What is the approach to a patient with terminal pancreatic cancer presenting to urgent care?

From the Guidelines

When approaching a terminal pancreatic cancer patient in urgent care, prioritize immediate symptom management while coordinating with their oncology team and palliative care providers, focusing on providing comfort and dignity. This approach is supported by the American Society of Clinical Oncology's clinical practice guideline update on metastatic pancreatic cancer 1, which emphasizes the importance of palliative care services in addressing non-treatment-related issues and providing support to patients.

Key Considerations

• Begin with a thorough pain assessment and provide appropriate analgesia, typically starting with opioids such as morphine (2.5-5mg IV every 4 hours as needed) or hydromorphone (0.5-1mg IV every 4 hours as needed), titrating to effect, as recommended by general palliative care principles.
• Address common symptoms like nausea with ondansetron 4-8mg IV/PO every 8 hours or prochlorperazine 5-10mg IV/PO every 6 hours.
• For respiratory distress, consider oxygen supplementation and low-dose benzodiazepines such as lorazepam 0.5-1mg IV/PO every 4-6 hours if anxiety is contributing.
• Manage bowel obstruction symptoms with nasogastric decompression, IV fluids, and octreotide 100-200mcg subcutaneously every 8 hours to reduce secretions.

Communication and Coordination

• Maintain clear communication with the patient and family about goals of care, respecting advance directives and DNR status, as emphasized by the importance of informed decisions in the care of pancreatic cancer patients 1.
• Document your interventions and arrange appropriate follow-up or transfer to inpatient care if symptoms cannot be adequately controlled in the urgent care setting.
• Ensure continuity with the patient's established care team, recognizing that pancreatic cancer patients often experience rapid decline with complex symptom management needs, and that early assessment of symptom burden, psychological status, and social supports is crucial 1.

From the Research

Approach to a Patient with Pancreatic Cancer in Urgent Care

• The primary goal in managing a patient with terminal pancreatic cancer is to improve their quality of life and alleviate symptoms 2, 3, 4.
• Palliative care should be integrated into the treatment plan early on, concurrently with active treatment, to address physical, mental, and psychosocial health 3, 4.
• Symptom management is crucial in pancreatic cancer patients, and oncologists should provide "primary palliative care" through scrupulous symptom management, sensitive communication, and advance care planning 4.
• Chemotherapeutic treatment options are available for palliative care, including gemcitabine monotherapy and newer regimens that have shown improved overall survival rates 5, 6.
• However, these regimens can have significant toxicity, and choosing the right treatment for each individual patient is a major challenge 6.

Key Considerations

• Patients with pancreatic cancer often present with complications that can impact treatment tolerance, making symptom management a vital component of treatment 2.
• A nurse-led palliative care intervention may improve quality of life and psychological distress in pancreatic cancer patients 2.
• Advance care planning is essential in oncology, including care at the end of life, and should be integrated into the treatment plan 3.
• Professional organizations recommend palliative care for all patients with pancreatic cancer early in the course of illness and concurrently with active treatment 4.