care

consultation for further exploration and intervention.

Assess for worries about caregiver burden and abandonment and re-emphasize physician commitment to the patient.

• 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.ff

• Address the request explicitly. If a patient uses a euphemism for death or refers to it indirectly, ask for clarification. Do not assume that a

wish for death to come soon is a wish for a lethal prescription.

• Distinguish wishing not to live in the patient’s current state from wishing for a hastened death.

• Consider a consult with a mental health professional to evaluate and treat reversible causes of psychological suffering.

• Offer information about the natural history of the disease and explain the process of dying.

• Discuss the differences between withdrawal of life-sustaining nutrition/hydration, voluntary cessation of eating or drinking, and/or sedation for refractory symptoms.

• Address the role of medical caregivers, including hospice if appropriate.

• Examine your own response as a clinician to a particular patient's request. Requests for hastened death can force clinicians to confront their own personal, professional, moral, and legal responsibilities. Dealing with an individual patient can be quite different from thinking about the issue in abstract circumstances. Consider a consultation with an ethics committee, palliative care service, or experienced colleague. These cases are usually complex and often benefit from consideration of multiple perspectives.

• Clarify the care plan. Requests for hastened death should prompt ongoing discussion and active attempts to ameliorate physical and

psychosocial, spiritual distress. Re-emphasize your own commitment to providing continuing care for the patient.

ff Spence RA, et al. J Oncol Pract 2017;13:693-699.

NCCN

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

SHARED DECISION-MAKING IN THE CARE OF THE IMMINENTLY DYING PATIENT

For an imminently dying patient whose goals have transitioned to comfort, consider the following physical, psychosocial, existential, spiritual,and practical interventions

·Physical

Obtain hospice evaluation, if available

Intensify comfort measures

◆ Implement skin safety protocol according to risk assessment:

-Regularly reposition the patient for comfort as indicated

-Reassess and premediate for wound care as needed

-Use a pressure-relieving mattress, if available

-Provide eye and mouth care to maintain moisture

- Treat for urinary retention and fecal impaction

Ensure deactivation of implanted defibrillator

Consider deactivation of implanted pacemaker in select patients

●Discontinue unnecessary diagnostic tests and interventions such as transfusions, needle sticks, blood glucose monitoring, oxygen saturation monitoring, and suctioning

Replace check of vital signs with regular(eg, every 4 h) symptom assessments

Switch routes of medication administration when the oral route is no longer feasible

Adjust doses of medications to optimal comfort

Treat terminal secretions (death rattle):

◆ Educate patient and caregiver

Reduce parenteral and enteral fluids

$\diamond$ Reposition the patient

◆Provide gentle oropharyngeal suctioning (avoid deep suctioning)

◆Utilize nonpharmacologic interventions first before anti-secretary agents

Treat dyspnea by adjusting the dose of medication(PAL-11)

Treat delirium PAL-24. See NCCN Guidelines for Distress Management

Consider proportional sedation for refractory symptoms (PAL-33)

Be prepared to discuss a request for organ donation and autopsy

●Psychosocial, spiritual, existential

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

Consider consultation with specialty palliative care team.

Ensure that the family/caregiver understands the signs and symptoms of imminent death and that they are supported throughout the dying process

●Offer anticipatory bereavement support and assess for complicated bereavement risk

Provide support to children and grandchildren and provide education to parents on age-appropriate griaving process

Encourage visits by children if consistent with family values

Support cultural practices

Ensure that caregivers understand and will honor advance directives

Promote healthy grieving

·Practical

●Mobilize in-hospital end-of-life care policies and procedures

Ensure that the patient's advance directives are documented and implemented

Discuss and document patient/family/caregiver wishes for resuscitation.CPR is unlikely to be effective; recommend other options such as DNR/DNAR/AND orders and promote comfort care

Provide the patient/family/caregiver with respectful space and uninterrupted time together

Facilitate virtual family visits, if in-person visits are restricted or not possible

Provide information on funeral planning, if desired

Inform other involved health care professionals of patient's death

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

PROPORTIONAL SEDATION

• Proportional sedation (formerly known as palliative sedation) is the intentional lowering of awareness towards, and including,

unconsciousness for patients with severe and refractory symptoms with the primary goal of symptom relief.

• Refractory symptoms are symptoms that cannot be adequately managed despite comprehensive, interprofessional palliative care that does not compromise consciousness.

• Consider interdisciplinary discussion prior to inception of sedation and throughout the process, to support the care team (including both the caregivers and family in support of the patient, and the medical staff taking care of the patient).

• Consider periodic reassessment of symptoms to ensure level of sedation is proportional to need for symptom relief.

• Refer to institutional guidelines/policy for additional guidance.

• "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).

• The NCCN Guidelines committee has replaced the term palliative sedation with proportional sedation. The change is intended to emphasize that the level of sedation should be proportionate to the patient’s symptom burden.

Note: All recommendations are category 2A unless otherwise indicated.

PAL-33

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

DEATH

ASSESSMENT

Death

●Free from avoidable patient:

●Free from avoidable distress and suffering for the patient, family, and caregiver(s).

● In general accord with the patient's and family's wishes

· Consistent with clinical, cultural,spiritual, and standards

AFTER-DEATH INTERVENTIONS

For family and caregiver(s)

●Immediate after-death care:

>Inform family (if not present) of death

Offer condolences

Provide the family time with the body

Involve spiritual care provider to assess family's desire for religious ritual or spiritual support

Remove tubes, drains, lines, and the Foley catheter unless an autopsy is planned

Ensure culturally sensitive, respectful treatment of the body

Address survivor concerns about organ donation and/or autopsy

File the death certificate, complete forms, and provide necessary information for the funeral director and family as appropriate

$\diamond$ Notify previous medical, palliative, and psychological care teams of patient's death

● Bereavement support:

Formally express condolences on the patient's death(eg, card, call, letter)

Refer to appropriate bereavement services within the institution or in the community

Facilitate a debriefing meeting with the family if they desire one

Periodically assess and monitor family/caregiver for risk factors associated with

complicated grief

For health care professionals

● General support:

Legimize discussion of personal issues that impact patient care

Create a climate of safety for discussion of patient deaths

●Provide regular opportunities for reflection and remembering for staff through a memorial ritual

●After-death support:

Review medical issues related to the patient's death

$\diamond$ Explore concerns and questions regarding quality of patient care

▶Review the family's emotional responses to the patient's death

>Review the staff's emotional responses to the patient's death

Identify any health care professionals at risk for complicated grief, moral distress, or compassion fatigue

◇Include nurses, nursing assistants, physician team members (including medical students, residents, and fellows), social workers, and chaplaincy, as appropriate

Consider a bereavement ritual for staff(eg, brief reading, moment of quiet)

NCCN

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

PALLIATIVE CARE DRUG APPENDIX

|Condition|Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology| |---|---| |Pain (PAL-10)|●Please see NCCN Guidelines for Adult Cancer Pain(PAIN-G) for detailed information on opioid principles, prescribing, titration,maintenance,and safety.Be aware of state and local regulations regarding opioid prescriptions.| |Dyspnea (PAL-11)|Life Expectancy: Years; Months to Year; and Weeks to Months General: Opioids a lowest effective dose with titration as appropriate can be used to treat dyspnea that is resistant to other therapies. Base dosing on patient's opioid requirement. If patient's opioid requirement is unknown, start with low doses and titrate up as appropriate. ●Fluid overload: Furosemide PRN dosing as per clinical situation| |Dyspnea (PAL-12)|Life Expectancy: Days to Weeks(dying patient) ●Anxiety:Benzodiazepines (eg,Lorazepam 0.25-2 mg PO,IV,or IM every 3-6h PRN)| |Secretions (PAL-12)|●Excessive secretions: Glycopryrrolate 0.2-0.4 mg IV or SC every 4 h PRN (less sedating),Scopolamine 1.5-mg patches, 1-2 patches every 72 h OR Stropine 1% ophthalmic solution 1-2 drops SL every 2 h up to 4 h PRN (caution in asthma) OR Hyoscymine 0.125-0.25 mg PO or SL every 4 h with max dose of 1.5 mg daily| |Anorexia/ Cachexia1 (PAL-13 and PAL-14)|Life Expectancy: Years; Months to Year; and Weeks to Weeks(Dying patient) Counsel family and patients about risks (eg, thrombosis), benefits, and options for cachexia treatment (eg, stopping therapy if ineffective) ●Gastropares is early satiety): Metoclopramide 5-10 mg PO QID 30 min before meals and QHS. Low/no appetite(avoid in setting of complete bowel obstruction): Olanzapine 2.5-5 mg/day PO OR Dexamethasone 3-8 mg/day IV or PO ●Clinicians may choose not to prescribe pharmacologic intervention for cancer cachexia treatment|

a Use caution if using opioids and benzodiazepines in combination outside of end-of-life care because of the risk of respiratory depression.

1 Roeland EJ, Bohlke K, Baracos VE, et al. Management of cancer cachexia: ASCO guideline. J Clin Oncol 2020,38:2438-2453.

NCCN Guidelines Index Table of Contents Discussion

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PALLIATIVE CARE DRUG APPENDIX

|Condition|Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology| |---|---| |Nausea and Vomiting (NV)|Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Common Etiologies ● See NCCN Guidelines for Antiemesis for chemotherapy/radiation-induced NV ● Gastroparesis: Metoclopramide 5-10 mg PO QID 30 min before meals and QHS (avoid in setting of complete bowel obstruction) CNS involvement: Dexamethasone 4-8 mg BID-TID ● Gastric outlet obstructions: Dexamethasone 4-8 mg/day; proton pump inhibitor ● Gastritis/GERD: Proton pump inhibitor OR H2 blocker ● Medication-induced gastropathy: Proton pump inhibitor OR Metoclopramide 5-10 mg PO QID 30 min before meals and QHS Nonspecific NV| |NCCN|Dopamine receptor antagonists or 5-HT3 receptor antagonists O Olanzapine 2.5-5 mg PO 1-2 times daily starting QHS HALoperidol 0.5 mg TID OR Metoclopramide 5-10 mg QID 30 min before meals and QHS OR Prochlorperazine 5-10 mg 3-4 times/ day, maximum 40 mg/day OR Danstonever every 4 h every 8 h ● Contributing anxiety: Lorazepam 0.5-1 mg every 4 h PRN ● Vertiginous component: Anticholinergic AND/OR antihistamine| |Refractory Nausea and Vomiting (NV)|Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Consider appropriate route of administration 1) Prescribe PO, SL, or rectal agent and titrate to maximum benefit 2) If NV persists, provide PRN, scheduled, or continuous parenteral infusion as necessary 3) Consider SC administration as an alternative ● Titrate to maximum benefit and tolerance ● For continued NV, consider additional agents: Dexamethasone 4-8 mg/day; Ondansetron 4-8 mg PO every 6 h; Scopolamine (patch or IV); PO cannabinoid| |Constipation (PAL-17)|Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Prophylaxis: Start with stimulant laxatives (senna BID 8.6 to 17.2 mg BID or bisacodyl 5-10 mg BID-TID) to achieve a goal of one non- forced bowel movement every 1-2 days and add an osmotic laxative fit patient can tolerate the volume of liquid (polyethylene glycol daily 17 gm/8 oz water PO) ● Persistent constipation:Titrate stimulant laxatives as tolerated.Bisacodyl 10-mg suppository,one rectally daily-BID;polyethylene glycol 17 gm/8 oz water PO QID;lactulose 30 mL PO BID-QID OR 60 mL daily; magnesium hydroxide 30-60 mL PO daily-BID (avoid in renal failure); or magnesium citrate 8 oz PO daily (avoid in renal failure)| ||Resistant opioid-induced constipation:If PO therapy is not effective,try enema PRN (caution with sodium phosphate enema - avoid in renal failure) Consider Methylnaltrexone, see prescribing information for weight-based dosing;Naloxegol 12.5-25 mg daily PO; Naldemedine 0.2 mg daily PO Not for postoperative ileus and mechanical bowel obstruction|

Abbreviations Key (PAL-A 5 of 5)

NCCN Guidelines Index Table of Contents Discussion

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NCCN Guidelines Version 1.2026 Palliative Care

PALLIATIVE CARE DRUG APPENDIX

|Condition|Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology| |---|---| |Diarrhea (PAL-18)|Life Expectancy: Years; Months to Year; and Weeks to Months $$\text{ If immunotherapy-induced diarrhea, see NCCN Guidelines for Management of Immunotherapy-Relates Toxicities}$$ Grade 1 (mild) ●General: Loperamide 4 mg PO x 1 dose then 2 mg PO every 4 h or after each loose stool, up to 16 mg/day ●Consider addition of bulk-forming agents with caution in patients on opioids $$\bullet\text{Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/ day}$$ Grade 2 (moderate) ●Initiate/continue Loperamide 4 mg PO x 1 dose then 2 mg PO after each loose stool, up to 16 mg/day ●Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/day ●Consider Ayoscyamine 0.125 mg PO/ODT/SL every 4 h PRN, max: 1.5 mg/day; Atropine 0.5-1 mg SC/lV/SL every 4-6 h PRN ●.C. diff-induced: see NCCN Guidelines for Prevention and Treatment of Cancer Related Infections (FEV-8) ●Non-C. diff infection: Treat appropriately based on culture findings Grades 3/4 (severe, inpatient hospitalization with ICU for Grade 4) ●Initiate/Continue Loperamide 4 mg PO x 1 dose then 2 mg PO after each loose stool, up to 16 mg/day ●Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/ day ●Consider Hyoscyamine 0.125 mg PO/ODT/SL every 4 h PRN, max: 1.5 mg/day; atropine 0.5-1 mg SC/lV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg/day SC/IV, every 8 h or by continuous infusion SC/IV ●Interactine ongoing antidiarheal, anticholinergic agents ●Atropine 0.5-1 mg SC/IV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg SC/IV every 8 h or continuous infusion| |Diarrhea (PAL-19)|Life Expectancy: Days to Weeks (dying patient) $$\text{Reevaluate ongoing antidiarheal, anticholinergic agents}$$ ●Atropine 0.5-1 mg SC/IV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg SC/IV every 8 h or continuous infusion| |Malignant Bowel (PAL-20)|Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Reduce opioid dose or rotate opioid ●Metoclopramide 5-10 mg PO QID 30 min before meals and QHS;avoid in the setting of complete obstruction ●Dexamethasone 4-12 mg IV daily, discontinue if no improvement in 3-5 days ●Scopolamine (patch or IV); Hyoscyamine 0.125 mg PO/ODT/SL every 4 h PRN ●Octreotide 100-300 mcg SC BID-TID or 10-40 mcg/h continuous SC/IV infusion; if prognosis >8 weeks, consider long-acting release (LAR)|

Abbreviations Key (PAL-A 5 of 5)

Version 1.2026,10/27/2025© 2025 National Comprehensive Cancer Network®(NCCN®),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

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NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

PALLIATIVE CARE DRUG APPENDIX

|Condition|Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology| |---|---| |Sleep/Wake Disturbance (PAL-22)|Life Expectancy: Years; Months to Year; and Weeks to Months to Months Isolated sleep-onset insomnia ●Dual orexin receptor antagonist (DORA) ●Daridorexant 25-50 mg PO 30 min before bedtime Lemborexant 5-10 mg PO QHS ●Suvorexant 10-20 mg PO QHS ●Ramelteon 8 mg PO QHS ●Melatonin 1-5 mg PO QHS ●Benzodiazepine receptor agonist(BZRA) (caution in patients who are older or frail) Zolpidem 5-10 mg PO QHS for immediate-release tablet, 6.25-12.5 mg PO QHS for extended-release tablet Eszopiclone 1-3 mg PO QHS ●Zaleplon 10-20 mg PO QHS Sleep maintenance ●DORA (see above) ●Doxepin 3-6 mg PO QHS (caution in patients who are older or frail) Additional agents for insomnia ●Sedating antidepressants ●Mirtazapine 7.5-30 mg PO QHS (better tolerated in patients who are older or frail) ●Trazodone 25-100 mg PO QHS TCAs such as Amitriptyline or nortriptyline (caution in patients who are older or frail) ●Sedating antipsychotics (monitor for extrapyramidal symptoms [EPS]) Olanzapine 2.5-5 mg PO QHS ●Quetiapine 12.5-25 mg PO QHS ●Benzodiazepines Lorazepam 0.5-1 mg PO QHS (caution in patients who are older or frail) ●Medical cannabis ●Oral form preferred in 2:1 or 1:1 ratios (caution in patients who are older or frail) ●Daytime sedation ●Caffeine 100-200 mg PO every 6 h, last dose 4 PM ●Methylphenidate 2.5-20 mg PO BID, second dose no later than 6 h before bedtime ●Dextroamphetamine 2.5-10 mg PO BID, second dose no later than 12 h before bedtime ●Modafinil 100-400 mg PO each morning ●Dextroamphetamine and Amphetamine: 10-60 mg per day in 1 to 3 divided dose|

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NCCN Guidelines Index Table of Contents Discussion

PALLIATIVE CARE DRUG APPENDIX

|Condition|Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology| |---|---| |Sleep/Wake Disturbance (cont.) (PAL-22)|Restless legs syndrome (RLS)$b $? ● Intermittent symptoms ● Carbidopa-levodopa 25/100 mg PO QHS PRN ● Chronic symptoms Rropinrole 0.25 mg PO 1-3 h before bedtime Pramipexole starting dose 0.125 mg PO QHS, 2-3 h before bedtime, may require titration Pregabapin 50-450 mg PO 1-3 h before bedtime Gabapentin 100-2400 mg PO in divided doses 2 h prior to bedtime. If divided dose: One-third of total daily dose given midday, remaining two-thirds of the total daily dose given in the evening| |Sleep/Wake Disturbance (PAL-22)|Life expectancy: Days to Weeks (dying patient) ● Titrate dose of existing pharmacotherapy| |Delirium (PAL-23)|Life Expectancy: Years; Months to Year; and Weeks to Months ● Maximize nonpharmacologic strategies for all patients with delirium and those at high risk for delirium Severe Delirium (agitation) $b, c, d $ ● Consider adding lorazepam 0.5-2 mg SC/IV every 4 h PRN with or without haloperidol if agitation is severe or either disrupting care or causing the patient distress ● Haloperidol 0.5-2 mg SC/IV every 1-4 h PRN ● Haloperidol 0.5-2 mg SC/IV every 1-4 h PRN ●Alternatives: Olanzapine 2.5-7.5 mg PO/SL every 2-4 h PRN (maximum = 30 mg/d); Chlorpromazine 25-100 mg PO/PR/IV every 4 h PRN for patients who are bedbound. For direct IV injection, administer diluted solution slow IV at a rate not to exceed 1 mg/minute. To reduce the risk of hypotension, patients receiving IV chlorpromazine must remain lying down during and for 30 minutes after the injection. ● Titrate starting dose to optimal effect with lowest possible dose.|

Abbreviations Key

Timing: BID(twice a day);d(day);h(hour);QHS(at bedtime);PRN(as needed);QID(four times per day);QOD(every other day);TID(three times per day)

Route of administration: IM (intramuscular); IV (intravenous); ODT (orally disintegrating tablet); PO (oral); PR (rectal); SC (subcutaneous);

SL(sublingual)

b Avoid these agents(ie, ropinirole, pramipexole) when dopamine antagonists(eg, haloperidol, olanzapine, quetiapine) are being utilized.

c Sedation may be a side effect of treatment. Ensure treatment plan is consistent with goals and prognosis.

d Evidence is conflicted and limited.

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NCCN Guidelines Index Table of Contents Discussion

Discussion

ABBREVIATIONS

ADL activities of daily living

AND allow natural death

BiPAP bilevel positive airway pressure

BZRA benzodiazepine receptor agonist

CNS central nervous system

CPAP continuous positive airway pressure

CPR cardiopulmonary resuscitation

DNAR do not attempt resuscitation

DNR do not resuscitate

DORA dual orexin receptor antagonist

DSM Diagnostic and Statistical Manual of Mental Disorders

ECOG Eastern Cooperative Oncology Group

EPS extrapyramidal symptoms

GERD gastroesophageal reflux disease

GI gastrointestinal

G-tube gastroostomy tube

GVHD graft-versus-host disease

HIV human immunodeficiency virus

IBS irritable bowel syndrome

ICU intensive care unit

KPS Karnofsky Performance Status

long-acting release

MAID medical aid in dying

MOLST Medical Orders for Life-Sustaining Treatment

Sustaining Treatment

NV nausea and vomiting

PAMORA peripheral acting mu-opioid receptor antagonist

POLST Physician Orders for Life-Sustaining Treatment

PRN as needed

RLS restless legs syndrome

TCA tricyclic antidepressant

TPN total parenteral nutrition

UTI urinary tract infection

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

NCCN Guidelines Index Table of Contents Discussion

|NCCN Categories of Evidence and Consensus|| |---|---| |Category 1|Based upon high-level evidence (≥1 randomized phase 3 trials or high-quality, robust meta-analyses), there is uniform NCCN consensus (≥85% support of the Panel) that the intervention is appropriate.| |Category 2A|Based upon lower-level evidence, there is uniform NCCN consensus (≥85% support of the Panel) that the intervention is appropriate.| |Category 2B|Based upon lower-level evidence, there is NCCN consensus (≥50%, but <85% support of the Panel) that the intervention is appropriate.| |Category 3|Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.|

All recommendations are category 2A unless otherwise indicated.

National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

Discussion

This discussion corresponds to the NCCN Guidelines for Palliative Care. Last updated: March 31, 2025.

||Overview|.2| |---|---|---| ||Guidelines Update Methodology|.2| ||Literature Search Criteria|.2| ||Sensitive/Inclusive Language Usage|.3|

Literature Search Criteria $\longdots$ 2

Sensitive/Inclusive Language Usage.3

Palliative Care in Oncology $\longdots$

Summary of Specialty Palliative Care$\longdots$5

Models and Methods for Early Integration of Palliative Care$\longdots$5

End-of-Life Care.6

Role of Hospice Care

Training in Palliative Care

Communication and Advance Care Planning in Palliative Care.$\longdots$

Communication Skills 0

NCCN Guidelines for Palliative Care

Assessment of Palliative Care Care Need $\ldots$ 10

Comprehensive Assessment..10

Palliative Care Interventions $\ldots$ 13

Cancer Therapy and Shared Decision-Making Considerations $\ldots$ 14

Advance Care Planning $\ldots$ 15

Symptom Management$\longdots$16

Pain $\ldots$ 17

Dyspnea $\ldots$ 17

Anorexia/Cachexia $\ldots$ 19

Nausea and Vomiting.20

Constipation $\ldots$ 21

Diarrhea $\ldots $ $\22

Malignant Bowel Obstruction..23

Sleep/Wake Disturbances Including Insomnia and Sedation..24

Delirium\longdots25

Malignant Wounds ..26

Social Support/Resource Management $\ldots$ 27

Palliative Care Reassessment.27

End-of-Life Care Issues $\ldots$ 28

Preparing Patients/Families/Caregivers for End-of-Life and Transition to Hospice Care

Response to Requests for Hastened Death $\longdots$

Shared Decision-Making in the Care of the Imminently Dying Hospitalized Patient...29

Proportional Sedation $\ldots$ 30

After-Death Care Interventions $\ldots$ 30

Putting Palliative Care Guidelines into Practice.31

Psychosocial-Spiritual Support for Oncology and Palliative Care Providers $\ldots$ .32

Conclusion $\ldots$ 33

Table 1: Palliative Care Internet Resources for Clinicians ${}^{a}$ $\longdots$

References..35

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National Comprehensive Cancer Network®

NCCN Guidelines Version 1.2026 Palliative Care

Overview

The aim of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Palliative Care is to help ensure that each patient with cancer experiences the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team. The NCCN Palliative Care Panel is an interprofessional group of representatives from NCCN Member Institutions consisting of medical oncologists, hematologists and hematologic oncologists, radiation oncologists, pediatric oncologists, neurologists and neurooncologists,psychiatrists and psychologists, internists, palliative care and pain management specialists, and geriatric medicine specialists. These Guidelines were developed and are updated annually by the collaborative efforts of these experts after institutional review based on their clinical experience and available scientific evidence.

More than 2 million people are expected to be diagnosed with cancer in the United States in 2025, and 618,120 people are expected to die of the disease.1 Global cancer rates are increasing, with an associated rise in the number of cancer survivors living with symptoms and disabilities as a result of their disease and/or its treatment (see the NCCN Guidelines for Survivorship [available at www.NCCN.org]).2.4 More than one-third of patients with cancer in a large observational cohort study reported moderate to severe symptoms in the majority of categories (pain, nausea,anxiety, depression, shortness of breath, drowsiness, well-being, loss of appetite, and tiredness) in the last weeks of life.5 Integration of palliative care with disease-directed care may help to address the challenges faced by oncology patients and their families.

The Center to Advance Palliative Care(CAPC;

https://www.capc.org/about/palliative-care) describes an optimal approach in which care is “provided by a specially-trained team of doctors, nurses,social workers, chaplains, and other specialists who work together with a

patient's other doctors to provide an extra layer of support. Palliative care is based on the needs of the patient, not on the patient's prognosis. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment."6 During the past 20 years,increasing attention has been paid to quality-of life issues in oncology throughout the disease trajectory.3,7-12 Palliative care in oncology began as hospice and end-of-life care, but it has developed into an integral part of comprehensive cancer care with the goal of early intervention to improve patient outcomes.

The NCCN Panel defines palliative care as an approach to patient/family/caregiver-centered health care that focuses on optimal management of distressing symptoms, while incorporating 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 only becomes the main focus of care when disease-directed, life-prolonging therapies are no longer effective, appropriate, or desired. 13,14

Guidelines Update Methodology

The complete details of the Development and Update of the NCCN Guidelines are available at www.NCCN.org.

Literature Search Criteria

Prior to the update of this version of the NCCN Guidelines® for Palliative Care, an electronic search of the PubMed database was performed to obtain key literature in palliative care published since the previous

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NCCN Guidelines Version 1.2026 Palliative Care

Guidelines update, using the following search terms: (palliative care OR hospice OR end of life) AND (cancer OR oncology). The PubMed database was chosen as it remains the most widely used resource for medical literature and indexes peer-reviewed biomedical literature.

individuals. NCCN encourages researchers to collect more specific data in future studies and organizations to use more inclusive and accurate language in their future analyses.

Palliative Care in Oncology

The search results were narrowed by selecting studies in humans published in English. Results were confined to the following article types:Clinical Trial, Phase II; Clinical Trial, Phase III; Clinical Trial, Phase IV;Guideline; Practice Guideline; Randomized Controlled Trial; Meta-Analysis; Systematic Reviews; and Validation Studies. The data from key PubMed articles as well as articles from additional sources deemed as relevant to these Guidelines as discussed by the Panel during the Guidelines update have been included in this version of the Discussion section. Recommendations for which high-level evidence is lacking are based on the Panel's review of lower-level evidence and expert opinion.

The importance of addressing palliative care needs throughout the trajectory of illness and the emphasis of integrating palliative care principles earlier into the continuum of cancer care is increasingly understood.15-20

Palliative care should be initiated by the primary oncology team, and should be augmented through collaboration with palliative care specialists in an interprofessional team(including but not limited to board-certified palliative care physicians, advanced practice providers, nurses, dietitians,social workers, mental health professionals, chaplains, and pharmacists)to address intractable symptoms and/or complex psychosocial issues.14 Additionally, palliative care should reach beyond the patient to family and caregivers. When further cancer therapy is likely to do more harm than good, palliative care becomes the predominant care offered to patients with advanced cancer. When this point in the disease trajectory is reached, palliative care can facilitate transfer to hospice care at home or in a care facility when appropriate. For patients too unstable for transfer out of the inpatient setting, palliative care and/or hospice may provide end-of-life care for patients in the hospital or other care facility. Palliative care should continue even after the patient's death in the form of bereavement support for the patient's family and caretakers.

Sensitive/Inclusive Language Usage

NCCN Guidelines strive to use language that advances the goals of equity, inclusion, and representation. NCCN Guidelines endeavor to use language that is person-first; not stigmatizing; anti-racist, anti-classist, anti-misogynist, anti-ageist, anti-ableist, and anti-weight-biased; and inclusive of individuals of all sexual orientations and gender identities. NCCN Guidelines incorporate non-gendered language, instead focusing on organ-specific recommendations. This language is both more accurate and more inclusive and can help fully address the needs of individuals of all sexual orientations and gender identities. NCCN Guidelines will continue to use the terms men, women, female, and male when citing statistics, recommendations, or data from organizations or sources that do not use inclusive terms. Most studies do not report how sex and gender data are collected and use these terms interchangeably or inconsistently.If sources do not differentiate gender from sex assigned at birth or organs present, the information is presumed to predominantly represent cisgender

As part of the cancer care continuum, institutions should develop processes for integrating palliative care into cancer care, both as part of usual oncology care and for patients with specialty palliative care(SPC)needs. All patients with cancer should be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically

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indicated. Patients/families/caregivers 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 palliative care knowledge, skills, and attitudes.

The American Academy of Hospice and Palliative Medicine (AAHPM,www.aahpm.org), National Hospice and Palliative Care Organization(NHPCO, www.nhpco.org), and the CAPC (www.capc.org) are organizations dedicated to advancing the discipline of hospice and palliative medicine. These organizations seek to expand access to quality palliative care services for people with advanced illnesses in all settings.Multiple groups have described their ideas and approaches for,experience and outcomes with, and barriers to developing successful programs that integrate palliative care into routine oncologic care.18,19,21-34

Impact of Palliative Care

Studies have shown that the integration of palliative care into the cancer care continuum enhances cancer care resulting in improved patient outcomes across multiple measures, including quality of life, symptom intensity, and end-of-life care. In addition, patients with advanced cancer who receive palliative care concurrently with standard oncology care consistently experience equal or better overall survival.

Survival

Several groups have investigated the potential survival benefit associated with the provision of palliative care to patients with cancer.35-40 A remarkable study suggested that early introduction of palliative care does not only improve quality of life for patients with advanced cancer but can also improve survival.35 Early Incorporation to Palliative Care(EPC)consultation was a positive prognostic factor for overall survival among patients who were discontinuing anticancer therapy when compared with

traditional care models.36 Similarly, a retrospective analysis of 609 patients with terminal cancer suggested that increased duration of palliative care services was positively correlated with survival time.37 In another study,home-based palliative care was associated with an equal or longer survival compared to inpatient palliative care in patients with cancer.38

Results were reported from the ENABLE III trial, which examined outcomes after early versus delayed initiation of palliative care in patients with advanced cancer. Patients in the EPC group had significantly higher Kaplan-Meier 1-year survival rates than the delayed palliative care group(63% vs.48%, P=.038).39 The timing of interventions for caregivers was also examined in this trial, suggesting that earlier provision of palliative care for caregivers lessened their depression and stress burden.41

Further, a meta-analysis of trial data comparing outpatient SPC with usual care in adults with advanced cancer revealed a 14% increase in 1-year survival compared with controls (n = 646; 56% vs. 42%; P < .001) and a median overall survival benefit of 4.56 months.42

Symptom Intensity and Quality of Life

Palliative care has been shown to have a positive impact on quality of life while reducing symptom intensity, particularly when integrated early in the course of cancer care. EPC interventions are essential to define care goals and timely reduction of symptom burden. In a systematic review and meta-analysis of 10 randomized controlled trials, patients with advanced illness who received specialized palliative care early,particularly those with advanced cancer(n = 1766/2454), had the most pronounced effects on quality of life. ${ }^{43}$ A Cochrane database review of seven randomized and cluster-randomized controlled trials in patients with advanced cancer(n = 1614) compared EPC to treatment as usual/standard of care. EPC significantly improved health-related quality of life and suggested lower symptom intensity compared with controls. ${ }^{46}$ Another study demonstrated significant improvement in multiple

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symptoms within one day of a palliative care consultation, highlighting the potential benefit of palliative care even during brief hospital stays.47

Another randomized controlled trial examined the added benefit of early and systematic integration of palliative care alongside standard psychosocial oncologic care.48 The overall quality-of-life score at 12 weeks by the EORTC QLQ-C30 assessed from 68 patients in the standard oncologic care(control) group versus 65 adherent patients in the early and systematic palliative care(intervention) group was 54.39 in the control group versus 61.98 in the intervention group(difference 7.60[95% CI,0.59-14.60]; P=.03); and by the MQOL Single Item Scale, 5.94(95% CI,5.50-6.39) in the control group versus 7.05(6.59-7.50) in the intervention group(difference 1.11[95% CI, 0.49-1.73]; P=.0006). The findings of this study also support the early integration of palliative care.

In addition to quality of life, psychosocial factors have also been studied.Early integration of palliative care for newly diagnosed lung and gastrointestinal cancers was assessed by studying change in quality-of-life measures between baseline, week 12, and week 24. Improvements in quality of life and depression were observed for the lung cancer cohort at 12 and 24 weeks, with improved quality of life and mood reported in the gastric cancer cohort by week 12.49 Compared with a care model in which palliative care was provided on an as-needed basis, standardized early palliative care also increased satisfaction with cancer care among caregivers of patients with advanced cancer.50

EPC has also led to significant improvements in quality of life,psychological state, and nutritional status in a group of patients with non-small cell lung cancer in a randomized controlled trial. ${ }^{51}$ Among 120 patients enrolled, combined EPC group had a better quality of life and nutritional status (P<.05; P=.001) and fewer patients had depressive (P=.005) symptoms.

Summary of Specialty Palliative Care

Systematic review of the EPC in oncology data supported best outcomes with care provided by an interprofessional palliative care team initiated within 8 weeks of diagnosis.52 In much of the existing trial data,oncologist-alone care serves as the usual care arm, while interprofessional palliative care is provided in the intervention arm. The data strongly suggest that using an interprofessional team approach to provide oncologic and palliative aspects of care is superior to placing the entire burden on the oncologist alone.

In addition to improvement in quality of life and survival as discussed above, specialist palliative care has also been linked to cost savings.Earlier palliative care consultations have been associated with decreased health care costs for patients with advanced cancer, including those with multiple comorbidities. ${ }^{53-55}$ According to published literature, dedicated palliative care units and programs can be cost-effective and favorably impact health system finances. ${ }^{56,57}$

Because of the evidence that we present in this report, consultation with SPC is recommended for patients with advanced cancer (including both advanced solid tumors and hematologic malignancies), complexity of care needs, and high burden of palliative care needs similar to recommendations in the American Society of Clinical Oncology's(ASCO's) recently updated guidance and by the World Health Organization. 20,58 Other examples of when SPC should be considered are highlighted in the updated NCCN Guidelines for Palliative Care.

Models and Methods for Early Integration of Palliative Care

An increasing amount of literature suggests approaches to ensuring EPC in the context of the real world. One example is the TEAM approach(Time, an extra hour a month; Education, especially about prognostic awareness, achievable goals, and advance care planning; Assessments

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done formally for symptoms, spiritual needs, and distress/coping; and Management, by an interprofessional team) as a structured way for oncologists to design their care. ${ }^{59}$

Recent large studies have provided insight on the equivalency of palliative care delivery via telehealth compared to in-person delivery, which is one way to expand access and improve feasibility of EPC.60 Further, an approach to "stepped" palliative care that may meet patients' needs may result in fewer palliative care visits while maintaining quality-of-life benefits.61

Another example described in a retrospective narrative review58 is the development of a biweekly palliative care conference modeled after traditional oncologic tumor board meetings, which allowed patients disease to be discussed in a multidisciplinary setting and resulted in changes in pain management and other cancer-related symptoms.

There is also growing literature about the use of artificial intelligence (Al)and machine learning systems aimed at increasing EPC by identifying patients with palliative care needs prospectively. 62-74 Emerging data from these studies suggest possible clinical benefit of these tools. Risk of bias should be considered, and more clinical validation is needed before Al-based tools can be routinely adopted in palliative care. 73,74

End-of-Life Care

Various studies have evaluated the impact of palliative care on end-of-life care, specifically aggressive anticancer therapy near the end of life. A retrospective analysis of patients with advanced cancer highlighted the importance of EPC consultations(>3 months before death) and revealed an association between outpatient palliative care and decreased aggressiveness of end-of-life care.75 An association between prognostic perceptions over time and end-of-life outcomes exists, and interventions are needed to improve prognostic perceptions and optimize end-of-life

care. In a single-institution study ${ }^{76}$ conducted in patients with incurable cancers,66.1%(154/233) reported that their cancer was likely curable at the assessment closest to death, and this resulted in reduced utility of hospice care(odds ratio[OR], 0.25; P=.002) or patients dying at home(OR,0.56, P=.043).

Several studies have shown that palliative care reduces chemotherapy provided at the end of life. A population- based study conducted in Japan(n= 26,012) showed that palliative care consultation reduced the percentage of patients receiving inpatient chemotherapy during the last 2 weeks of life.77 In one trial, patients receiving EPC were less likely to receive intravenous(IV) chemotherapy in the last 60 days of life(OR,0.47; 95% CI, 0.23-0.99; P=.05),78 likely because these patients had a more accurate understanding of their prognosis, which impacted decisions about their care.79 A prospective study showed that early integration of palliative care facilitated the discontinuation of anticancer regimens and improved measures of quality of life for patients with advanced breast or gynecologic cancers.${}^{36}$ Likewise, the lack of palliative care team consultation has been shown to be a predisposing factor for futile life-sustaining treatments at the end of life. ${ }^{80}$

Studies have also demonstrated that community-based or home-based palliative care services can positively influence patient care. These services have been associated with reduced need for end-of-life emergency department visits, reduced length and frequency of hospitalization, as well as fewer intensive care unit (ICU) admissions and in-hospital deaths.81-85 Palliative care has been shown to reduce symptom burden, improve quality of life, and increase the odds of dying at home.Similarly, a 2013 Cochrane Database systematic review that analyzed home palliative care in patients with advanced illness demonstrated reliable reduction of symptom burden and increased likelihood of dying at home without a negative impact on caregiver grief.86

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Death anxiety/distress and its associations with clinical, psychosocial, and personal characteristics in patients with cancer receiving palliative care was explored by Emanuel et al87 by using a validated Death Anxiety and Distress Scale(DADDS). These scores were positively correlated with religious struggle (P<.001) and dignity-related distress (P<.001) and negatively correlated with existential quality of life (P<.001) and warrants more evaluation on the nature and timing of spiritual and psychosocial interventions. Significant risk factors associated with high-intensity end-of-life care among older adults were identified with the four most common malignancies-including breast, prostate, lung, and colorectal cancer-using SEER Medicare data, ${}^{88}$ and this includes comorbidity burden,female sex,Black race, other race/ethnicity stage III disease. These predictors may help in developing new interventions for high-intensity care for patients at the end of life.

Role of Hospice Care

Hospice is the most established model of palliative care for patients with a prognosis of <6 months and is eligible for coverage by third-party payers and Medicare. Enrollment in hospice has been shown to reduce hospitalization and receipt of high-intensity non-hospice care at the end of life. End-of-life care can often be more aggressive than what is supported by current evidence. Historically, provision of end-of life care has been shown to be inconsistent and variable across regions, even among comprehensive cancer centers.89,90 Medicare patients with poor-prognosis cancer receive highly intensive end-of life care, including administration of cancer-directed treatments last in the course of cancer care.89,91 Furthermore, oncologists have reported that they have found hospice regulations and reimbursement limitations to be too restrictive.92

An analysis of the SEER database revealed that men with advanced prostate cancer who were enrolled in hospice were less likely to receive high-intensity care, including ICU admission and inpatient hospital stays,

at the end of life. ${ }^{93}$ Moreover, a study of 207 deceased patients with cancer who had stopped cancer treatment showed reduced emergency department visits, hospitalizations, and other noncancer clinic visits for those who had been enrolled in hospice.94 Additionally, analyses of data from 3069 deceased patients who had been>50 years of age(extracted from the Health and Retirement Study) revealed that hospice enrollment significantly decreased hospitalization, non-hospice health care utilization,and cost of care.95

Unfortunately, many studies have suggested that palliative and hospice care often go underutilized.84,96-102 An analysis of SEER/Medicare care on hospice use in end-of-life cancer care(n= 55,058) found that hospice enrollment ranged from about 51% for colorectal cancers to up to 62% for prostate cancers.96 Despite the 6-month prognosis eligibility, the median length of hospice service(LOS) for Medicare patients with cancer in 2016 was 19 days.103 Approximately 28% of patients receiving hospice care died or were discharged within 7 days of admission to hospice care.103 Thus, barriers to early referrals still exist.19,99 Additionally, one study at an academic medical center revealed marked and unwarranted variation in hospice LOS within divisions and by doctors. For instance, in thoracic oncology, several oncologists had an average LOS of 36 days while others were clustered around 4 days for the same patient population.However, oncologists were receptive to feedback and training.104 By establishing hospice referrals as a quality improvement measure, one health system reported that median LOS in hospice doubled within a year of implementation.105 Similarly, another study revealed that educational outreach and implementation of specific triggers for palliative care consultation were associated with increased hospice referrals and LOS.106

Training in Palliative Care

All health care professionals and trainees should participate in education that results in acquisition of palliative care knowledge, skills, and attitudes.

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The establishment of hospice and palliative medicine as a medical specialty in 2008 received support from at least 10 cosponsoring American Board of Medical Specialties(ABMS; www.abms.org) boards,including Anesthesiology, Family Medicine, Internal Medicine, Physical Medicine and Rehabilitation, Psychiatry and Neurology,Surgery, and Pediatrics. Support for the expansion of palliative medicine education has been offered by the Liaison Committee on Medical Education(LCME;www.lcme.org),which has mandated palliative medicine education for medical schools. In addition, the Accreditation Council for Graduate Medical Education(ACGME;www.acgme.org) now requires training in palliative medicine for oncology fellows, including training in pain,psychosocial-spiritual care, personal awareness, and hospice care.

Researchers at a large urban teaching hospital demonstrated the effectiveness of education on palliative care and referral criteria for increasing overall referrals to palliative care services and enhanced referrals for the purpose of pain management.107 Effective training in palliative care can also positively impact provider, patient, and caregiver quality of life. One study suggested that an online palliative care education intervention for primary care physicians led to measurable improvements in patient outcomes such as pain, symptoms, and quality of life.108 In a survey study, oncology fellows reported that training on end-of-life issues and goal-of-care discussions mitigated burnout and distress. ${}^{109}$ Interactive palliative care education programs that incorporate participant discussion and/or coaching helps towards effective practice change. ${}^{110,111}$

CAPACITI(Community Access to Palliative Care via Interprofessional Teams Intervention) is a virtual education program that teaches primary care teams how to provide an early palliative approach to care.112 An in-depth qualitative study with CAPACITI participants assessed the effectiveness of the components and gained understanding of the challenges and enablers to virtual palliative care education. Cross analysis

of the data revealed three major themes: 1) changes in practice derived from involvement in CAPACITI; 2) utility of specific elements of the program; and 3) barriers and challenges to enacting CAPACITI in practice.The participants reported that CAPACITI was helpful in applying a palliative approach to care.

Palliative care resources that may be useful for clinicians are listed in Table 1 at the end of this Discussion section.

Communication and Advance Care Planning in Palliative Care

A National Academy of Medicine report, Communicating with Patients on Health Care Evidence, found that 90% of Americans surveyed want to know their options for tests and treatments and to be involved in decision-making for their health, with almost 50% wanting to discuss the option of forgoing anticancer therapy and continuing non-chemotherapy palliative care.112,113 However, the report also found that few respondents had such discussions with their physicians.

Clinicians should assess and cultivate prognostic awareness and engage in advance care planning with patients and their families to ensure patient-centered care plans. Research suggests that the majority of patients queried express a desire to receive detailed prognostic information about their disease.114-117 Assessment and confirmation of understanding of prognosis is important and may guide treatment decisions. In addition,determining the decision-making styles of patients and their families helps facilitate congruence of a patient's goals, values, and expectations with those of the family/caregiver(s). Clinicians should also determine the patient's assessment of the relative importance of quality of life compared with length of life. Information about the natural history of the specific tumor and the realistic outcomes of anticancer therapy should be included in the discussion. Many investigators have shown that seriously ill patients who are middle-aged and older tend to be more optimistic and less

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accurate about their prognosis than their physicians; misunderstanding a disease progression timeline can impair timely decision-making, including discussions of preferences for cardiopulmonary resuscitation(CPR) and other life-extending measures.118 In addition to physicians, oncology nurses can be positioned to provide primary palliative care and provide increased advance care planning with patients with advanced cancers.119

whether these patients were not told their prognosis, did not or could not understand the information, or merely disagreed with the information and answered the survey with a high degree of optimism.124 This result,however, demonstrates a clear need for improvement in the area of physician-patient communication. Additional analyses of 722 patients with stage IV lung or colorectal cancer showed that only 33% of patients recognized that their chemotherapy regimens were“not at all” likely to cure their cancer.125 Similar misconceptions also apply to palliative radiation therapy(RT). In a study of 384 patients with inoperable lung cancer, 64% of patients did not understand that their RT was not curative.126 Notably, in a cohort of 686 patients with metastatic lung or colorectal cancer from CanCORS, only 16.5% were able to accurately state their prognosis.127

Patients nearing the end of life should be assisted in reviewing and revising their life priorities, resolving unfinished business, and putting financial and personal affairs in order. Spiritual, existential, and cultural issues are often best addressed through collaboration with spiritual care counselors, professional translators, the patient's personal clergy, and representatives from the patient's cultural community. Religious and cultural matters surrounding the beliefs and practices near the time of death should be anticipated and carefully managed.120-122 Finally, social and spiritual support, as well as careful resource management should be provided to ensure a safe end-of-life care environment, a competent primary caregiver, and access to necessary medications and treatments.Providers must be sensitive to cultural values that may influence the best way for this information to be presented and discussed.

Survey and observational data have revealed that many doctors are hesitant to have honest discussions with their patients, in part because these discussions can be very difficult and emotionally draining for the physicians.128-130 Oncologists revealed a high level of perceived burden regarding discussions about discontinuing anticancer treatments, and study results have indicated a desire on the part of providers for additional communication skills training.129,130 Training in communication has been shown to improve clinician-patient communication 131-135 and to mitigate physician burnout and improve physician empathy and mood.136 For example, a randomized controlled trial showed that an 11-hour communication skills training workshop for oncologists was effective at improving communication skills, including those specific to the transition to palliative care.137 Additionally, the VOICE cluster randomized controlled trial demonstrated the effectiveness of patient-centered communication training for physicians caring for patients with advanced cancer.135

Communication Skills

Provider communication skills play a particularly important role for palliative care in oncology. However, several studies have revealed gaps in patient-centered communication regarding patient prognosis and understanding of the intent of treatment. Valuable insight has been garnered regarding provider communication and patient understanding from the Cancer Care Outcomes Research and Surveillance(CanCORS)study of approximately 10,000 patients with lung or colorectal cancer. A survey of 1193 patients from CanCORS found that 69% of patients with advanced lung cancer and 81% of those with advanced colorectal cancer thought that their palliative chemotherapy could cure them.123 It is unclear

Clear, consistent, and empathetic communication with the patient, family,and caregiver(s) about the natural history of the cancer and its prognosis

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is at the core of effective advance care planning and palliative care.138-142 A newly developed compact communication skills training(PALLI-COM)was investigated in a randomized controlled trial and was shown to increase oncologists' competencies in addressing palliative care/-end-of-life-related issues early.143 Following intervention in 141 oncologists, the intervention group showed significantly more improvement in four assessed communication skills: 1)“reacting to emotions and showing empathy%; 2)“pointing out opportunities and giving hope”; 3)“addressing the EoE[end of life]"; and 4)“explaining the concept of PC[palliative care]."

It is important to assess and cultivate prognostic awareness and patient goals and preferences in the context of clinical uncertainties or difficult news over the course of disease.144 When patients accurately understand the goals of treatment, they are enabled to make choices that are consistent with their life goals. A multicenter observational study revealed that prognostic disclosure from physicians resulted in more realistic patient expectations regarding life expectancy without reducing emotional well-being or patient ratings of their physician relationship. ${}^{145}$ In addition,effective patient-physician communication has been shown to decrease patient stress, increase adherence to treatment, and improve outcomes. ${}^{146,147}$ Open communication with relatives or caregivers of patients with cancer is also critical, particularly when patients near the end of life. ${}^{141,148}$ The use of question prompt sheets (QPS) facilitated generation of new questions without increasing participants' anxiety. ${}^{149}$

Based on existing evidence and expert consensus, ASCO released a Consensus Guideline in 2017 addressing how to improve patient-clinician communication on topics such as goals of care, prognosis, end-of-life care, and facilitating family involvement in care.150

One large effort to improve advance care planning(ACP) and communication skills was recently published by the Alliance of Dedicated

Cancer Centers (ADCC), representing 10 U.S. academic cancer hospitals. They undertook the Improving Goal Concordant Care Initiative (IGCC) to improve goals of care communication by implementing a training program on primary palliative care principles.151

NCCN Guidelines for Palliative Care

The NCCN Guidelines for Palliative Care were developed to facilitate the appropriate integration of palliative care into oncology practice. The Guidelines outline procedures for palliative care needs assessment,interventions, reassessment, and after-death care. The Panel initially focused on the needs of patients in their last 12 months of life in order to distill the content of textbooks and curricula into Guidelines in a manner similar to existing NCCN disease- and symptom-oriented Guidelines. The NCCN Guidelines for Palliative Care have expanded the focus to all patients and family experiencing cancer throughout the disease trajectory,consistent with the Clinical Practice Guideline from ASCO.52

Assessment of Palliative Care Need

The primary oncology team should assess all patients at every visit for palliative care needs. Patients with identified needs should be assessed,treated, and reassessed. Patients without an identified need should be re-evaluated at the next visit. In addition, the oncology team should inform patients, family, and caregivers about palliative care services. Anticipation of palliative care needs and prevention of symptoms should be discussed,and conversations regarding advance care planning should be initiated.

Comprehensive Assessment

Patients with cancer should undergo a comprehensive palliative care assessment by their primary oncology team evaluating the benefits and burdens of cancer therapy; symptoms; personal goals/values/expectations;financial toxicity; decision-making capacity;coping strategies; functional status; psychosocial or spiritual distress

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(including financial toxicity); educational and informational needs; and cultural factors affecting care.7-9 Patients with identified needs will likely benefit from palliative interventions. As part of a comprehensive assessment, oncology teams can consider whether consultation with SPC would be a beneficial addition to the care team, especially for patients with advanced cancer, complex care needs, or a high burden of palliative care needs including distress related to the cancer diagnosis and/or cancer therapy.

communicating with patients with advanced cancer.152-156 Shared decision-making with the patient, family, and caregiver(s) is important. A 2015 systematic review of quantitative studies identified the following elements of palliative care that were ranked as most important by patients and their families: effective communication and shared decision-making;expert care; respectful and compassionate care; and trust and confidence in clinicians.142

Assessment for Benefits and Burdens of Cancer Therapy

Many cancer symptoms can be relieved by control of the cancer with cancer therapy. Assessment of the benefits and burdens of anticancer therapy for each individual is based on the existing NCCN disease-specific Guidelines (the most recent versions of all Guidelines can be found on the NCCN website at www.NCCN.org). Special attention should be given to the natural history of the specific tumor; the potential for response to further treatment (taking into consideration the patient's functional status);the meaning of anticancer therapy to the patient/family/caregiver(s); the potential for treatment-related toxicities including impairment of vital organs and performance status; and serious comorbid conditions. Specific recommendations regarding cancer therapy for patients with various life expectancies are discussed in Palliative Care Interventions, below.

Patients' priorities should be discussed, including their goals, their definition of quality of life, and their perception of how anticancer therapy will fit into their lives. Survival statistics may be helpful in these conversations; however, patients' abilities to assimilate such data should be assessed. Goals and expectations that might be better met by the hospice model of palliative care should be identified. Patients should be given the opportunity to understand the expected trajectory of their disease, particularly if it is incurable.

Assessment of Physical Symptoms and Functional Status

Physical symptoms and changes in functional status can impact a patient's quality of life and how they tolerate cancer-directed therapy and whether they are a candidate for anti-tumor therapy. The most common symptoms for patients with cancer are pain, dyspnea, anorexia, cachexia,nausea, vomiting, constipation, diarrhea, malignant bowel obstruction(MBO),fatigue,weakness,asthenia,insomnia,daytime sedation,delirium,lymphedema, and hormone-related symptoms.157 Palliative interventions for symptoms are discussed individually in the Symptom Management section; for management of lymphedema and hormone-related symptoms,please see SLYMPH-1 and SHRS-1 in the NCCN Guidelines for Survivorship(available at www.NCCN.org). For management of adult cancer pain, please see the NCCN Guidelines for Adult Cancer Pain(available at www.NCCN.org).For management of chemotherapy-induced nausea/vomiting, please see the NCCN Guidelines for Antiemesis

Assessment of Decision-Making Capacity, Coping Strategies, and Patient/Family/Caregiver Values, Goals, and Expectations

Patients and their families should engage in advance care planning with their oncology team and be asked about their personal goals, values,expectations, and priorities. Assessing decision-making capacity and identifying appropriate surrogate decision-makers for patients who lack

identifying appropriate surrogate decision-makers for patients who lack decision-making capacity(now or at some point in the future) is a key aspect of communication and decision-making. Further, understanding coping strategies and prognostic awareness is also central for

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(available at www.NCCN.org).For management of cancer-related fatigue,please see the NCCN Guidelines for Cancer-Related Fatigue(available at www.NCCN.org).For chemotherapy-induced thrombocytopenia,anemia, and neutropenia, please see the NCCN Guidelines for Hematopoietic Growth Factors(available at www.NCCN.org).Immune checkpoint inhibitor-related toxicities, chimeric antigen receptor(CAR) T-cell-related toxicities, and lymphocyte engager-related toxicities are covered in the NCCN Guidelines for Management of Immunotherapy-Related Toxicities(available at www.NCCN.org). Cancer-related infections are covered in the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections(available at www.NCCN.org).

Assessment of Psychosocial-Spiritual Distress

Assessment of psychosocial distress should include both the patient and the caregivers, and should focus on illness-related distress and psychosocial, spiritual, or existential needs according to the NCCN Guidelines for Distress Management(available at www.NCCN.org).For management of spiritual or existential needs, consultation with a palliative care specialist and/or spiritual or psychosocial-spiritual resources(eg,chapains, clinical psychologists, community resources, social workers)may be considered. Concerns regarding social support and resources(eg,home,family,community, or financial toxicity including access barriers)must also be assessed. Recommendations for the management of psychosocial distress can be found below and in the NCCN Guidelines for Distress Management(available at www.NCCN.org). Other concerns that may increase distress include employment(or loss of employment) and social isolation(or loneliness); these issues should be assessed to ensure appropriate interventions can be provided, as feasible and desired.Barriers barring access to palliative care services should be discussed,and common concerns such as financial toxicity or geographical issues(eg, limited or difficult transportation) should be addressed.

Assessment of Educational and Informational Needs and Cultural Factors Affecting Care

The values and preferences of patients and families regarding information and communication should also be assessed. The oncology team should inquire about cultural factors affecting care and perceptions of the patient/family/caregiver regarding the patient's disease status.121,158

Consideration for Consultation with Specialty Palliative Care

Palliative care consultation can be considered for all patients with advanced cancer(advanced solid tumors and hematologic malignancies),and especially for those with complex care needs based on patient characteristics, social circumstances, and/or anticipatory bereavement issues. The oncology team should consider consultation for patients with limited cancer treatment options; disease refractory to cancer treatment;multiple/severe comorbid conditions; progressive functional decline; or persistently poor performance status. Additional criteria include high risk for poor pain management(see the NCCN Guidelines for Adult Cancer Pain[available at www.NCCN.org]); high burden of non-pain symptoms resistant to conventional management; frequent emergency department visits or hospital admissions; need for ICU-level care; need for invasive procedures(eg), palliative stenting/gastrostomy); advanced age and frailty;or a high level of psychological distress based on standardized distress screening(see the NCCN Guidelines for Distress Management[available at www.NCCN.org]). Consultation with palliative care specialists should also be considered when there is a need for clarification of the goals of care; patient/family/caregiver or provider dissatisfaction with the care plan;resistance to advance care planning; or a request for hastened death. If applicable, concerns regarding a patient's decision-making capacity should also be assessed; for some approaches, see the NCCN Guidelines for Older Adult Oncology(available at ww.NCCN.org). Communication needs such as language, literacy, cultural sensitivity and cognitive impairment can be considered for SPC consultation. Evidence of

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worsening prognosis including poor performance score (ECOG ≥ 3 or KPS≤50),cachexia,persistent hypercalcemia, brain or cerebrospinal fluid metastasis, persistent delirium, MBO requiring venting gastronomy,superior vena cava(SVC) syndrome, spinal cord compression, malignant effusions, paraneoplastic syndromes, or the need for palliative stenting,venting gastrostomy or pulmonary obstruction, great vessel invasion with potential rupture, and meningismus spread are also considered for SPC care.

Difficult social circumstances or a high risk for persistent complicated grief indicate a need for referral for consultation with a palliative care specialist.These may include family/caregiver limitations, inadequate social support,substance use disorder impacting care and/or concerns regarding substance use disorders, financial limitations, limited access to care,family discord, spiritual or existential distress, unresolved or multiple prior losses, dependent children and/or older relatives living in the household care planning for children of a parent with poor prognosis, support for active caregivers, and/or other complexities related to social determinants of health.

Patient-reported outcome measures(PROMs) may be useful for identifying SPC needs and improving survival in patients with cancer.159 The diagnostic validity of the Integrated Palliative Care Outcome Scale(IPOS) and NCCN Distress Thermometer(NCCN DT) in identifying need for SPC in patients with incurable cancer was assessed by Muller et al ${160}$ and showed that their implementation may facilitate integration of SPC.Other studies have also successfully implemented the use of the NCCN DT as a screening tool in oncologic palliative care.161 Palliative care consultation should also be considered when complex care coordination issues exist within or among multiple care teams, or if staff issues such as intra- or inter-team conflict, compassion fatigue, moral distress and/or

ethical concerns, communication regarding complex decision-making, or burnout are present.

Palliative Care Interventions

The oncology team should ensure cancer therapy and appropriate treatment of comorbid physical and psychosocial-spiritual conditions as medically indicated and concurrent with patient-centered care plans,including coordination of care with other health care providers. The oncology team should integrate palliative treatments following the specific recommendations described in these Guidelines. Referrals should be made as needed to mental health, social, and psychosocial support services; spiritual care; health care interpreters; or other specialists. The oncology team may be helpful in identifying additional support through religious organizations, schools, or other agencies in the community.Finally, the oncology team should promote adaptive coping, introduce advance care planning, participate in shared decision-making, collaborate with palliative care specialists and teams as needed(especially for patients with complex care needs as indicated above), and ensure timely referral to hospice services when appropriate.

The Panel divided patients into three groups to address the effect of life expectancy on the delivery of key palliative care interventions: 1) patients with years to months to live; 2) patients with months to weeks to live; and 3) dying patients in their final weeks to days. Patients in their final hours of life are referred to as imminently dying and may require special interventions. The Panel recognizes the lack of precision in estimating life expectancy but believes that this delineation is useful for the delivery of appropriate palliative care interventions. The patient and family's personal,spiritual and existential, cultural, and religious goals, values, and expectations may change throughout these timeframes. Optimal provision of palliative care requires ongoing reassessment and modification of

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strategies, as well as ongoing communication between the patient, family,caregiver(s), and health care team.

Indicators that a patient's prognosis is worsening include decreased performance status(ECOG score≥3; KPS score≤50), persistent hypercalcemia, central nervous system metastases, delirium, MBO, SVC syndrome, spinal cord compression, cachexia, malignant effusions, need for palliative stenting or venting gastrointestinal, potentially life-limiting disease, or other serious comorbid conditions. Many patients with stage IV cancers, especially those with metastatic lung cancer, pancreatic cancer,and glioblastoma multiforme, would benefit from palliative care beginning at diagnosis, because expected survival is limited.162-164 Palliative care interventions for managing specific symptoms and the benefits and burdens of anticancer therapy are discussed below as outlined in the algorithm.

Cancer Therapy and Shared Decision-Making Considerations

Patients who have years to months to live and a good performance status are likely to be interested in continuing cancer therapy to prolong survival and reduce cancer-related symptoms.165-168 Cancer therapy may be conventional evidence-based treatment as outlined in the NCCN disease-specific Guidelines(available at www.NCCN.org) or treatment in the context of a clinical trial. In some of the advanced-stage cancers,chemotherapy may be superior to best supportive care and may prolong survival.169,170 Palliative RT and/or interventional procedures also play an important role in the comprehensive care of patients with advanced cancer.171-177 To assess the risk of serious complications in patients with neutropenic fever, the Panel recommends referring to the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections and NCCN Guidelines for Hematopoietic Growth Factors(available at www.NCCN.org).

Furthermore, patients with advanced cancer who are not eligible for systemic chemotherapy may benefit from immunotherapy or molecular targeted therapies that may be effective for relieving symptoms,maintaining stable disease, and/or improving quality of life without the adverse events that may be associated with cytotoxic cancer therapies.178.179 Physicians, patients, and their families should discuss prognosis, intent and goals of therapy(curative or noncurative), range of choices, benefits and burdens of cancer therapy, and possible effects on quality of life. In addition, the oncology team should discuss the possibility of disease progression or recurrence. For an approach to decision-making in older adults and geriatric screening tools, see the NCCN Guidelines for Older Adult Oncology(available at www.NCCN.org).

Clinicians should provide primary palliative care to include both cancer treatments aligned with patient goals and priorities and disease-related symptom management. The appropriateness of palliative RT or interventional procedures should be assessed, and palliative procedures conducted should be in line with the goals of care. Cancer therapy should be in line with stated patient goals and priorities and be accompanied by appropriate prevention/management of side effects as well as palliative care. A longitudinal cohort study evaluated the impact of palliative chemotherapy on quality of life near death as a function of patient performance status. In patients with progressive metastatic cancer,palliative chemotherapy did not improve quality of life near death for those with moderate or poor performance status and worsened quality of life near death for those with initially good performance status.180 Studies have reported that, at times, cancer therapy may continue beyond what is evidence-based for patients with advanced or metastatic disease.77,181,182 In some cases, nonpharmacologic and/or integrative interventions(eg,cognitive-behavioral, massage, and music or art therapy) may be considered.

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Patients with months to weeks to live should be provided with guidance regarding the anticipated course of the disease. Physicians should reassess prognostic awareness and goals of therapy. As functional status worsens, these patients may become more concerned about the side effects of cancer-directed treatment and consider focusing their care on maintaining quality of life. The option of discontinuing cancer treatment aligned with goals of care and initiating goal-directed supportive care should be discussed.179,180,183-185 A retrospective, single-center,observational study suggests that palliative care may be associated with longer survival after chemotherapy discontinuation in patients with advanced pancreatic adenocarcinoma.186 The Panel emphasizes the importance of initiating or continuing advance care planning conversations and systematically reviewing advance care plans to ensure ongoing accuracy as illness or situation evolves. To avoid demeaning the value of end-of-life care, palliative care and/or hospice care should not be framed as“giving up,” but instead refocusing the care plan to achieve a better quality of life. It may be helpful to determine the patient and family's prior experience(s) with end-of-life care. In addition, if appropriate, patients and families should be encouraged to complete any necessary legal documents. Clinicians, if appropriate, may assess and document the preferred location of death. Education and support related to care including referral to specialized palliative care services or hospice at the end of life should be offered.

In general, patients with weeks to days to live (eg, dying patients) and comfort-oriented goals should discontinue all treatments not directly contributing to patient comfort. Intensive palliative care focusing on symptom management should be provided in addition to preparation for the dying process. Referral for hospice care should be placed, if not already done. Culturally/spiritually significant rituals/ceremonies important at the end of life may be considered upon patient request.

Advance Care Planning

The oncology team should assess and cultivate prognostic awareness and integrate discussions of personal values and preferences for current and future care while patients have a life expectancy of years to months. The patient's decision-making capacity should also be assessed, and a surrogate decision-maker should be identified. Several studies have shown that these discussions frequently happen too late in the trajectory of disease, often during acute hospital care and often with health professionals other than the primary oncologist.187-189 Earlier integration of advance care planning discussions has been associated with less aggressive care and increased use of hospice,1901,191 while less aggressive care has been associated with an improved quality of life.192 Studies suggest that most patients with cancer would prefer to die at home,193,194 but lack of timely advance care planning can render this impossible.

A randomized controlled trial of a structured intervention to facilitate end-of-life discussions (consisting of an informational pamphlet and provider discussion) led to earlier designation of do-not-resuscitate orders and decreased the likelihood of patients dying in the hospital.195 In addition, a recent study showed that electronic prompts and email reminders to doctors could increase documentation rates of code status in patients with advanced lung cancer.196 A 2015 systematic review summarizes the evidence base from randomized trials of interventions designed to promote shared decision-making and advance care planning in patients with serious illness.197

Advance care planning should identify personal values, goals,expectations, and priorities and assess their congruence with those of the family/caregiver/health care team. Formal documents including advance directives, living wills, medical powers of attorney, and health care proxy should be completed. Any other documents delineating specific limitations regarding life-sustaining treatments(eg, CPR, mechanical ventilation,

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artificial nutrition/hydration), as well as an open discussion about palliative care options such as hospice should be completed as appropriate. A patient's values and preferences and any decisions should be documented in the medical record, including MOLST or POLST(Medical Orders for Life-Sustaining Treatment or Physician Orders for Life-Sustaining Treatment) if completed.198

When the patient's life expectancy is reduced to months to weeks, the oncology team should actively facilitate the completion of appropriate advance directives and ensure their availability in all care settings.MOLST/POLST should be documented and accessible to all providers across care settings. Documentation of surrogate decision maker is best practice. The team should also confirm the patient's values and decisions in light of changes in status.

Clinicians, if appropriate, may assess and document the preferred location of death. Most patients with cancer would prefer to spend their remaining time at home, ${ }^{193,194}$ but sometimes their care needs are too great to be feasible in the home. Some patients request to receive end-of-life care in a skilled nursing facility or an in-patient hospice facility. ${ }^{194,199}$ A prospective study showed that patients dying in an ICU had higher levels of physical and emotional distress compared with patients dying at home or in hospice. Additionally, caregivers of these patients had a greater incidence of prolonged grief disorder. ${ }^{200}$ Providing palliative care services has been shown to decrease deaths in ICUs. ${ }^{199}$ A retrospective cohort study showed that patients who wanted to be at home at the end of life were more likely to do so if they had daily hospice visits, if they were married, if they had advance directives, if they did not have moderate or severe pain, or if they had good performance status. ${ }^{194}$ A second retrospective study suggested that referral to specialist palliative care at a greater interval of time prior to death increased the likelihood of patients dying at home or in hospice rather than in the hospital. ${ }^{201}$ If advance care plans have not been

completed, the oncology team should explore the patient's reluctance to engage in advance care planning and refer to palliative care if needed.Referral to a specialized palliative care service can be considered if the patient is having difficulty engaging in discussion of advance care planning to explore their fears and worries about illness. Additional referrals to a chaplain/spiritual care counselor and to a mental health clinician can be considered to explore mental well-being. Additional information on assessment and management of psychosocial and emotional distress can be found in the NCCN Guidelines for Distress Management (available at www.NCCN.org).Anxiety and depression could result in lesser engagement with advance care planning since they are commonly elevated among patients with advanced cancers. Practical strategies and sample scripts for oncology care providers are provided to reduce the effects of anxiety and depression in these contexts.202

In patients with a life expectancy of weeks to days, the patient's decision regarding CPR and other life-sustaining treatments should be clarified and confirmed. Education about the benefits and limitations of CPR should be provided, and documentation of the resuscitation orders including in POLST/MOLST as per patient/family/caregiver preferences should be completed as appropriate. Providers should facilitate continued involvement of the primary care physician and primary oncology team. The desire for organ donation and/or autopsy should also be explored with the patient. The oncology team should ensure that the care provided adheres to the patient's advance care plan. Education and support related to care at the end of life should be offered.

Symptom Management

With regard to symptoms, the management of pain, dyspnea,anorexia/cachexia, nausea and vomiting, constipation, diarrhea, MBO,fatigue, delirium, and psychological distress are fundamental203-205 and are discussed in detail below. Symptoms should be comprehensively

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assessed in all patients. In patients who are non-communicative, symptom intensity may be assessed using physical signs. Education should be provided to the patient/family/caregiver on the patient's condition and the risk/benefit of treatment options. In addition to education, psychosocial and emotional support for the patient/family/caregiver(s) is also an important part of symptom management. As a general principle, if/when appropriate, providers should try to use palliative interventions that may address multiple symptoms.

Pain

See the NCCN Guidelines for Adult Cancer Pain(available at www.NCCN.org)for specific recommendations for pain management,including opioid principles, prescribing, titration, maintenance, and safety. Clinicians should be aware of state and local regulations regarding opioid prescriptions.

In addition, it is also important to be aware of several general considerations when addressing pain symptoms near the end of life. It is important to educate the patient/family about the patient's condition,prognosis, and the role of pain medications in the dying process.Optimizing psychosocial and spiritual support for the patient/family/caregiver and customizing the education and support to the patient and family/caregivers need to be considered. Consider nonpharmacologic and/or integrative interventions such as massage, art,or music therapy; acupuncture; relaxation; mindfulness; and guided imagery. If feasible and desired, pain management should be balanced against reduced level of consciousness. If the patient's goals are comfort-oriented, avoid opioid dose reduction solely for decreased blood pressure or respiration rate. Routes of pain medication delivery may need to be modified as a patient approaches the end of life applying equianalgesic dose conversions. It is also important to recognize and treat opioid-induced neurotoxicity, including myoclonus and

hyperalgesia. Single-fraction palliative RT may be used to address pain associated with bone metastases.176,177,206,207 Study data suggest that 40% of patients(122/298) who received a single 8 Gy RT dose for painful bone metastases experienced pain reduction and improved quality of life within 10 days and may be recommended for patients with a life expectancy of multiple weeks.207 208-214

Dyspnea

Dyspnea is one of the most common symptoms in patients with advanced lung cancer.215 The American Thoracic Society consensus statement defines dyspnea as“a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”216 Potentially reversible underlying causes or comorbid conditions should be treated using chemotherapy or RT or other interventional strategies as appropriate; If dyspnea is immunotherapy-induced, refer to the NCCN Guidelines for Management of Immunotherapy-Related Toxicities(available at www.NCCN.org);Therapeutic procedures for cardiac,pleural, or abdominal fluid217-219; bronchoscopic therapy; or bronchodilators, diuretics, steroids, antibiotics, transfusions, or anticoagulants for pulmonary emboli. Oxygen therapy for symptomatic hypoxia is also recommended. Both pharmacologic and non-pharmacologic interventions have been investigated in the management of dyspnea. While there are little definitive data evaluating the effectiveness of dyspnea interventions, 220,221 the Panel members agree that there are sufficient data to make treatment recommendations.218.222

The Panel recommends first considering non-pharmacologic interventions including the use of handheld fans directed at the face,223,224 cooler temperatures, stress management, relaxation therapy, and physical comfort measures. A randomized controlled trial examined the effects of room air versus palliative oxygen delivered via nasal cannula in patients with refractory dyspnea. Dyspnea scores were no different among patients

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receiving palliative oxygen versus room air, encouraging the use of less burdensome interventions after brief assessment of the effect of oxygen therapy on the individual patient.225 If nonpharmacologic measures do not provide desired relief, pharmacologic interventions may be considered including opioids.218,220,221,226-229 The reported beneficial effect of benzodiazepines on dyspnea in patients with advanced cancer is small,and the addition of benzodiazepines to opioids can increase the risk of respiratory depression. In patients towards the end of life, benzodiazepine can be considered, particularly when dyspnea is associated with anxiety and when opioids and other non-pharmacologic measures have not controlled dyspnea.220,230 If fluid overload is thought to be a contributing factor for dyspnea, consider decreasing fluids and/or low-dose diuretics,based on the clinical situation.

Opioids, in low doses, with titration as appropriate, can be used to treat dyspnea that is resistant to other therapies. Low-dose opioid can be initiated in the opioid-naive patient.231-236 For patients receiving chronic opioids, the Panel recommends consideration of a 25% dose increase to treat symptomatic dyspnea. Morphine should be avoided in patients with known renal compromise. For additional information on opioid medications and opioid titration, please see the NCCN Guidelines for Adult Cancer Pain(available at www.NCCN.org).

Scopolamine, atropine, hyoscyamine, and glycopyrrolate are options to reduce excessive secretions associated with dyspnea, particularly if at the end of life.237-241 Glycopyrrolate does not effectively cross the blood-brain barrier and is less likely than the other drug options to cause delirium, but this agent can still produce anticholinergic side effects.242-244 Scopolamine can be administered transdermally. Physicians should be aware that the onset of benefit for transdermal scopolamine patches is about 12 hours;245 thus, they may not be an appropriate choice for imminently dying patients.

High-flow nasal oxygen and noninvasive mechanical ventilation are generally not available outside of the acute care setting but may provide temporary improvements in hypoxemia and dyspnea. In a feasibility study of 200 patients with solid tumors randomized to receive either noninvasive positive-pressure ventilation(bilevel positive airway pressure, BiPAP) or conventional oxygen therapy, patients in the ventilation group had greater improvements in dyspnea symptoms and required lower doses of opiates than patients in the oxygen group.246 A smaller phase II randomized trial comparing high-flow oxygen to BiPAP for persistent dyspnea in patients with advanced cancer revealed no significant differences between the two approaches.247 Palliative RT can be considered in appropriate situations,such as for patients with symptomatic SVC syndrome or those who have respiratory obstruction by tumor mass.171,248,249 Noninvasive positive-pressure ventilation support(eg, continuous positive airway pressure[CPAP], BiPAP) is recommended if clinically indicated for a severe,potentially reversible condition if in line with a patient's goals of care.

When caring for actively dying patients, providers should discuss the reversibility of respiratory failure and treatment options, and provide anticipatory guidance for patient/family/caregiver(s) about dying of respiratory failure. Options such as a time-limited trial of mechanical ventilation250 or therapy with high-flow nasal cannula may be considered, if consistent with the patient's goals and values. However, as life expectancy decreases, the role of mechanical ventilation and oxygen diminishes, and the role of other non-pharmacologic therapies and pharmacologic interventions increases. The Panel recommends first considering nonpharmacologic therapies, including educational, psychosocial-spiritual,and emotional supportive measures. Other interventions to maintain cooler temperatures(including fans) should be considered. If nonpharmacologic measures do not provide desired relief, pharmacologic therapies may be considered as discussed above, including oxygen supplementation(if hypoxia present and/or subjective relief is reported); opioids; and/or

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benzodiazepines, when opioids and other non-pharmacologic measures have not controlled dyspnea. If fluid overload is a contributing factor, there should be consideration of decreasing enteral and parenteral fluids and/or addition of low-dose diuretics (such as furosemide) given as needed and dosed as per clinical scenario.

Anorexia/Cachexia

Cachexia, characterized by physical wasting with loss of both skeletal and visceral muscle mass, is a common condition among patients with cancer.251,252 Many patients with cancer lose the desire to eat(anorexia),which contributes to cachexia. Cachexia can also occur independently from anorexia, as proinflammatory cytokines and tumor-derived factors directly lead to muscle proteolysis.251,252 Cachexia leads to ashenia(weakness), hypoalbuminemia,emaciation, immune system impairment,metabolic dysfunction, and autonomic failure. Cancer-related cachexia has also been associated with disease progression despite cancer treatment,increased treatment toxicity, delayed treatment initiation, early treatment termination, shorter survival, and psychosocial distress.251-253 A study that examined cancer cachexia in a cohort of 1473 patients across all weight ranges showed that muscle depletion conveys a similarly poor prognosis as involuntary weight loss, regardless of body mass index.254

Initial steps include evaluating the rate and severity of weight loss and associated symptoms and educating the patient/family/caregiver on the patient's condition and discussing the risk/benefit of available treatment options. Clinicians should address conditions or symptoms that interfere with food intake, such as dysgeusia, xerostomia, dental/jaw issues,intractable hiccups,mucositis,oropharyngeal candidiasis, depression,early satiety, nausea and vomiting, pain, fatigue, and pancreatic exocrine enzyme insufficiency, among others, and psychiatric evaluation may be considered if the patient has a history of an eating disorder or phobia/anxiety related to swallowing/eating challenges. Treatment may

include modifying medications or the relief of symptoms that interfere with food intake(eg, pain, constipation, nausea/vomiting), as well as metoclopramide for early satiety due to gut dysmotility.218,222,255 The Panel recommends avoiding metoclopramide in the setting of complete bowel obstruction. A swallowing evaluation may also be considered. It is important to assess complexities related to social determinants of health.

Appetite stimulants may be helpful(eg, dexamethasone, olanzapine) if increased appetite is an important aspect of quality of life.256-260 Systematic reviews and meta-analyses of megestrol acetate demonstrate improved appetite and slight improvements in weight gain when using this drug to treat anorexia/cachexia in patients with cancer.257,261 While one quarter of patients treated with megestrol acetate may have increased appetite and 1 in 12 may improve their weight, clinicians should be mindful of the increased risks of thromboembolic phenomena and death.257

A Cochrane review published in 2013257 that reviewed 35 clinical trials that showed some improvement in weight gain, quality of life, and appetite in patients with cancer when compared to placebo, highlighted the higher rates of edema, thrombosis, and death among patients using the drug.When compared to other drugs, such as corticosteroids, there was no improvement in quality of life or appetite.

Although cannabinoid-based interventions (eg, dronabinol, cannabis [colloquially known as marijuana]) have some demonstrated efficacy for treating chemotherapy-induced nausea and vomiting and AIDS-related anorexia, the data to support cannabinoid-based interventions for treating anorexia/cachexia in patients with cancer are very limited, in part due to legal constraints within this field of research.262 A randomized clinical trial of cannabis extract and delta-9-tetrahydrocannabinol in patients with cancer-related anorexia-cachexia syndrome did not demonstrate a benefit of these agents over placebo on appetite and quality of life.263 Another randomized trial comparing megestrol acetate to dronabinol in treating

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cancer-associated anorexia revealed megestol acetate to be superior for promoting weight gain (75% vs. 49% of patients) and appetite (11% vs.3%) in patients with advanced cancer.264 However, to a lesser extent,dronabinol did improve appetite and weight gain in some study patients.Ultimately, for some patients with cancer-related anorexia, cannabisinoids could be helpful. However, it is important to note that cannabinoid administration in patients who are older may induce delirium, and providers should be aware of the local state rules and regulations regarding medicinal cannabinoid use. On a narrative review on the use of cannabinoids in palliating cancer-related symptoms, Hatsfield et al concluded that cannabisin products should not be routinely recommended for cancer supportive care based on conflicting evidence.265 The Panel noted that the quality of evidence for the routine use of megestol acetate or cannabisinoids in patients with cancer cachexia is lacking, and clinicians must assess if the benefits of using pharmacologic therapy outweighing the risks. The Panel highlighted that clinicians may choose not to prescribe pharmacologic intervention for cancer cachexia and treatment. If they do choose to use pharmacologic interventions,clinicians should counsel patients about the risks,benefits, and options for cachexia treatment and reassess on an ongoing basis with consideration of stopping therapy if ineffective.262-265

Although some studies show nutritional interventions to be ineffective,266 consultation with a registered dietitian should be considered, because calorie-dense, high-protein supplementation has demonstrated some efficacy for weight stabilization.218,251,267-269 A meta-analysis found that while nutritional intervention does not significantly affect weight gain or energy intake, it can improve some aspects of quality of life, including emotional functioning, dyspnea, and hunger.270 Nutritional support,including enteral and parenteral feeding as appropriate, should also be considered when the disease or treatment affects the ability to eat and/or absorb nutrients and the patient's life expectancy is months to years.271

The goals and intensity of nutritional support change as life expectancy is reduced to weeks to days. Absence of hunger and thirst is normal in the dying patient, and nutritional support may not reverse weight loss in patients with advanced cancer. Education and emotional support should be provided regarding the natural history of the disease, as artificial nutrition and hydration may increase the risk of fluid overload, aspiration,infection, and hastened death. Overly aggressive enteral or parenteral nutrition therapies can actually increase the suffering of dying patients,and therefore, discontinuing previously initiated enteral or parenteral nutrition near the end of life is appropriate, is ethically permissible, and may improve some symptoms.271-274 A randomized controlled trial of patients with cancer enrolled in hospice found that parenteral hydration had no effect on dehydration symptoms such as fatigue and hallucination,nor any effect on quality of life or survival.275 Therefore, instead of artificial hydration and nutrition, palliative care in the final weeks of life focuses on treating dry mouth and thirst, and providing education and emotional support to the patient, family, and caregiver(s) regarding the emotional aspects of withdrawal of nutritional support. Nutritional consultation may be considered. Eating for pleasure may also be considered but should not be forced upon patients with no hunger or thirst.

Nausea and Vomiting

Chemotherapy-induced nausea and vomiting has a major impact on a patient's quality of life.276 Nausea and vomiting induced by chemotherapy or RT should be managed as outlined in the NCCN Guidelines for Antiemesis(available at www.NCCN.org). Patients who are looking for alternative treatment options for nausea and vomiting related to chemotherapy or RT may consider acupressure.277 Patients can also experience nausea and vomiting unrelated to chemotherapy and radiation,resulting from gastrointestinal obstruction, bowel obstruction, constipation,opioid use, or hypercalcemia.278 These causes should be identified and treated. Palliative RT and corticosteroids should be considered for nausea

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and vomiting related to brain metastases.171,279,280 Proton pump inhibitors and histamine-2 (H2) receptor antagonists can be used to manage gastritis or gastroesophageal reflux. Gastrointestinal obstruction may benefit from treatment with corticosteroids, a proton pump inhibitor, and metoclopramide. However, for patients with complete gastric outlet obstruction, metoclopramide should be avoided; alternative treatment options include endoscopic steric and insertion of a decompressing gastrostomy tube (G-tube). Many medications (including non-prescribed supplements and herbs) can also cause nausea and vomiting. Blood levels should be checked for possible culprits, such as digoxin, phenytoin,carbamazepine, and tricyclic antidepressants $^{281,282 }$ Also, patients should be screened for excess use of cannabis for possible cannabis-associated hyperemesis syndrome, and counseled regarding cessation if indicated.

Non-specific nausea and vomiting are often managed with dopamine- or 5-HT3 (5-hydroxytryptamine 3)-receptor antagonists (eg,prochlorperazine, haloperidol, metoclopramide, olanzapine, ondansetron).However, experts have debated the quality and strength of the evidence to support specific agents in the management of nonspecific nausea and vomiting in palliative care.283,284 A systematic review assessed the level of evidence for antiemesis unrelated to chemotherapy, concluding that antiemetic recommendations have moderate to weak evidence at best.284 More recently, there is an emerging body of evidence for olanzapine for the use in non-specific nausea and vomiting. 285-287 For anxiety-related nausea, the addition of benzodiazepines can be considered. If a vertiginous component to nausea and vomiting exists,anticholinergic/antihistamine agents may be appropriate.

Non-pharmacologic therapies such as acupuncture, hypnosis, and cognitive behavioral therapy (CBT) can also be considered. ${}^{288-290}$ When patients experience dehydration, uremia, or hypercalcemia, the Panel

For persistent nausea and vomiting, the Panel recommends titrating dopamine receptor antagonists to maximum benefit and tolerance. ${ }^{291-295}$ In the setting of continued nausea and vomiting, consider additional drug classes with potential antiemetic properties: corticosteroids, ${ }^{296-298}$ 5-HT3 receptor antagonists, ${ }^{299-301}$ anticholinergic agents and/or antihistamines, ${ }^{297}$ or oral cannabis ${ }^{302,303}$ The appropriate route and frequency of administration should be considered; the Panel recommends prescribing oral, sublingual, or rectal agent as appropriate and titrating to maximum benefit. Opioid rotation can also be considered for patients taking opioid medications that may be causing or exacerbating nausea and vomiting.For persistent/refractory nausea and vomiting, parenteral infusions can be provided as needed, scheduled, or continuously. Subcutaneous or parenteral administration of antiemetic agents can also be used as an alternative. An around-the-clock dosing schedule may provide the most consistent benefit to the patient. Continuous IV or subcutaneous infusions of different antiemetics may be necessary for the management of intractable nausea and vomiting. Alternating timing of agents can be considered to optimize nausea and vomiting control.

Constipation

Constipation occurs in approximately 60% of patients with advanced cancer and most patients treated with opioids.304,305 Although several drugs including antacids, anticholinergic drugs (antidepressants,antispasmodics, phenothiazines, and haloperidol), and antiemetics are known to cause constipation,306 opioid analgesics are most commonly associated with constipation. In addition to physical discomfort,constipation in patients with advanced cancer can cause psychological distress and anxiety regarding continued opioid use.307 Opioid-induced constipation (OIC) should be anticipated and treated prophylactically with a stimulant laxative to achieve a goal of one non-forced bowel movement every 1 to 2 days and add an osmotic laxative if patient can tolerate the liquid volume.308 Increasing intake of fluid and physical activity should also

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be encouraged, when appropriate. Added dietary fiber may be considered for patients with adequate fluid intake.

Preventive measures for constipation include increased fluid intake,increase of dietary fiber, and exercise (if appropriate). If constipation is present, the cause and severity should be assessed. Impaction,obstruction, and other treatable causes, such as hypercalcemia,hypokalemia, hypothyroidism, and diabetes mellitus, and side effects of immunotherapy should be identified and treated. Providers should discontinue any nonessential constipating medications. If impaction is observed, glycerine suppositories (with or without mineral oil retention enema) may be administered or manual disimpaction may be performed following pre-medication with an analgesic and/or anxiolytic. Suppositories and enemas should be used with caution in patients receiving chemotherapy due to the increased risk of the rectal route of administration in the setting of cytopenia. While there is limited evidence regarding the best initial bowel regimen im patients with cancer, 309 one small study compared the use of senna alone versus a senna-docusate combination. The results suggested that the addition of the stool softener docusate was not necessary.310 If constipation persists, adding other laxatives may be considered, such as rectal bisacodyl once daily or oral polyethylene glycol, lactulose, magnesium hydroxide, or magnesium citrate.309 Magnesium-containing products should be avoided in patients with renal failure. If gastroparesis is suspected, the addition of a prokinetic agent, such as metoclopramide, may be considered.

Peripherally acting u-opioid receptor antagonists (PAMORA) may help to relieve resistant OIC while maintaining pain management.311 Studies have shown that methylnaltrexone provided effective relief of OIC while preserving opioid-mediated analgesia.312,313 Naloxegol, a similar PAMORA, has also been studied for treating OIC in patients receiving chronic opioids for noncancer pain.314,315 Based on these results,

methylnaltreoxene every other day (no more than once a day) can be considered for patients experiencing OIC that has not responded to at least two different classes of standard laxative therapy. Methylnaltreoxene should not be used in patients with postoperative ileus or mechanical bowel obstruction.

Diarrhea

In patients with cancer, diarrhea can be caused by a number of potential factors, including cancer treatment-related side effects, infection, antibiotic use, dietary changes, or fecal impaction.316 Diarrhea is a common side effect of various chemotherapeutics(eg, fluorouracil and irinotecan), as well as tyrosine kinase inhibitors and certain biologic agents(eg,ipilimumab, cetuximab, panitumumab).317-320 Abdominal and pelvic RT(alone or as part of chemoradiation regimens) can also induce gastrointestinal toxicity resulting in diarrhea.318,319

The National Cancer Institute Common Terminology Criteria for Adverse Events(CTCAE) are typically used for measuring diarrhea in this patient population.316 The Panel recommends that patients be screened and assessed to determine the severity(grade) and cause of diarrhea.

For patients who have grade 1 (mild) or 2 (moderate) diarrhea,recommendations include hydration and electrolyte replacement (oral or IV fluids as appropriate) and antidiarrheal medications(eg, loperamide). If diarrhea is thought to be chemotherapy-related, dose reduction or discontinuation of therapy may be appropriate. For diarrhea due to irritable bowel syndrome(IBS), utilize cognitive behavioral interventions complementary to medication intervention.321

For grade 2 diarrhea, anticholinergic agents such as hyoscyamine or atropine can be considered in addition to the interventions recommended

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for grade 1. Infection-induced diarrhea should be treated with the appropriate antibiotic. Immunotherapy-related diarrhea can be treated with corticosteroids, infliximab, and/or probiotics (see the NCCN Guidelines for Management of Immunotherapy-Related Toxicities [available at www.NCCN.org). Patients with grade 3 or 4 (severe) diarrhea should receive inpatient treatment (intensive care for Grade 4 diarrhea) if consistent with patient goals. In addition to fluid replacement, antidiarrhe therapy, and anticholinergics, somatostatin analogs (eg, octrootide) can also be considered. For diarrhea due to graft-versus-host disease (GVHD), diet alterations including IV nutrition and steroids may be necessary. In the home setting, subcutaneous hydration can be considered.

For patients with weeks to days of estimated life expectancy, the above interventions can be considered if consistent with the patient's goals of care. At-home IV hydration may be considered in addition to scopolamine or hyoscyamine. If diarrhea persists, consider octrootide or glycopyrrolate.Patients with pain may be started with a tincture of opium if appropriate.

Malignant Bowel Obstruction

Initial steps should include evaluating the severity and cause(s) of bowel obstruction and educating the patient, family, and caregiver(s) on the patient's condition and available treatment options. Underlying causes that are potentially reversible as well as malignant causes should be identified and treated. MBOs are usually diagnosed clinically and confirmed with radiography. The choice of intervention should be guided by the goals of treatment, considering prognosis and relative invasiveness of the intervention proposed.

For patients with years to months to live, surgery(eg,resection, bypass,diverting ostomy) following CT scan is the primary treatment option. While surgery can lead to improvements in quality of life, surgical risks should be

discussed with patients and families, including risk of mortality, morbidity,and re-obstruction.322 Although surgery is the primary treatment for malignant obstruction, some patients with advanced disease or patients in generally poor condition are unfit for surgery and require alternative treatment to relieve distressing symptoms. Risk factors for poor surgical outcome include ascites, carcinomatosis, palpable intra-abdominal masses, multifocal bowel obstructions, previous abdominal radiation,advanced disease, and poor overall clinical status.323 In these patients,medical management can include pharmacologic measures, parenteral fluids, endoscopic management, and enteral tube drainage(silicone tubing)may offer superior comfort over vinyl).

Pharmacologic management of MBO can be separated into two groups of patients: those for whom the goal is to maintain gut function and those for whom gut function is no longer possible. When the goal is maintaining gut function, patients can be treated with opioids, antiemetics, and corticosteroids, alone or in combination. When gut function is no longer considered possible, pharmacologic options also include somatostatin analogs(eg, octrootide) and/or anticholinergics.324-328 If octrootide is helpful and the patient has a life expectancy of at least 1 month, it may be beneficial to consider a depot form of octrootide once an optimal dose is established. Antiemetics that increase gastrointestinal mobility such as metoclopramide should not be used in patients with complete obstruction but may be beneficial when obstruction is partial. Use of octrootide is recommended early in the diagnosis because of its efficacy and tolerability.329,330 Despite positive findings from several smaller randomized trials, a phase III trial of octrootide in 87 patients with MBO did not demonstrate a significant effect of this drug on days free of vomiting;however, in the octrootide group, multivariate analysis did suggest a reduced number of vomiting episodes during the study period.331 If steroids are used, discontinue them if ineffective after 3 to 5 days.

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A venting G-tube(inserted by interventional radiology, endoscopy, or surgery) or an endoscopically placed stent can also palliate symptoms of MBO.332-336 Total parental nutrition can be considered to improve quality of life in patients with a life expectancy of years to months. These interventions have been shown to have little positive impact on survival time but may improve quality of life. ${ }^{162,163}$

adults from the American Academy of Sleep Medicine (AASM)222,351-356 recommend that clinicians use multicomponent CBT for insomnia for the treatment of chronic insomnia disorder in adults.351 A consult to a physiatrist for a tailored exercise therapy program is also an appropriate intervention. For more interventions for sleep disorders, see https://www.wwc.cng.org/professionals/physician gls/pdf/survivorship.pdf.

Sleep/Wake Disturbances Including Insomnia and Sedation

Patients with cancer often suffer from insomnia or daytime sedation.337-339 In a study of 442 patients with advanced cancer, 330 (75%) patients were assessed as having baseline sleep disturbance as assessed by the Edmonton Symptom Assessment System (ESAS) sleep item.340 Clinicians should assess the patient's desire to have insomnia and sedation treated.

The type and severity of sleep/wake disturbance should first be evaluated,including daytime impairments and co-sleeper observations. Primary sleep disorders, such as obstructive sleep apnea (OSA),restless legs syndrome, and periodic limb movement disorder, should be considered for evaluation with a sleep study (if prognosis allows) and treated with nocturnal CPAP or BiPAP.341 Restless legs syndrome, if present, can be treated with ropinrole, pramipexole, pregabalin, gabapentin (for chronic symptoms), or carbidopa-levodopa and clonazepam (for intermittent symptoms). 342-350 Dopamine agonists (eg, ropinirole and pramipexole)should be avoided with concurrent usage of dopamine antagonists (eg,haloperidol, olanzapine, quetiapine). Worries and anxiety regarding cancer-related stressors should be explored, and other contributing factors to sleep/wake disturbances should be treated, including pain, depression,anxiety, delirium, and nausea.

For isolated nceep-onset insomnia, consider pharmacologic management options that include dual orexin receptor antagonists (DORA) such as daridorexant, lemborexant,suvorexant,ramelteon, melatonin, and benzodiazepine receptor agonists (BZRA) such as zolpidem, eszolipem1, and and zaleplon. Caution needs to be exercised when using BZRA in patients who are older, frail, have cognitive impairment, or are taking opioid medications. For sleep maintenance, DORA and doxinpin can be considered. For refractory insomnia, pharmacologic management options include antipsychotic medications such as chlorpromazine, quetiapine,and olanzapine; melatonin or the melatonin-receptor agonist ramelteon;and sedating antidepressants such as trazodone and mirtazapine. ${}^{357}$ The Panel suggests that mirtazapine may be especially effective in patients with concurrent depression and anorexia. Benzodiazepines should be avoided, particularly among patients who are older, on opioid medications,and with cognitive impairment, because these agents have been shown to cause decreased cognitive performance. ${ }^{358}$ Similar caution for these patients should also be exercised when administering zolpidem due to the known risk of next-morning impairment. Additional agents for insomnia are listed in the Palliative Care Drug Appendix in the algorithm.

For refractory daytime sedation, the Guidelines suggest several options.The central nervous system stimulants methylphenidate or dextroamphetamine can be given. If the effect of the drug does not last through lunch, a second dose can be given at lunch, preferably no later than 2:00 PM. Doses can be escalated as needed.359 Another option for

CBT for insomnia(CBT-I) is a preferred strategy of first-line therapy over pharmacologic intervention. The clinical practice guidelines for the use of behavioral and psychological treatments for chronic insomnia disorder in

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refractory daytime sedation is the psychostimulant modafinil, which has been approved in adults for excessive sleepiness associated with OSA/hypopnea syndrome(OSAHS), shift work sleep disorder, and narcolepsy.360 A combination of dextroamptetamine and amphetamine is also recommended at 10 to 60 mg per day in 1 to 3 divided doses for daytime sedation. The Panel also recommends caffeine as an additional option for refractory daytime sedation. The last dose of caffeine should be given no later than 4:00 PM. Please also see the NCCN Guidelines for Adult Cancer Pain and the NCCN Guidelines for Cancer-Related Fatigue(available at www.NCCN.org) for their discussions on sleep/wake disturbances.

Delirium

Delirium should be evaluated for severity and cause using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)criteria.361 NCCN DT for distress evaluation can be found in the NCCN Guidelines for Distress Management (available at www.NCCN.org).Potentially reversible causes should be identified and treated appropriately.362 Delirium may present as either a hypactive or a hyperactive subtype.363 Studies have suggested that hypoactive delirium was the most prevalent subtype in patients receiving palliative care and that this condition is often underdiagnosed due to its presentation.364,365

Delirium-inducing medications(eg, steroids, anticholinergics,

benzodiazepines) should be reduced or eliminated as much as possible.366

Non-pharmacologic interventions(eg, optimize sleep-wake cycle, address sensory impairment, provide glasses/hearing aids) should be maximized before pharmacologic interventions are used for both patients with delirium

and those at high risk for delirium. Caregivers should be supported in caring for their loved one and coping with this distressing condition.

The Panel emphasized the importance of maximizing nonpharmacologic interventions and considering risks and benefits in the context of prognosis

for pharmacologic treatment of delirium. ${}^{367}$ Limited studies are available to inform pharmacologic choices in treating delirium. A 2020 Cochrane review meta-analysis concluded that there was no high-quality evidence to support or recommend against drug therapy in patients with delirium at the end of life. ${}^{368}$ Despite widespread use of antipsychotics for managing symptoms of delirium in palliative care, mixed evidence has been presented regarding use for delirium in patients with advanced cancer. In general, historical evidence supported the use of short-term, low-dose antipsychotics for managing symptoms of delirium with close monitoring for potential adverse effects. ${}^{369,370}$ Haloperidol has often been used as a first-line agent, with alternative options such as olanzapine, risperidone,and quetiapine, titrating dose to optimal effect with the lowest possible dose. ${}^{371-373}$ However, more recent data favor the use of benzodiazepines over antipsychotics, particularly in mild to moderate delirium. ${}^{374,375}$ In studies of patients in palliative care or critically ill patients in the ICU,antipsychotics such as haloperidol, risperidone, and zipirosidone were ineffective at significantly reducing symptoms of delirium. ${}^{374,376}$ Additionally, in one trial, the cohort receiving placebo with supportive care had longer overall survival times than the cohort receiving halperolidol. ${}^{374}$ Based on the mixed evidence available, the Panel recommends maximizing nonpharmacologic interventions and considering use of low-dose benzodiazepines with or without antipsychotic medications if agitation is severe and either disrupting care or causing the patient distress.

The dosages of these symptom-management medications should be titrated to optimal effect with the lowest effective dose. Opioid dose reduction or rotation can also be considered for patients with severe delirium. In a recent multicenter, patient-based registry cohort study, Yoo et al377 found a significant, dose-dependent association between increased risk of delirium in patients with advanced cancer and use of opioid.

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decision-making. RT can be considered for patients with delirium due to brain metastases; however, there are currently no data demonstrating improvement, and palliative efforts should be intensified with the awareness that delirium is often a marker for a shorter prognosis.378-380

For the dying patient, the focus should shift to family/caregiver support and education. Supportive caregivers should be allowed to be present at bedside if that aligns with patient and family preferences. Medications that are no longer necessary should be discontinued, and dose reductions of all other medications should be considered, especially if dependent on hepatic/renal function. Under- or overtreatment of pain can exacerbate delirium, as can fecal impaction, urinary tract infection(UTI), or distended bladder; these should be excluded as potential causes. Opioid rotation can be considered(see NCCN Guidelines for Adult Cancer Pain[available at www.NCCN.org]) if the delirium is believed to be caused by neurotoxicity from the current opioid. If delirium is a result of disease progression and goals of care are comfort-oriented at the end of life, palliative care should be focused on symptom management and family support. Benzodiazepine medications with or without antipsychotics should be dose adjusted and/or have their route of administration changed to ensure adequate delirium symptom management, as appropriate,381 It is also important to note that sedation may be a side effect of the treatment, and it is recommended to ensure that the treatment plan is consistent with goals and prognosis. In severe delirium, sedation is also the goal and the evidence for effective pharmacologic intervention is conflicting and limited. It is also necessary to prepare the family and caregivers that delirium may not resolve. For refractory delirium that is causing distress in dying patients, proportional sedation can be considered following consultation with a palliative care specialist and/or psychiatrist(see below). Please also see the NCCN Guidelines for Distress Management for further discussion of delirium in patients with cancer.

Malignant Wounds

Malignant wounds are the result of cancerous cells infiltrating the skin and its supporting blood and lymph vessels, causing loss in vascularity that leads to tissue death. Malignant wounds may originate as a primary cancer or as a metastasis to the skin from a local or distant tumor.382 Malignant wounds may cause many distressing symptoms that negatively impact quality of life. In most cases, a combination of discharge, odor,bleeding, pruritus, local inflammation, and/or pain accompany the wound,requiring medical attention and treatment.383

The Panel recommends treating malignant wounds if potentially reversible in patients with an estimated life expectancy of years to months.Management of malignant wounds may include treatment of underlying cancer and comorbid conditions, including poor nutritional status that increases risk for impaired wound healing; local wound management; and symptom relief. Treatment options include surgical debridement, skin grafting, wound-directed treatment with radiation, systemic treatment,vacuum-assisted wound closure, wound cleansing/irrigation, dressing changes,treating infection, optimizing nutrition/mobilization, and preventing wound spread. Cancer-directed systemic therapy may need to be adjusted based on associated side effects of antineoplastic drugs and risk to exacerbate wounds.383 Selection of the appropriate wound dressing is highly important for malignant wound care and, if available,the Panel recommends consultation with wound care specialists.

In the dying patient, the Panel recommends interventions focused on symptom relief. For odor, wound cleansing/debridement, topical antibiotic gel, activated charcoal/silver sulfadiazine dressings, external odor absorbers, and/or avoiding strong“cover” odors are recommended. For infection, topical/systemic antibiotics and/or irradiated honey applications are recommended. For exudate, absorbent alginate, foam dressings,and/or drainage stoma appliance(if high volume) are recommended. For

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bleeding, hemostatic dressings (alginate, collagen, non-adherent gauze,gelfoam, and sucralfate paste), oral antifibrinolytics, radiotherapy or embolization (if brisk bleeding), dark-colored linens, anxiolytics, and/or pain management are recommended. For pain, use of non-absorbent dressing or reducing frequency of dressing changes may be considered.Topical opioid and/or local anesthetic may be applied. Pain should be treated according to the NCCN Guidelines for Adult Cancer Pain(available at www.NCCN.org).For purritus, topical doxinep cream, cooled hydrogel sheet dressings, and/or transcutaneous electrical nerve stimulation (TENS) trial are recommended. For body image,recommended strategies include maintaining symmetry in dressings,managing wound odor and exudate, and/or screening for depression or anxiety.

Social Support/Resource Management

For distress related to psychological or psychiatric complications and spiritual or existential crisis, please see the NCCN Guidelines for Distress Management(available at www.NCCN.org).

For best outcomes, psychosocial-spiritual support should be integrated into routine cancer care across all disease stages and in both the inpatient and outpatient settings.30,384-386 A systematic review of patients with advanced cancer identified psychosocial-spiritual resources among the factors that promoted personal growth during the experience of cancer.387

For patients with estimated life expectancy ranging from years to months experiencing psychosocial-spiritual distress, social support/resource management should be offered. Patient/family/caregiver(s)' coping and adjustment to the illness should be assessed, along with the safety of the environment and the availability of caregivers. In addition, it is important to ensure that the patient has adequate access to transportation and sufficient financial resources. Cultural issues, including the need for

medical interpreters/translators unrelated to the patient, should be addressed. Support from social services (social worker, psychologist,and/or psychiatrist) may also be appropriate for the patient as well as caregivers and family members, and should be provided in the form of counseling, child life services, art and music therapy (if available), support groups, and physical medicine/rehabilitation training for transfers and repositioning. 388-390 Personal, spiritual, or cultural issues related to the patient's illness and prognosis should be addressed.391 Family/caregivers for risk factors associated with complicated grief need to be periodically assessed and monitored. Respite care for families and caregivers in crisis should be considered. Complexities related to social determinants of health need to be assessed and addressed adequately.

In a dying patient with an estimated life expectancy of weeks to days, the patient's desires for comfort should be evaluated and supported. The process of dying and the expected events should be explained to the patient, family, and caregivers. Child life services should be provided if appropriate and available, and clinicians should respond to caregiver-specific demands, stresses, and conflicts (consider social work referral).Medical interpreters/translators who are not related to the patient and family may be obtained as needed. Periodic reassessment and monitoring of family/caregiver for risk factors associated with complicated grief is recommended. Culturally and spiritually congruent care should be ensured. Eligibility, readiness, and need for specialized palliative/hospice care including open access hospice programs (if available) should be determined.

Palliative Care Reassessment

All patients should be reassessed regularly, and effective communication and information sharing must exist between the patient, caregivers, and health care providers. Patients and family members benefit most from ongoing discussions about the natural history of the disease and

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prognosis in clear, consistent language. Desired outcomes as a result of palliative care assessment and intervention include the following: 1)patient satisfied with response to cancer therapy; 2) adequate symptom management; 3) reduction of patient/family/caregiver distress; 4)acceptable sense of control; 5) decision-making capacity; 6) decreased caregiver burden; 7) strengthened relationships; 8) optimized quality of life; 9) personal growth and enhanced meaning; and 10) advanced care planning in progress.392-395

If there are ongoing needs, upon reassessment, the oncology or palliative care team should reevaluate intervention options, and intensify as possible,if needed. The Panel also recommends promoting adaptive coping strategies.152 The oncology team should also consult specialized palliative care services, hospice, or an ethics committee when needed. Consultation with a mental health professional and/or addiction specialist to evaluate and treat undiagnosed psychiatric disorders and substance use disorders should be considered as appropriate. If psychosocial-spiritual distress persists, palliative care options should be intensified, and patients should receive care according to the NCCN Guidelines for Distress Management(available at www.NCCN.org).

Patients' treatment goals and expectations may change and evolve as disease progresses. Reassessment should be ongoing, with continuation or modification of life-expectancy-guided palliative care until the patient's death or survivorship.

End-of-Life Care Issues

Preparing Patients/Families/Caregivers for End-of-Life and Transition to Hospice Care

A multicenter survey of acute care hospitals revealed discordance between patients' stated values and corresponding treatment preferences for end-of-life care. The study highlighted the need for medical decision

support to ensure that patient preferences were grounded in a clear understanding of their illness and end-of-life treatment options. ${ }^{396}$ SPC consultation should be considered to assist in conflict resolution when the patient, family, and/or medical professional team do not agree on the benefit/efficacy of interventions.

For patients with an estimated life expectancy of years or years to months,health care professionals should engage in clear, consistent discussion with the patient, family, and caregiver(s) about prognosis and anticipated care needs on an ongoing basis. Advance care planning should be initiated, along with an assessment of decision-making capacity and the need to identify a surrogate decision-maker. Providers should elicit patient values and preferences with respect to quality of life and the need for specialized palliative care, or eligibility and readiness for hospice care should be introduced, educated, and assessed as appropriate. When the patient's functional status indicates a 6- to 12-month prognosis, a dedicated“hospice information” visit with the oncologist may ease transition to hospice care in the future by preparing the patient, family, and caregiver(s), and reassuring them that their oncologist can remain involved.

For patients with an estimated life expectancy of months to weeks or weeks to days, the oncology team should assess patient/family/caregiver understanding of the dying process and provide education as needed.Providers should address potential need for transitions in care while ensuring continued involvement of the primary care physician and primary oncology team. Referrals should be made to hospice care agencies, as well as for psychosocial assessment, legacy work, grief counseling,spiritual screening, and funeral/memorial service planning, as necessary.The goals and needs of the patient and family regarding the dying process should be respected.

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Dying patients may wish to prepare for death and help prepare family members to go on without them. Both patients and families benefit from education in the dying process. Families should be guided through their anticipatory grief, and arrangements should be made to ensure that the patient, family, and caregiver needs and goals regarding the dying process are respected. Planning to ensure continuing care and referrals to appropriate care is important. Arrangements should be available to ensure that the patient does not die alone unless that is the patient's preference.Other involved health care professionals should be informed of the patient's death.

Response to Requests for Hastened Death

The most appropriate initial response to a request for hastened death is to explore the meanings behind that request and ensure palliative care needs are being met.397 The AAHPM has released a position statement and advisory brief regarding this topic with guidance for health care professionals on how to evaluate and respond to these requests.398,399 The Panel recommends that patients requesting hastened death may be referred to a palliative care specialist. Open exploration of the patient's request for hastened death may identify unmet needs and new palliative care interventions that may be helpful.397,400 Concerns related to the withdrawal of life-sustaining treatment, voluntary cessation of eating and drinking, and/or sedation should be discussed with patients and families.Psychiatric consultation to evaluate and treat reversible causes of psychological suffering should be considered. Patients should be assured that their health care team is committed to providing continuing care. It is important for physicians to know the local legal status and local health system policies and procedures of medical aid in dying(MAID), as other states have pending legislation regarding either prohibiting or permitting MAID.397 Several organizations have released position statements and/or helpful websites on the issue of MAID(see Table 1 at the end of this Discussion section).

Shared Decision-Making in the Care of the Imminenly Dying Hospitalized Patient

An imminently dying patient is defined as one within hours of death who is not stable enough for transport.401 Caring for an imminently dying patient is intense for the patient, family, caregiver(s), and health care team.An international qualitative study described many of the common non-pharmacologic palliative care activities provided in the last days of life.402 An end-of-life care order set for patients wishing to focus on comfort that includes physical, practical, and psychosocial-spiritual interventions may be beneficial for practitioners to use for imminently dying patients. If not already done, obtaining a hospice evaluation may also be helpful.

For patients whose goals shift to comfort at the end of life, the physical aspects of care for an imminently dying patient focus on adequate symptom management. Approaches may include intensifying comfort care; discontinuation of unnecessary diagnostic tests and interventions;deactivation of implanted devices as indicated; alternate routes of medication administration if the oral route is not feasible; and managing terminal secretions, delirium, and dyspnea. Proportional sedation can be considered for refractory symptoms. ${ }^{241,403,404}$ It is also important to be prepared for patient and family requests for autopsy and/or organ donation.

The psychosocial-spiritual aspects of care for an imminently dying patient whose goals have transitioned to comfort focus on individual and family goals, preferences, cultures, and religious beliefs. Open communication should occur between the patient, family, caregiver(s), and care team regarding the physical and psychological aspects of the dying process and the importance of honoring any advanced directives. The patient/family/caregiver should be educated about the signs and symptoms of dying and the rationale for discontinuation of treatment or medications that may not add to the patient's comfort. The care plan may

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also include consultation with psychosocial-spiritual providers, including but not limited to social workers, chaplains, child life specialists, and psychologists to meet the social and spiritual needs of the patient and their family/caregivers; counseling to promote healthy grieving; support for children/grandchildren; and education for parents on age-appropriate giving processes.

The practical aspects of care for an imminently dying patient in the hospital include mobilizing in-hospital end-of-life care policy and procedures; ensuring that the patient's advance directive is documented and implemented; securing a private room for the patient when possible;and enabling family presence around the clock as appropriate. If not already done, patient/family/caregiver wishes for resuscitation should be discussed and documented. In this context,CPR is unlikely to be effective;providers should recommend other options for resuscitation such as"Do Not Resuscitate"(DNR),"Do Not Attempt Resuscitation"(DNAR), and“Allow Natural Death”(AND) orders and promote comfort care. Providers should be aware that policies regarding resuscitation may differ based on treatment setting. A patient with a documented inpatient DNAR order may also require DNAR orders for out-of-hospital settings(eg, residential care,ambulance transport). In states where MOLST/POLST has been established, it is important to complete this document, as it will protect the patient's wishes across all treatment settings. If in-person visits are restricted or not possible, facilitate virtual visits.

Proportional Sedation

Proportional sedation(formerly known as palliative sedation) is the intentional lowering of awareness towards, and including,

unconsciousness for patients with severe and refractory symptoms with the primary goal of symptom relief. The NCCN Guidelines committee has replaced the term palliative sedation with proportional sedation. The change is intended to emphasize that the level of sedation should be

proportionate to the patient's symptom burden. Proportional sedation may be considered for imminently dying patients (life expectancy of hours to days) with refractory symptoms that persist despite comprehensive,interprofessional palliative care.4045,406 The Panel recommends referring to institutional guidelines/policy and state/national regulations for additional guidance, as well as involvement of an ethics consultation as appropriate.406

Generally, if proportional sedation is being considered, a prognosis of imminent death should be confirmed and informed consent must be obtained from the patient and/or a surrogate or family member following discussions of the patient's disease status, treatment goals, prognosis,and expected outcomes.407

Proportional sedation has its ethical justification in the Doctrine of Double Effect, 408-413 which provides guidance for situations where an attempt to do good may have unwanted side effects(eg), providing medication for the relief of suffering that also causes sedation). Studies have investigated whether palliative sedation shortens survival. Results obtained from systematic reviews did not reveal a clear impact of palliative sedation on survival time, although many of the included studies lacked high-quality data. 414,415

After-Death Care Interventions

Comprehensive palliative care for the patient's family and caregivers continues after the patient's death. Immediate issues include informing the family(if not present), offering condolences, and providing the family time with the body. Chaplain or other spiritual leader involvement to assess the family's desire for religious ritual or spiritual support may be helpful.Additional concerns include ensuring culturally sensitive and respectful treatment of the body,including removal of tubes, drains, lines, and the Foley catheter(unless an autopsy is planned); addressing concerns about

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organ donation or autopsy; facilitating funeral arrangements through completion of necessary paperwork; and informing insurance companies and previous medical, palliative, and psychological care teams of the patient's death.

Bereavement support should be offered, beginning with a personal visit or telephone call from the patient's primary oncology team, followed by a condolence letter. Periodic assessment and monitoring of family/caregiver for risk factors associated with complicated grief is recommended.

intense, prolonged symptoms of grief, coupled with functional impairment beyond 6 months post-loss. ${416-419}$ Children of patients with cancer

Additionally, a study suggested that certain predictors of prolonged grief could be identified in family caregivers at the time of the patient's entry to palliative care; these factors include severity of pre-death symptoms;condition of the caregiver's relationship to the patient; impact of caregiving duties on the caregiver's schedule; quality of family functioning; and level of optimism, especially if low.420

Bereavement care is often best provided by an experienced hospice team or a skilled mental health care professional. The family may request a debriefing meeting from the medical team and may require assistance in identifying community bereavement resources. A well-supported end-of-life care experience will facilitate the family's acceptance of appropriate referrals for cancer risk assessment and risk modification. If not already recommended, providers should direct family members towards genetic screening, especially if the deceased patient was positive for known genetic markers that confer risk. For more information, see the NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast,Ovarian, Pancreatic, and Prostate and NCCN Guidelines for

Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric(available at www.NCCN.org).

Putting Palliative Care Guidelines into Practice

Institutions should develop processes for integrating palliative care into cancer care, both as part of usual oncology care and for patients with SPC needs. Many approaches to this have been described, but there is no single best practice.21-29,421

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 palliative care knowledge, skills, and attitudes. Skilled palliative care specialists and interprofessional palliative care teams,including board-certified palliative care physicians and advanced practice providers, should be readily available to provide consultative or direct care to patients and families who request or require their expertise. Finally, the quality of palliative care should be monitored by institutional quality improvement programs.

The experiences of patients with cancer begin with diagnosis, and many palliative care questions should be considered early in the comprehensive cancer care plan. As cancer progresses and the value of further anticancer therapy diminishes, palliative measures should be intensified.Clear and consistent discussion of goals, values, preferences, prognostic information, and therapeutic options can help patients, families, and providers make appropriate decisions in a shared manner.

Undergoing anticancer therapy should not preclude addressing end-of-life issues. Collaborating with palliative care experts on such matters extends oncologists' therapeutic repertoire and diminishes the stress of caring for patients who have incurable disease. Increasing emphasis on palliative care in oncology should improve patient outcomes and provide new

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avenues for clinical research and professional satisfaction. The timely introduction of members of the institutional or community palliative care team allows patients to meet the individuals who will help them and their families through their experience. Because the diagnosis of cancer and impending death is such a frightening experience, oncologists must work to alleviate those fears by assuring patients that the members of the oncology and palliative care teams will work with them and their families regardless of what happens. Additionally, oncologists must discuss prognosis with both the family and the palliative care team in order to anticipate and manage concerns commonly associated with the diagnosis and treatment of cancer.

As the disease progresses, many patients and families need help coping with the implications of increasing disease burden. Some patients and families have great difficulty accepting a poor prognosis and, as a result,do not engage in advance care planning.422,423 This may be a sign of imperfect understanding of the disease and should be addressed directly and compassionately.423 Palliative care supports ongoing education to help patients and families better understand and prepare for disease progression.

Oncologists should encourage advance care planning early in the disease trajectory in order to assess and cultivate prognostic awareness and create a care plan that is consistent with the patient's wishes. In addition,advance care planning can lessen the burden of making difficult end-of-life decisions. The combined efforts of the oncology team and the hospice/palliative care team can improve the overall outcome for patients and their families.

Psychosocial-Spiritual Support for Oncology and Palliative Care Providers

After the loss of a patient, psychosocial-spiritual support should be available for providers who have been involved in the patient's care. A bereavement or memorial ritual, such as a brief reading or moment of quiet, can be considered. Funeral attendance by health care professionals may also be considered. Health care professionals should review medical issues related to patient death, explore concerns and questions about quality of patient care, and review emotional responses of family and staff to the patient's death.

Oncology and palliative care teams commonly encounter patient loss and deal with grief, and over time the resultant emotional distress can lead to compromised resilience, including provider burnout, intra-team conflicts or disagreements, compassion fatigue, and ethical concerns or moral distress.424-428 These syndromes can manifest as symptoms of depression,anxiety,fatigue,and low mental quality of life.429 Personnel experiencing such symptoms should be identified and assisted. Considerable research has been dedicated to evaluating patterns of patient, family, and caregiver grief, and interventions to mediate this distress. Far less attention has been devoted to similar issues among health care providers and teams;further research is needed. For a summary of the literature on compassion fatigue and burnout among oncology providers, see reviews by Najiar and colleagues,424 Shanafelt and Dyrbye,429 and Sherman and colleagues.430

Although limited in quantity, most studies on compassion fatigue are derived from the oncology nursing literature. A large survey of hospice and palliative care providers(eg, clinical, administrative, allied health workers)revealed a strong correlation between burnout and compassion fatigue,and revealed the need for enhanced support of individuals in this field.431 Additionally, a cross-sectional survey of nurses, medical assistants, and radiology technicians at a comprehensive cancer center revealed

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concerning levels of burnout and compassion fatigue in both inpatient and outpatient care settings.432 A resiliency program was piloted and eventually scaled hospital-wide to educate providers on these issues and provide interventional strategies. Improvements in burnout and secondary traumatic stress were observed.432,433 Several studies from the Mayo Clinic demonstrated that mindfulness training through the Stress Management and Resiliency Training(SMART) program was able to improve anxiety,stress, quality of life, and mindfulness among providers.434-436 A meta-analysis of efficacy data on meditative interventions for health professionals demonstrated a small to moderate benefit according to measures of emotional exhaustion(effect size 0.37; 95% CI, 0.04-0.70),sense of personal accomplishment(effect size 1.18; 95% CI, 0.10-2.25),and life satisfaction(effect size 0.48; 95% CI, 0.15-0.81).437

Qualitative research on compassion fatigue interventions reveals that oncology clinicians rated the following resources as helpful: educational interventions, support programs or resources in the workplace, retreats,and self-care measures.424,438 Unfortunately, despite the reported desire for such interventions, access can be limited. In a nationwide survey of oncology nurses, only 60% of survey respondents reported access to an employee assistance program,45% reported no offerings of education addressing workplace coping, and 82% of respondents reported no off-site programs such as retreats.438

Generally,evidence-based interventions for compassion fatigue, moral distress, and burnout in physicians are lacking. When asked to provide useful preventive measures and coping strategies, palliative care specialists recommended emphasizing the rewarding aspects of their work and strategies for “enhanced meaning-making.”439 Experts in the field have also highlighted the importance of self-awareness and self-care measures for oncologists and palliative care specialists to decrease levels of compassion fatigue.440 To this end, self-care was established as a core

competency area for fellows in hospice and palliative medicine.440 Examples and evidence for additional preventive strategies and solutions for oncologist burnout have been reviewed by Shanafelt and Dyrbye.429

Conclusion

These Guidelines are intended to help oncology teams incorporate palliative care into their practice and thereby provide the best and most comprehensive cancer treatment possible for patients with incurable cancer. Patients with advanced disease may be overly optimistic about their chances of cure and survival, and this can have a negative effect on their quality of life. One study found that those who overestimated their survival were more likely to die a bad death.118 Using a decision aid, Smith et al found that most patients want honest information, even if it is bad news.441 Although use of the decision aid typically took 20 minutes and was challenging for oncologists, it did not cause patients to give up hope or become distressed. Physician-led discussion of disease progression and death can improve quality of care and quality of life for both patients and families.442 Providing information in a collaborative manner protects the autonomy of patients to make informed decisions based on potential treatment outcomes.443 Palliative care can help patients and families set realistic expectations and meet short- and longer-term goals, such as important life-cycle events. Much of the care outlined in these Guidelines is geared toward a different hope than that for cure of the disease itself.127,441,444 Even when cure is no longer possible, hope remains: hope for dignity, comfort, and closure and for growth at the end of life. It is our hope that these Guidelines will help oncology and palliative care professionals together create a better future for patients, families, and providers.

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Table 1: Palliative Care Internet Resources for Clinicians

$^{a}$ Adapted with permission from Khatcheressian J, Cassel JB, Lyckholm L, et al. Improving palliative and supportive care in cancer patients. Oncology (Williston Park) 2005;19:1365-1376.

|Palliative Care Clinical Competencies|| |---|---| |www.epec.net|Education in Palliative and End-of-Life Care (EPEC): Comprehensive curriculum covering fundamentals of palliative medicine; teaching guides| |www.bidmc.org|Hospice & Palliative Medicine Educational Curriculum at Beth Israel Deaconess Medical Center: Online education for physicians, nurses, and pharmacists| |Clinical,Educational, Educational, Professional, and Public Resources|| |www.palliativedrugs.org|Extensive information on pharmacologic symptom management| |www.aahpm.org|American Academy of Hospice and Palliative Medicine (AAHPM): Physician membership organization; board review courses; publications| |www.abim.org|American Board of Internal Medicine: Physician Board Certification| |www.nhpco.org|National Hospice and Palliative Care Organization: Nonprofit membership organization representing hospice and palliative care programs and professionals in the United States| |www.hpna.org|Hospice & Palliative Nurses Association: Specialty nursing organization with evidence-based educational tools for the nursing team| |pallcare.hms.harvard.edu|Center for Palliative Care at Harvard Medical School: Faculty development courses, other educational programs| |www.nationalcoalitionhpc.org/ncp|National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care, 4th edition (NCP Guidelines)| |www.americangeriatrics.org|American Geriatrics Society: Clinical guidelines and continuing education| |www.cancerpatienteducation.org|Cancer Patient Education Network (CPEN): Health care professional organization for sharing experiences and best practices in all aspects of cancer patient education| |Palliative Care Program Development|| |www.capc.org|Center to Advance Palliative Care: Technical assistance for clinicians and hospitals seeking to establish or strengthen a palliative care program| |www.capc.org/palliative-care-leadership-centers|Palliative Care Leadership Centers: Eight exemplary palliative care programs providing site visits, hands-on training, and technical assistance for new palliative care clinicians and programs| |Physician-Assisted Dying|Statement on Physician-Assisted Dying approved by the AAHPM Board of Directors|

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NCCN Guidelines Version 1.2026 Palliative Care

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表 1
ASSESSMENT BY ONCOLOGY TEAM
·Natural history of specific tumor	●Natural history of specific tumor
·Potential for response to further treatment
·Potential for treatment-related toxicities
·Patient's understanding of disease prognosis	PAL-89,h
·Hopes for and understanding of cancer therapy	●Hopes for and understanding of cancer therapy
·Impairment of vital organs	●Impairment of vital organs
·Performance status
·Serious comorbid conditions
·Shared decision-making with patient/family/caregiver(s)
·Document surrogate and discuss advance care planning	PAL-89,h
·Patient/family/caregiver values and preferences about information	Advance Care Planning (PAL-29)
·Patient/family/caregiver values and communication	Preparing Patients/Families/Caregiver(s) for End
·Hopes for and understanding of cancer therapy	of Life and Transition to Hospice Care
·Quality of life	(PAL-28)
·Dyspnea	Pain (PAL-10)
·Dyspnea/cachexia	Dyspnea (PAL-11)
·Anorexia/cachexia	Anorexia/Cachexia (PAL-13)
·Nausea/vomiting (NV)	Nausea/Vomiting (PAL-15)
·Constipation	Constipation (PAL-17)
·Diarrhea	Diarrhea (PAL-18)
·Malignant bowel obstruction	Malignant Bowel Obstruction (PAL-20)
·Fatigue/weakness/asthenia	NCCN Guidelines for Cancer-Related Fatigue
·Insomnia/sedation	Insomnia/Sedation (PAL-22)
·Delirium	Delirium (PAL-23)
·Malignant wounds	Malignant Wounds (PAL-25)
● Lymphedema	NCCN Guidelines for Survivorship
● Hormone-related symptoms	NCCN Guidelines for Distress Management
● Distress	NCCN Guidelines for Distress Management
● Immunotherapy-related toxicities	NCCN Guidelines for Management of Immunotherapy-Related Toxicities
●Fertility and intimacy concerns	NCCN Guidelines for Survivorship

表 2
● Educational and informational needs	● Patient/family/caregiver values and preferences about information and communication ● Cultural factors ● Patient/family/caregiver perceptions of disease status	Preparing Patients/Families/Caregivers for End of Life and Transition to Hospice Care (PAL-28)
● Cultural factors	● Patient/family/caregiver perceptions of disease status	● Property of Life and Transition to Hospice Care (PAL-28)
● affecting care	● Patient/family/caregiver perceptions of disease status	● Property of Life and Transition to Hospice Care (PAL-28)

表 3
ASSESSMENT	ASSESSMENT	INTERVENTION
Any Grade		● Treat underlying cause as appropriate ● If chemotherapy induced, decrease or delay the next dose of chemotherapy ● If immunotherapy-induced diarrhea, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities ● For GVHD diarrhea, consider limiting diet, steroids, and IV nutrition ● Provide oral hydration and electrolyte replacement ● Provide IV fluids and hydration if patient is unable to tolerate oral fluids
Mild/Grade 1		● Consider antidiarrheal agents (eg, loperamide) and/or dietary changes if infection ruled out ● If IBS-related, utilize cognitive behavioral interventions complementary to medication interventions
Moderate/Grade 2		● Provide IV fluids if patient is unable to tolerate oral fluids ● Initiate/continue antidiarrheal agents-as above if infection ruled out ● Consider anticholinergic agents ● If non-C. diff infection-related, treat with appropriate antibiotics ● If C. diff infection-related, administer antibiotics and probiotics as appropriate
Severe/Grades 3/4		• Inpatient hospitalization (intensive care for Grade 4) if consistent with goals ● Provide IV fluids and use antidiarrheal agents and anticholinergics ● Consider somatostatin analog

表 4
ESTIMATED LIFE EXPECTANCY	ASSESSMENT AND INTERVENTIONS●Assess patient's desire to have insomnia and sedation treated and provide cognitive behavioral interventions ●Ueducate patient/family/caregivers on patient's condition and treatment options ●Evaluate type/severity of sleep-wake disturbance, including daytime impairments and co-sleeper observations ●Explore worries and anxiety regarding cancer-related stressors ●Provide sleep hygiene education ●Refer to cognitive behavioral therapy for insomnia (CBT-I)aa,bb Sleep restriction and stimulus control ●Assess for and treat contributing factors ●Pain,depression,anxiety,delirium,and nausea ●Medication side effects or withdrawal syndromes ●(eg,corticosteroids,opioids,anticonvulsants,caffeine, hormones, herbals,barbiturates, benzodiazepines, alcohol, TCAs) ●Primary sleep disorders such as obstructive sleep apnea,restless legs syndrome, and periodic limb movement disorder ●Continuous positive airway pressure (CPAP)/Bilevel positive airway pressure (BiPAP) ●Obtain sleep study (if prognosis allows) ●Consider addition of pharmacologic therapies for refractory	Outcomes●Adequate management of symptoms ●Reduction of patient/family/caregiver distress ●Re-evaluate contributing etiologies ●Change insomnia or antisedation therapy ●Re-evaluate palliative care interventions and is possible ●Consult or refer to specialized palliative care services or hospice
(dying patient)	sleep/wake disturbance ●Insomnia: ●Antipsychotics ●Sedative/hypnotics ●Antidepressants ●Daytime sedation: ●CNS stimulant/wakefulness-promoting agents ●Consider consult to physiatrist for tailored exercise therapy program	※es could give distress on the problem. ●Relangeessment ●Re-evaluate contributing etiologies ●Change insomnia or antisedation therapy ●Re-evaluate palliative care interventions and is possible ●Consult or refer to specialized palliative care services or hospice

表 5
Condition	Recommended Agents and Dosage by Estimated Life Expectancy and Symptom Etiology
Pain (PAL-10)	●Please see NCCN Guidelines for Adult Cancer Pain(PAIN-G) for detailed information on opioid principles, prescribing, titration,maintenance,and safety.Be aware of state and local regulations regarding opioid prescriptions.
Dyspnea (PAL-11)	Life Expectancy: Years; Months to Year; and Weeks to Months General: Opioids a lowest effective dose with titration as appropriate can be used to treat dyspnea that is resistant to other therapies. Base dosing on patient's opioid requirement. If patient's opioid requirement is unknown, start with low doses and titrate up as appropriate. ●Fluid overload: Furosemide PRN dosing as per clinical situation
Dyspnea (PAL-12)	Life Expectancy: Days to Weeks(dying patient) ●Anxiety:Benzodiazepines (eg,Lorazepam 0.25-2 mg PO,IV,or IM every 3-6h PRN)
Secretions (PAL-12)	●Excessive secretions: Glycopryrrolate 0.2-0.4 mg IV or SC every 4 h PRN (less sedating),Scopolamine 1.5-mg patches, 1-2 patches every 72 h OR Stropine 1% ophthalmic solution 1-2 drops SL every 2 h up to 4 h PRN (caution in asthma) OR Hyoscymine 0.125-0.25 mg PO or SL every 4 h with max dose of 1.5 mg daily
Anorexia/ Cachexia1 (PAL-13 and PAL-14)	Life Expectancy: Years; Months to Year; and Weeks to Weeks(Dying patient) Counsel family and patients about risks (eg, thrombosis), benefits, and options for cachexia treatment (eg, stopping therapy if ineffective) ●Gastropares is early satiety): Metoclopramide 5-10 mg PO QID 30 min before meals and QHS. Low/no appetite(avoid in setting of complete bowel obstruction): Olanzapine 2.5-5 mg/day PO OR Dexamethasone 3-8 mg/day IV or PO ●Clinicians may choose not to prescribe pharmacologic intervention for cancer cachexia treatment
Nausea and Vomiting (NV)	Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Common Etiologies ● See NCCN Guidelines for Antiemesis for chemotherapy/radiation-induced NV ● Gastroparesis: Metoclopramide 5-10 mg PO QID 30 min before meals and QHS (avoid in setting of complete bowel obstruction) CNS involvement: Dexamethasone 4-8 mg BID-TID ● Gastric outlet obstructions: Dexamethasone 4-8 mg/day; proton pump inhibitor ● Gastritis/GERD: Proton pump inhibitor OR H2 blocker ● Medication-induced gastropathy: Proton pump inhibitor OR Metoclopramide 5-10 mg PO QID 30 min before meals and QHS Nonspecific NV
NCCN	Dopamine receptor antagonists or 5-HT3 receptor antagonists O Olanzapine 2.5-5 mg PO 1-2 times daily starting QHS HALoperidol 0.5 mg TID OR Metoclopramide 5-10 mg QID 30 min before meals and QHS OR Prochlorperazine 5-10 mg 3-4 times/ day, maximum 40 mg/day OR Danstonever every 4 h every 8 h ● Contributing anxiety: Lorazepam 0.5-1 mg every 4 h PRN ● Vertiginous component: Anticholinergic AND/OR antihistamine
Refractory Nausea and Vomiting (NV)	Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Consider appropriate route of administration 1) Prescribe PO, SL, or rectal agent and titrate to maximum benefit 2) If NV persists, provide PRN, scheduled, or continuous parenteral infusion as necessary 3) Consider SC administration as an alternative ● Titrate to maximum benefit and tolerance ● For continued NV, consider additional agents: Dexamethasone 4-8 mg/day; Ondansetron 4-8 mg PO every 6 h; Scopolamine (patch or IV); PO cannabinoid
Constipation (PAL-17)	Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Prophylaxis: Start with stimulant laxatives (senna BID 8.6 to 17.2 mg BID or bisacodyl 5-10 mg BID-TID) to achieve a goal of one non- forced bowel movement every 1-2 days and add an osmotic laxative fit patient can tolerate the volume of liquid (polyethylene glycol daily 17 gm/8 oz water PO) ● Persistent constipation:Titrate stimulant laxatives as tolerated.Bisacodyl 10-mg suppository,one rectally daily-BID;polyethylene glycol 17 gm/8 oz water PO QID;lactulose 30 mL PO BID-QID OR 60 mL daily; magnesium hydroxide 30-60 mL PO daily-BID (avoid in renal failure); or magnesium citrate 8 oz PO daily (avoid in renal failure)
	Resistant opioid-induced constipation:If PO therapy is not effective,try enema PRN (caution with sodium phosphate enema - avoid in renal failure) Consider Methylnaltrexone, see prescribing information for weight-based dosing;Naloxegol 12.5-25 mg daily PO; Naldemedine 0.2 mg daily PO Not for postoperative ileus and mechanical bowel obstruction
Diarrhea (PAL-18)	Life Expectancy: Years; Months to Year; and Weeks to Months $$\text{ If immunotherapy-induced diarrhea, see NCCN Guidelines for Management of Immunotherapy-Relates Toxicities}$$ Grade 1 (mild) ●General: Loperamide 4 mg PO x 1 dose then 2 mg PO every 4 h or after each loose stool, up to 16 mg/day ●Consider addition of bulk-forming agents with caution in patients on opioids $$\bullet\text{Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/ day}$$ Grade 2 (moderate) ●Initiate/continue Loperamide 4 mg PO x 1 dose then 2 mg PO after each loose stool, up to 16 mg/day ●Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/day ●Consider Ayoscyamine 0.125 mg PO/ODT/SL every 4 h PRN, max: 1.5 mg/day; Atropine 0.5-1 mg SC/lV/SL every 4-6 h PRN ●.C. diff-induced: see NCCN Guidelines for Prevention and Treatment of Cancer Related Infections (FEV-8) ●Non-C. diff infection: Treat appropriately based on culture findings Grades 3/4 (severe, inpatient hospitalization with ICU for Grade 4) ●Initiate/Continue Loperamide 4 mg PO x 1 dose then 2 mg PO after each loose stool, up to 16 mg/day ●Diphenoxylate/Atropine 1-2 tabs PO every 6 h PRN, maximum 8 tabs/ day ●Consider Hyoscyamine 0.125 mg PO/ODT/SL every 4 h PRN, max: 1.5 mg/day; atropine 0.5-1 mg SC/lV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg/day SC/IV, every 8 h or by continuous infusion SC/IV ●Interactine ongoing antidiarheal, anticholinergic agents ●Atropine 0.5-1 mg SC/IV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg SC/IV every 8 h or continuous infusion
Diarrhea (PAL-19)	Life Expectancy: Days to Weeks (dying patient) $$\text{Reevaluate ongoing antidiarheal, anticholinergic agents}$$ ●Atropine 0.5-1 mg SC/IV/SL every 4-6 h PRN ●Consider Octroide 100-200 mcg SC/IV every 8 h or continuous infusion
Malignant Bowel (PAL-20)	Life Expectancy: Years; Months to Year; and Weeks to Months; Days to Weeks (dying patient) Reduce opioid dose or rotate opioid ●Metoclopramide 5-10 mg PO QID 30 min before meals and QHS;avoid in the setting of complete obstruction ●Dexamethasone 4-12 mg IV daily, discontinue if no improvement in 3-5 days ●Scopolamine (patch or IV); Hyoscyamine 0.125 mg PO/ODT/SL every 4 h PRN ●Octreotide 100-300 mcg SC BID-TID or 10-40 mcg/h continuous SC/IV infusion; if prognosis >8 weeks, consider long-acting release (LAR)
Sleep/Wake Disturbance (PAL-22)	Life Expectancy: Years; Months to Year; and Weeks to Months to Months Isolated sleep-onset insomnia ●Dual orexin receptor antagonist (DORA) ●Daridorexant 25-50 mg PO 30 min before bedtime Lemborexant 5-10 mg PO QHS ●Suvorexant 10-20 mg PO QHS ●Ramelteon 8 mg PO QHS ●Melatonin 1-5 mg PO QHS ●Benzodiazepine receptor agonist(BZRA) (caution in patients who are older or frail) Zolpidem 5-10 mg PO QHS for immediate-release tablet, 6.25-12.5 mg PO QHS for extended-release tablet Eszopiclone 1-3 mg PO QHS ●Zaleplon 10-20 mg PO QHS Sleep maintenance ●DORA (see above) ●Doxepin 3-6 mg PO QHS (caution in patients who are older or frail) Additional agents for insomnia ●Sedating antidepressants ●Mirtazapine 7.5-30 mg PO QHS (better tolerated in patients who are older or frail) ●Trazodone 25-100 mg PO QHS TCAs such as Amitriptyline or nortriptyline (caution in patients who are older or frail) ●Sedating antipsychotics (monitor for extrapyramidal symptoms [EPS]) Olanzapine 2.5-5 mg PO QHS ●Quetiapine 12.5-25 mg PO QHS ●Benzodiazepines Lorazepam 0.5-1 mg PO QHS (caution in patients who are older or frail) ●Medical cannabis ●Oral form preferred in 2:1 or 1:1 ratios (caution in patients who are older or frail) ●Daytime sedation ●Caffeine 100-200 mg PO every 6 h, last dose 4 PM ●Methylphenidate 2.5-20 mg PO BID, second dose no later than 6 h before bedtime ●Dextroamphetamine 2.5-10 mg PO BID, second dose no later than 12 h before bedtime ●Modafinil 100-400 mg PO each morning ●Dextroamphetamine and Amphetamine: 10-60 mg per day in 1 to 3 divided dose
Sleep/Wake Disturbance (cont.) (PAL-22)	Restless legs syndrome (RLS)$b $? ● Intermittent symptoms ● Carbidopa-levodopa 25/100 mg PO QHS PRN ● Chronic symptoms Rropinrole 0.25 mg PO 1-3 h before bedtime Pramipexole starting dose 0.125 mg PO QHS, 2-3 h before bedtime, may require titration Pregabapin 50-450 mg PO 1-3 h before bedtime Gabapentin 100-2400 mg PO in divided doses 2 h prior to bedtime. If divided dose: One-third of total daily dose given midday, remaining two-thirds of the total daily dose given in the evening
Sleep/Wake Disturbance (PAL-22)	Life expectancy: Days to Weeks (dying patient) ● Titrate dose of existing pharmacotherapy
Delirium (PAL-23)	Life Expectancy: Years; Months to Year; and Weeks to Months ● Maximize nonpharmacologic strategies for all patients with delirium and those at high risk for delirium Severe Delirium (agitation) $b, c, d $ ● Consider adding lorazepam 0.5-2 mg SC/IV every 4 h PRN with or without haloperidol if agitation is severe or either disrupting care or causing the patient distress ● Haloperidol 0.5-2 mg SC/IV every 1-4 h PRN ● Haloperidol 0.5-2 mg SC/IV every 1-4 h PRN ●Alternatives: Olanzapine 2.5-7.5 mg PO/SL every 2-4 h PRN (maximum = 30 mg/d); Chlorpromazine 25-100 mg PO/PR/IV every 4 h PRN for patients who are bedbound. For direct IV injection, administer diluted solution slow IV at a rate not to exceed 1 mg/minute. To reduce the risk of hypotension, patients receiving IV chlorpromazine must remain lying down during and for 30 minutes after the injection. ● Titrate starting dose to optimal effect with lowest possible dose.

表 10
NCCN Categories of Evidence and Consensus
Category 1	Based upon high-level evidence (≥1 randomized phase 3 trials or high-quality, robust meta-analyses), there is uniform NCCN consensus (≥85% support of the Panel) that the intervention is appropriate.
Category 2A	Based upon lower-level evidence, there is uniform NCCN consensus (≥85% support of the Panel) that the intervention is appropriate.
Category 2B	Based upon lower-level evidence, there is NCCN consensus (≥50%, but <85% support of the Panel) that the intervention is appropriate.
Category 3	Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

表 11
	Overview	.2
	Guidelines Update Methodology	.2
	Literature Search Criteria	.2
	Sensitive/Inclusive Language Usage	.3

表 12
Palliative Care Clinical Competencies
www.epec.net	Education in Palliative and End-of-Life Care (EPEC): Comprehensive curriculum covering fundamentals of palliative medicine; teaching guides
www.bidmc.org	Hospice & Palliative Medicine Educational Curriculum at Beth Israel Deaconess Medical Center: Online education for physicians, nurses, and pharmacists
Clinical,Educational, Educational, Professional, and Public Resources
www.palliativedrugs.org	Extensive information on pharmacologic symptom management
www.aahpm.org	American Academy of Hospice and Palliative Medicine (AAHPM): Physician membership organization; board review courses; publications
www.abim.org	American Board of Internal Medicine: Physician Board Certification
www.nhpco.org	National Hospice and Palliative Care Organization: Nonprofit membership organization representing hospice and palliative care programs and professionals in the United States
www.hpna.org	Hospice & Palliative Nurses Association: Specialty nursing organization with evidence-based educational tools for the nursing team
pallcare.hms.harvard.edu	Center for Palliative Care at Harvard Medical School: Faculty development courses, other educational programs
www.nationalcoalitionhpc.org/ncp	National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care, 4th edition (NCP Guidelines)
www.americangeriatrics.org	American Geriatrics Society: Clinical guidelines and continuing education
www.cancerpatienteducation.org	Cancer Patient Education Network (CPEN): Health care professional organization for sharing experiences and best practices in all aspects of cancer patient education
Palliative Care Program Development
www.capc.org	Center to Advance Palliative Care: Technical assistance for clinicians and hospitals seeking to establish or strengthen a palliative care program
www.capc.org/palliative-care-leadership-centers	Palliative Care Leadership Centers: Eight exemplary palliative care programs providing site visits, hands-on training, and technical assistance for new palliative care clinicians and programs
Physician-Assisted Dying	Statement on Physician-Assisted Dying approved by the AAHPM Board of Directors

图示：ASSESSMENT BY ONCOLOGY TEAM -Benefits/burdens of cancer therapy -Apprompative treatment of comorbid physical and psychosocial, spiritual conditions ● Consideration for consultation with specialty palliative care team (PAL-6) ●Coping strategies ●Cultural factors affecting care (PAL-4) ●Cultural factors affecting capacity ●Coordination of care with other health care providers ●Consultation with specialty palliative care team (PAL-4) ●Ongoing reassessment ●Outcomes: ●Acceptable sense of control ●Adequate symptom management ●Decision-making patient ●Decination of care with other health care providers ●Decreased caregiver stress and burden ●Optimized quality of life ●Patient satisfied with response to cancer therapy ●Personal growth and enhanced meaning ●Reduction of patient/family/caregiver distress ●Strengthened relationships ●Strengthening needs conditions ●Personal public life ●Effect of death ●Death→ →Doth→ ●Psychological bereavement support ●Psychological bereavement support ●Personal growth and enhanced meaning ●Reduction of patient/family/caregiver distress ●Strengthened relationships

图示：ASSESSMENT BY ONCOLOGY TEAM Psychosocial, spiritual/psychiatric Psychiatric Depression/anxiety Distress Spiritual or existential needs Social/practical challenges or concerns Social support Home Family Financial toxicity Access barriers, including geography/transportation Community • Resource needs Provide age-appropriate social support services Social isolation and/or loneliness ·Social support/ajouschocatalytic professional photosocial ·eg, spiritual care providers, clinical psychologists, community resources ·social workers) (PAL-7)

图示：•Collaborate with palliative care specialist/team,e,f - Collaborate with other health care professionals treating the patient •恢复ate with other health care professionals treating the patient. Evaluate and treat undiagnosed physical and mental health issues. Consider additional referrals: Mental/behavioral health Psychosocial, spiritual services - Behavioral health. Other specialists - Substance use disorders - See NCCN Guidelines for Adult Cancer Pain - 摩动cell community support - Religious/Spiritual - School Community agencies - Introduce needs- ● Introduce advance care planning conversations - Expedite referral to hospice services when appropriate|\`l ongoing needs\→ post.Rone NCCN Guidelines 108\→ supportate intervention options and intensify as possible.\` See NCCN Guidelines for Distress Management\| Ongoing re-evaluation and communication between the patient and health care team Optimized quality of life Personal growth and enhanced meaning Behavioral health and Other specialists - Advance care planning in progress ·Collaborate with palliative care in adult Religious/Spiritual - School community agencies - Introduce needs- ● Introduce advance care planning conversations - Expedite referral to hospice services when appropriate

图示：## Complex patient/family/ caregiver Complex patient/family/ caregiver Cancer circumstances × ▶▶ Dither NCCN Noncal思维 lines Version 1.2026 NCCN Noty 2.06 1.0554-2019 Palliative Care Tatal care giving 2 ● Patient's concerns regarding family/caregiver well-being Dependent children and/or older relatives requiring care living in the household Care planning for children of parent with poor prognosis 2 Support for active caregivers - Substance use disorder impacting care "Spiritual or existential distress ● Unresolved or multiple prior losses

图示：Oncology care\,team\,staff\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,challenges\,chologuations\,challenges\,chologuants\,chologuants\,chologu$\in$ C.ncon n 1.2026, 10/27/2025©2025 National Comprehensive Cancer Network®(NCCN®),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

图示：####ESTIMATED INTERVAL FIREPANSORY LIFE EXPECTANCY Assess understanding of prognosis, goals of therapy, and implications of disease and/or treatment on their physical and cognitive function ●Discuss whether cancer therapy is curative or noncurative ● Discuss whether cancer therapy is curative or recurrence ● Offer goal-directed supportive care, including referral to specialized palliative care services, if indicated ● Provide appropriate cancer therapy that is aligned with stated patient Months to years ●Assess for appropriateness of palliative radiation therapy (RT) or interventional procedures that are aligned with goals of care ●Provide cancer treatment and disease-related symptom management ●Observe a discrentation of applications of disease and/or integrative interventions (eg, cognitive behavioral, massage, art, or music therapy) ●Consider rehabilitation services and physical activity aligned with goals ●Reassess prognostic awareness and goals of therapy ●Redirect goals and hopes to those that are achievable based on likely prognosis and life expectancy ●Provide guidance regarding anticipated course of disease ●Assess for appropriateness of palliative RT and/or interventional weeks ●Procedures (eg, single fraction) ●Consider discontinuation of cancer treatment not aligned with goals of care ●In this level ●If ongoing care planning ●Systematically review advance care plans to ensure ongoing accuracy as illness or situation evolves ●Offer goal-directed supportive care ●Offer education and support related to care at end of life, including referral to specialized palliative care services or hospice ●Assess and document preferred location of death ●Explore culturally/spiritually significant rituals/ceremonies important at ●ying d of life palant)

图示：Days to weeks Contributionor ●Discontinue all treatments not directly contributing to patient comfort ●Intensify palliative care in preparationor death ●Providece guidance ●Intensify palliative care in preparationor death ●Provide guidance regarding anticipated dying process ●Consider psychological support and education ●Consider psychosocial, spiritual support regarding anticipatory grief for patients/families/caregivers ●Focus on symptom management and comfort ●Refer to hospice team ●Assist with completion of legal documents, if appropriate ●Assess and document preferred location of death ●Consider nonpharmacologic and/or integrative interventions (eg, heat or ice, positioning or support) ●Consider nonpharmacologic and/or integrative interventions (eg, heat or ice, positioning or support) ●Offer education and support related to care at end of life ●Ordering culturally/spiritually significant rituals/ceremonies important at end of life ●Explore culturally/spiritually significant rituals/needs ①ing needs ●Annected for the future of future generations, this may be difficult to continue and give a care plan ●Review advance care planning ●Review advance care planning needs ①cere$\bullet$Re-evaluate palliative care interventions and②Consult or refer to specialized palliative care services or hospital ●Consult or refer to specialized pathiative care services or hospital ●Consider hospice ●Consider hospice ①Report ●Review hospital ●Consider planning ①Re-evaluate palliative care interventions and②Consult or refer to specialized pathiative care services or hospital ●Simplicie ●Consult or refer to specialized pathiative ●Consider hospice referral

图示：####ESTIMATED LIFE EXPECTANCY Treat according to NCCN Guidelines for Adult Cancer Pain years ●Treat according to NCCN Guidelines for Adult Cancer Pain ●Pain In addition: ●Educate patient/family/caregiver on the importance of pain control at the end of life ●Optimize psychosocial, spiritual support for patient and family/caregivers ●Consider integrative interventions. See NCCN ●Guidelines for Adult Cancer Pain (PAIN-D). ●Consider interventional strategies. See NCCN Guidelines for Adult Cancer Pain (PAIN-M) ●Use ongoing shared decision making to balance desired pain control with acceptable toxicities Days to weeks pairant patients ●Maintain analgesic therapy; titrate to optimal comfort ●Balance analgesia against reduced level of consciousness as possible or desired If ongoing conversions. Intertransderly administered medications have longer times to onset than other routes. IV bolus dosing combined with drip titration may be the effective method of rapid titration; drip titration alone ●Recognize and treat opioid-induced neurotoxicity,including myoclonus and hyperalgesia; consider opioid rotation if needed. ●Consider single-fraction palliative RT for painful bone metastases for patients with a life expectancy of multiple weeks ●Optimized generally of life ●Personal growth and enhanced meaning If ongoing needs Pain NCCN Guidelines ●Consider for Adult Cancer Pain Ongoing In</td> </tr>

图示：####ESTIMATED INTERVAL 1INTERVENTIONS DYPSPNEA REASSESSMENT LIFE EXPECTANCY ●Assess symptoms comprehensively ●Educate patient/family/caregiver on patient's condition and risk/benefit of treatment options ●Consider discontinuing therapies that may be causing dyspnea ●Treat potentially reversible underlying causes/comorbid conditions using:Radiation/chemotherapy/interventional strategies as appropriate ●Inmunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy ●Optimized quality of life ●Decreased caregiver burden ●Relieve symptoms Oxygen therapy for symptomatic hypoxia Educational, psychosocial, spiritual, and emotional support for the patient/family/caregiver caregiver Nonpharmacologic therapies, including fans,cooler temperatures, stress management,relaxation therapy, and physical comfort ●Pharmacologic therapy (if nonpharmacologic and nonopioid interventions are ineffective)◆Trial of low-dose opioids with close monitoring of adverse events ●Noninvasive positive-pressure ventilation(eg, CPAP, BiPAP) support if clinically indicated for severe reversible condition Days to weeks of dying-pylying (PAL-12) Events ●Interventions (PAL-12) ●Proving reassess (o) Inerventions (PAL-12) YPS ●Re-evaluate palliative care interventions and initiatives and possible instructions ●Consult or refer to needs (If needs ●Consulted palliative care services or hospice ●Re-evaluate palliative care interventions and ongoing:1.2026,10/27/2025©2025 National Comprehensive Cancer Network (NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

图示：NCCN National Comprehensive Cancer Network®

图示：ESTIMATED LIFE EXPECTANCY INTERVENTIONS${}^{n}$ Assess symptoms comprehensively Use labored breathing or other physical signs of dyspnea in patients who are noncommunicative Apsema patient and family/caregiver preferences Months to year Interventions (PAL-11) Weekss to $\times$ Days to weeks (dying patient) Years Suppression options Of people Provide anticipatory guidance for patient/family/ caregiver Caregiver regarding dying or respiratory failure Provide emotional and spiritual/ family/ Focus on comfort Continue to treat underlying condition as appropriate ● Provide emotional and spiritual support ● Focus on comfort Continue to treat patient/ family/caregiver Dysmpnea Weekss to Emotional, psychosocial, spiritual, and emotional support (PAL-11) Dysmpacologic therapies Fox, cooler temperatures Pharmacologic therapies Years Days to weeks (dying patient) Oxygen if hypoxia present and/or subjective relief is reported If opioid naive, low-dose opioid '-If on chronic opioids, consider increasing dose by 25% for unrelied dyspnea; see NCCN Guidelines for Adult Cancer Pain for additional information on opioid titration Consider benzodiazepines when opioids and other non-pharmacologic measures have failed to control dyspnea Consider therapy with high-flow nasal cannula Noninvasive positive-pressure ventilation (eg,CPAP,BiPAP) support if clinically indicated for severe reversible condition If fluid overload is a contributing factor: Decrease/discontinue enteral or parenteral fluid Consider low-dose diuretics ● Consider excessive secretions with nonpharmacologic interventions and anti-secretory agents Reduce IV fluids and consider repositioning Gentle suction of oral harynx, avoiding deep suctioning

图示：####ESTIMATED LIFE EXPECTANCY ASSESSMENT AND INTERVENTIONS Outcomes:●Outcomes:●Weight stabilization or gain ● Improvement in symptoms that interfere with intake dyspnea(PAL-11) ·Educate patient/family/caregiver on patient's condition and risk/benefits of treatment options ●Screen for conditions/symptoms that interfere with intake Dyspnea(PAL-11) ·Screen for intense with intake ·Improved energy with Fatigue (See NCCN Guidelines for Cancer-Related Fatigue Years Months to year Memory to year Intractable hiccups Dental and/or jaw issues Dysgeusia Mucositis Oropharyngeal candidiasis Xerostomia Pain (See NCCN Guidelines for Adult Cancer Pain) Pancreatic exocrine enzyme insufficiency Psychiatric Anxiety Dysperian & Depression Eating disorders/distortedbody image ●Review/modify medications that interfere with intake ·Equity evaluating for endocrine abnormalities ·Supervised energy needs ·Consider evaluating for endocrine abnormalities of health ·Consider appetite stimulant ANIOX ●Assess complexities related to social determinants of healthm ●Encourage, if able, high protein, high nutrition food ●Consider swallowing evaluation ●Consider psychiatric consultation if patient has an eating disorder or phobia/anxiety related to eating/swallowing weeks to Consider nutrition support, enteral and parenteral feeding (as appropriate) Dental and/or jaw issues Dysgeusia Mucositis Oropharyngeal candidiasis Xerostomia Pain (See NCCN Guidelines for Adult Cancer Pain) Pancreatic exocrine enzyme insufficiency Psychiatric Anxiety Dysperian & Depression Eating disorders/distortedbody image ●Review/modify medications that interfere with intake ·Equity evaluating for endocrine abnormalities ·Assess complexities related to social determinants of healthm ●Consider adversarial ·Equage or ability ·Conserve, if able, high protein, high nutrition food ●Consider swallowing evaluation ·Consideor psychiatric consultation if patient has an eating disorder or phobia/anxiety related to eating/swallowing $\cdot$Consider答题 Days to weeks (dying years of patient) ·Consider enrolling patient in a clinical trial with novel cachexia medication `Invertions (PAL-14) Patient) Interventions (PAL-14) Note: All recommendations are category 2A unless otherwise indicated.

图示：### 2 ESTIMATED LIFE EXPECTANCY Years Months to year Interventions (PAL-13) Months to year Treat reversible causes of anorexia (PAL-13) Assess anorexia/cachexia severity and associated symptoms ● Educate patient/family/caregiver on patient's condition and risk/benefit of treatment options ● Counsel patient and family about benefits, risks, and options for pharmacologic management of cachexia ● Focus on patient goals and preferences ● Provide education and emotional support to patient/ family/caregiver regarding natural history of disease, including the following points: Absence of hunger and thirst is normal in the dying patient ● Uncortical support may not reverse weight loss in patients with advanced cancer ● Artificial nutrition and hydration may increase risk of fluid overload, aspiration, infection, and hastened death ● Symptoms like dry mouth should be treated with local measures (eg, mouth care, small amounts of liquids) ● Discontinuing previously initiated enteral or parenteral nutrition near the end of life is appropriate, ethically permissible, and may improve some symptoms ● Counsel patient and family about benefits, risks, and options for pharmacologic management of cachexia ● Acceptable sense of control ● Focus on patient goals and preferences ● ● Provide Education and emotional support to patient/ family/caregiver regarding natural history of disease, including the following points: ● Absence of hunger and thirst is normal in the dying patient ● Nutritional support may not reverse weight loss in patients with advanced cancer ● Artificial nutrition and hydration may increase risk of fluid overload, aspiration, infection, and hastened death ● Symptoms like dry mouth should be treated with local measures (eg, mouth care, small amounts of liquids) ● Discontinuing previously initiated enteral or parenteral nutrition near the end of life is appropriate, ethically permissible, and may improve some symptoms ● Discuel patient and family about benefits, risks, and options for pharmacologic management of cachexia ● Acceptable sense of control ● Focus on patient goals and preferences ● ● Dieveare palliative care (needs)

图示：Outcomes: Dequate symptom management Reduction of patient/family/caregiver distress Acceptable sense of control ● Decreased caregiver burden ● Optimized quality of life Ongoing reassess Continue to treat and monitor symptoms and quality of life If needs Re-evaluate palliative care interventions and intensify as possible ● Consult or refer to specialized palliative care services or hospice If nceeds ● Re-evaluate palliative care interventions and intensify as possible ● Consult or refer to specialized palliative care services or hospice In stage or persisting what for you? Pooi rotation when opioid may be causing or exacerbating NV needsing Re-evaluate all palliative care services or hospice No Ionging has a three-nterstest Inventories, interventions for online needsing Re-evaluate all palliative care services or hospice

图示：##############0 ·Optimize food intake ●Optimize through my of physical activity as appropriate #####·Administer prophylactic medications #####·Stimulant laxative±osmotic laxative dose with goal of one non-forced bowel movement every 1-2 days Increase laxative damage #############dows in no-forced bowel day Increase Laxative damage ############days Increase Laxative movement every 1-2 days ########### NCCN National Comprehensive Version 2020 NCCN Comprehensive Version 2020 Palliative Care CONSTYPATION ################################################################### ########## ######### ######## ####### ####### ####### ####### ####### ###### ###### ##### }\# ############# ######### ######## ######## ######## ####### ####### ####### ####### ####### ####### ####### ####### ####### ####### ###### #####"

图示：● Tailor treatment to potential causes If immunotherapy-induced, see NCCN Guidelines for Management of Immunotherapy-Related Toxicities Graft-versus-host disease (GVHD) and/or immunotherapy-related colitis Chemotherapy regimen Radiation-induced enteritis or other RT side effects Infection $\diamond$ Screen for Clostridioides difficile, human immunodeficiency virus (HIV), and other comorbid infections(ie, ova/parasites) Drugs that frequently induce diarrhea Dietary changes Post-surgical/atomic changes (ie, short bowel syndrome) Prancreatic insufficiency in pancreatic cancer Irritable bowel syndrome (IBS)/Crohn's disease ● Recent antibiotic use ● If fecal impaction is suspected, see PAL-17 indicated by grade ● If chemotherapy induced, decrease or delay the next dose of chemotherapy ● Consider endoscopy if diagnostic uncertainty

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图示：ESTIMATED LIFE EXPECTANCY ASSESSMENT ● Evaluate severity and cause(s) of malignant bowel obstruction ● Educate patient/family/caregivers on patient's condition and treatment options ● Screen for and treat underlying potentially reversible causes Adhesions Radiation-induced strictures ● Surgical and strictures ● Internal hernias ● Assess for malignant causes ● Tumor mass ● Carcinomatosis ● Consider patient goals, prognosis(including life span post procedure), and relative invasiveness of proposed intervention ● Consider medical management is got for treatment to guide choice(s) of intervention2(eg, decrease in intervention3) Procedural Interventions(PAL-21)

图示：Weeks to months ● Consider medical management rather than surgical management ●Assess patient's goals for treatment to guide choice of intervention ●Intravenous or subcutaneous fluids ●Enteral tube drainage ●Consider only if other measures ●fail to reduce vomiting ●Endoscopic management ●Endoscopic management ●PAL-21

图示：####ESTIMATED LIFE EXPECTANCY ASSESSMENT ●Evaluate delirium severity and cause(eg, DSM criteriacc)See also NCCN Guidelines for Distress Management and NCCN Guidelines for Older Adult Oncology Hyperactive Hypoactive ·Ueducate patient/family/ caregivers; provide变异 patient's conditions and treatment options ·Screen for and treat underlying reversible causes, such as ·Metabolic causes ·Dehydration + deposits or failure is disrupting year ●Unrelieved pain ●Hypoxia - Brain metastases (consider palliative RT) or other CNS events ·Urinary retention .Medication or substance effect or withdrawal (eg, benzodiazepines, opioids, anticholinergics, non-prescribed substances) ●Reduce or eliminate delirium-OR ●Supercive distress ●Decreased caregiver burden ●Outcomes:●Adequate symptom management to treat and monitor symptoms ●Reduction of patient/family/ caregiver distress ● Decreased caregiver burden ●Adequate symptom management ●Reduction of patient/family/ caregiver distress ●Reduction of healthy of life Weeks to months 2033 ●Undering months ●Infection ●Consider opinion dose 截opic dose reduction or rotation bedside ●Encourage supportive caregiver presence at bedside for withdrawal (eg, basedide caregivers ●Support caregivers ●Support medications as possible moderate interventions .●Orient patient with family/ interventions ●Cargiver nonpharmacologic interventions Days to weeks (dying patient) Interventions (PAL-24) Note:All recommendations are category 2A unless otherwise indicated.

图示：ESTIMATED LIFE EXPECTANCY INTERVENTIONS Years Interventions ● Educate family and caregiver(s) about delirium and how to support patient ● Maximize nonpharmacologic interventions (optimize sleep-wake cycle; address sensory impairment; provide unnecessary medications, tubes, etc. ● Review treatment plan and discontinue unnecessary medications, tubes, etc. ● Decrease doses of medications dependent upon hepatic or renal function ● Consider that under- or overtreatment of pain may exacerbate delirium ● Examine for fecal impaction, urinary tract infection (UTI), or distended bladder as potential causes of delirium ● Examine for fecal impaction, urinary tract infection (UTI), or distended bladder as potential causes of delirium ● Reg-evaluate palliative care interventions ● Outcomes: ● Adequate symptom management ● Reduction of patient/family/ caregiver distress ● Reduction to treat and monitor caregivers and dilutive quality of life ● Outcomes: ● Adequate symptom management ● Re-evaluate palliative care interventions ● Consultages: ● Under to treat and symptom/family/ caregiver distress ● Reduction of patient/family/ caregiver distress ● Consultages: ● To treat and symptoms and quality of life ● Consultages: ● Consult with specialty care team ● Consult with specialty care team ● Consider proportional sedation (PAL-33)

图示：ESTIMATED LIFE EXPECTANCY INTERVENTIONS TESTAM INTERVENTIONS REASSESSMENT Years Assess wound comprehensively Educative symptom atpatient's conditions and risk/benefit of treatment options Treat if potentially reversible: Surgical debridement; consideration of skin grafting Radiation/chemotherapy/hormonal therapy Wound cleansing and irrigation Dressing changes Weeks to months Year Years �着要济ment Proting infection Optimize nutrition and mobilization Reduce or prevent odor from wounds or exudates rent wound spread-keep patient dry and clean; position to avoid pressure on bony prominences; avoid shearing force on fragile skin when repositioning Resolve symptoms: Odor: wound cleansing and debridement; topical antibiotic gel; activated charcoal or silver sulfadiazine dressings; external odor absorbers. Avoid strong "cover" odors. Infection: topical or systemic antibiotics; irradiated honey applications Exudate: absorbent alginate, foam dressings; drainage stoma appliance if high volume Bleeding: hemostatic dressings (alginate, collagen, non-adherent gauze, gelfoams, suscalfate paste; oral antifibrinolytics;consider radiotherapy or embolization if brisk bleeding; dark-colored linens, anxiolytics, and pain management) Purritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial Proportions: Not aume: maintain symmetry in dressings; manage wound odor and exudate; screen for depression; anxiety; address intimacy concerns PAL-2507/2025 10/27/2025© 2025 National Comprehensive Cancer Network®(NCCN),All rights reserved. NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN Dying: treat according to NCCN Guidelines for Adult Cancer Pain; see PAL-8 and PAL-10; use non-absorbent dressing or reduce frequency if associated with dressing changes; topical opioid and/or local anesthetic; complementary therapies Pruritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #onging needs If needs Continue to treat and continue to lead to medical injury and disease and surgery #8. Re-evaluate palliative care interventions and intensify as possible #9. Consult or refer to specialized palliative care services or hospice ● Consult or refer to specialized paliative care services or hospice Days to weeks to fit the topical osterical gauge, foam dressings; drainage stoma appliance if high volume Bleeding: hemostatic dressings (alginate, collagen, non-adherent gauze, gelfoams, suscalfate paste; oral antifibrinolytics;consider radiotherapy or embolization if brisk bleeding; dark-colored linens, anxiolytics, and pain management) Pain: treat according to NCCN Guidelines for Adult Cancer Pain; see PAL-8 and PAL-10; use non-absorbent dressing or reduce frequency if associated with dressing changes; topical opioid and/or local anesthetic; complementary therapies Pruritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8. Overall we have a positive effect, long-term alcohol mice Puritus: topical doexpin cream; cooled hydrogel sheet dressings; transcutaneous electrical nerve stimulation trial #8.851/2025/2025 #8.506/2025 3010/2025/2025 1000/2025/2025/2025 3010/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/2025/

图示：NCCN National Comprehensive Cancer Network®

图示：ESTIMATED LIFE EXPECTANCY INTERVENTIONS ●Assess: Coping and adjustment to illness by patient/family/caregivers Caregiver(s) availability Safe home environment Adequate access to transportation Sufficient financial resources Assess for substance use disorder (See NCCN Guidelines for Adult Cancer Pain) Culture-specific needs Assess complexities related to social determinants of healthm Obtain medical interpreters/translators as needed who are not related to the patient ●Obtain medical interpreters/translators as needed who are not related to the patient ●Mobilize family and community financial resources Ensure support and education to caregiver(s) and family members ●Ensure support and education to child life services Art and music therapy, if available For and music therapy, if available propositioning Physical medicine and rehabilitation training for transfers and repositioning Psychosocial, spiritual support ●Respond to caregiver-specific burdens and stresses ●Periodically assess and monitor family/ caregiver for risk factors associated with complicated grief ●Consider repsite care for families and caregivers (dying patients) Interventions(PAL-27) Weeks (dying patient)

图示：Years Interventions (PAL-26) Days to weeks (dying days for patient)' Weeks (years 10 0 or 20 Interventions Palliative Care NCCN Guidelines Version 1.2026 NCCN Guidelines 1.026 Pongoing 2 Ongoing modelling 1 Fli needs Lingong ongoing 3 Olying long ongoing 3 Re-evaluation and 1 patient/family/caregiver between the patient and health care team - Acceptable sense of control Personal growth and enhanced meaning I goining 3 Lingong ongoing 3 Re-evaluate palliative care interventions and intensify as possible - Consult and 1 Constructions (PAL-26) Ongoing possible Lingong ongoing 3 Ongoing care services, hospitals (or ethics committee burden ● Reduction of patient/family/caregiver communication distress ● Acceptable sense of control ● Personal growth and enhanced meaning If needs $Ongoing Inversion Lingong ongoing 3 Re-evaluate all potential care and 3 longing ongoing 3 Ongoing possible hospice, or ethics committee Ind秀ing NCCN Guidelines for 3 Consider referral to social worker, psychologist, and/or psychiatrist ● See NCCN Guidelines for Distress Management

图示：ESTIMATED LIFE EXPECTANCY ASSESSMENT/INTERVENTIONS Outcomes:● Reduction of patient/family/caregiver distress ●Reduction of patient/family/caregiver distress ●Acceptable sense of control family/caregiver about prognosis and anticipated care ●Increaseded family and caregiver resilience Stromstened SSESSMENT/INTERVENTIONS Palliative decision maker Years ●Assess for decision-making capacity and need for a surrogate decision maker ●If ongoing needs: Re-evaluate palliative care interventions and intensify as possible ●Introduce,educate,and assess need for specialized palliative care/or eligibility and readiness for hospice care ●Induceate patient/family/caregiver on dying process ●Address potential need for transitions in care while ensuring continued involvement of primary care physician and primary oncology team Weeks to months ●Refer to hospice care agencies ●Provide information and additional referrals, as necessary, for: ●Psychosocial assessment ●Legacy work ●Grief counseling welsys Spiritual screening ◆Spiritual support if needed ◆Funeral/memorial service planning ●Respect goals and needs of the patient/family/ caregiver regarding the dying process ●Inform other involved health care professionals of the patient's death ●Inform other involved health care professionals of ●Inform other involved health care professionals of

图示：# 2 ESTIMATED LIFE EXPECTANCY INTERVENTIONS Assess decision-making capacity and identify surrogate decision maker if necessary ● Ask if patient has completed any advance care planning documents (eg, a living will, medical power of attorney, health care proxy, patient surrogate for health care) # For not, encourage patient to prepare one refer to social worker ● Explore hopes, worries, and fears about the future Initiate discussion of personal values and preferences ● Make recommendation about future care if patient values and goals lead to a clear recommendation regarding future treatment Documenting values (eg, a living will, medical power of attorney, health care proxy, patient surrogate for health care) ● Approximate advance care planning documentation ● Adequate advance care planning documentation ● Reduction of patient/family/ ● Paying customer distress ● Acceptable sense of control ● Decreased caregiver burden ● Optimized quality of life Outcomes:\Odequate advance care planning ● Acceptable sense of control ● Decreased caregiver burden ● Optimized quality of life Ongoing reassessment Ongoing

图示：ESTIMATED LIFE EXPECTANCY INTERVENTIONS Years Interventions (PAL-29) Months ● Address months-to-years interventions (PAL-29) ● Determine patient/family/caregiver preferences for the location of the patient's death ● Confirm the patient's values and decisions in light of changes in status ● Avoidance of goal-inconsistent interventions all� Days to be months ●Acceptable sense of control ●Decreased caregiver burden ● Optimized quality of life ● Explore patient reluctance cable to engage in advance care plan ● Avoidance of goal-inconsistent interventions ● Exploreing also the following decision's values ●Acceptable sense of control ● Decreased caregiver burden ●Optimized quality of life ● Explore patient reluctance) Weeks (dying patient) ● Explore destination for personal and/or autopsy ● Educate patient/family/caregiver on benefits and limitation of CPR ● Document resuscitation orders per patient/family/caregiver in the medical record, including MOLST/POLSTee ● Optimized quality of life ● Explore patient reluctance) ● Acknowledge of goal-inconsistent interventions ● Avoidance of goal-inconsistent interventions ● Explore more for organ donation and/or autopsy ● Educate patient/family/caregiver on benefits and limitations of CPR ● Document resuscitation orders per patient/family/caregiver in the medical record, including MOLST/POLSTE ● Optized quality of life ● Explore patient reluctance)

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引用 / 出处

（2026.V1）NCCN临床实践指南：姑息治疗. 2026.