What are the appropriate discharge instructions for a 56-year-old male patient with stage IV pancreatic adenocarcinoma, presenting with intractable nausea and vomiting, severe abdominal pain, and new chest pain, who has a history of Heart Failure with Reduced Ejection Fraction (HFrEF), recent atrial fibrillation, Coronary Artery Disease (CAD), Hypertension (HTN), Hyperlipidemia (HLD), poorly controlled Type 2 Diabetes Mellitus (T2DM), Gastroesophageal Reflux Disease (GERD), Obstructive Sleep Apnea (OSA), obesity, and chronic pain on scheduled opioids?

Discharge Instructions for Stage IV Pancreatic Adenocarcinoma with Multiple Comorbidities

This patient requires structured follow-up within 7 days post-discharge with close monitoring of heart failure status, pain control, and gastrointestinal symptoms, while continuing guideline-directed medical therapy for HFrEF unless hemodynamically unstable. 1

Immediate Post-Discharge Follow-Up

• Schedule follow-up within 7 days of discharge with either an in-person clinic visit or structured telephone contact with a nurse or pharmacist to assess clinical status, medication adherence, and symptom progression. 1
• Arrange cardiology follow-up within 2 weeks specifically to reassess HFrEF management, volume status, and optimization of guideline-directed medical therapy (GDMT). 1
• Confirm oncology and interventional radiology appointments within 1 week as planned for ongoing cancer management and potential palliative interventions. 1

Medication Management and Reconciliation

Heart Failure Medications

• Continue all GDMT medications including ACE inhibitors/ARBs, beta-blockers, and SGLT2 inhibitors unless contraindicated by hemodynamic instability or acute kidney injury. 1, 2
• Resume any medications held during hospitalization with specific plans for titration to goal doses as tolerated, particularly beta-blockers which should only be restarted once volume status is optimized. 1, 2
• Monitor daily weights and maintain strict fluid balance, with instructions to call if weight increases by more than 2-3 pounds in 24 hours or 5 pounds in one week. 1

Pain and Symptom Control

• Continue scheduled opioids via oral route as preferred; consider parenteral or transdermal routes if gastrointestinal obstruction worsens or swallowing becomes impaired. 1
• Use phenergan suppository as prescribed for breakthrough nausea, recognizing that pro-kinetics like metoclopramide may be beneficial if gastric emptying is delayed. 1
• Increase pantoprazole as directed for GERD management, particularly important given the combination of opioid therapy and gastrointestinal symptoms. 1

Antiemetic Strategy

• Maintain multimodal antiemetic approach using ondansetron and droperidol as needed, with phenergan suppository for breakthrough symptoms, as combination therapy improves efficacy in difficult-to-treat nausea. 3

Critical Warning Signs Requiring Emergency Care

• Seek immediate medical attention if:
  • Chest pain lasting more than 2-3 minutes despite rest 1
  • Severe shortness of breath or inability to lie flat 1
  • Sudden weight gain of more than 5 pounds in one week 1
  • Worsening abdominal pain uncontrolled by prescribed medications 1
  • Persistent vomiting preventing oral medication intake 1
  • Signs of dehydration or decreased urine output 1
  • New confusion or altered mental status 1

Daily Self-Monitoring Requirements

• Weigh yourself daily at the same time (preferably morning after urination, before breakfast) and record the weight. 1
• Monitor blood pressure and heart rate if equipment available at home, particularly given recent atrial fibrillation. 1
• Check blood glucose regularly given poorly controlled T2DM, with specific targets discussed with your primary care physician. 1
• Assess for peripheral edema by checking ankles and legs for swelling daily. 1

Electrolyte and Laboratory Monitoring

• Schedule laboratory work within 3-5 days of discharge to check potassium, magnesium, and renal function, particularly after receiving IV electrolyte replacement and given ongoing diuretic therapy. 1
• Coordinate safety laboratory checks with primary care physician for monitoring of electrolytes after any changes to GDMT medications. 1

Dietary and Lifestyle Modifications

• Restrict sodium intake to less than 2-3 grams daily to prevent fluid retention and heart failure exacerbation. 1
• Limit fluid intake as directed by your cardiologist, typically 1.5-2 liters daily in advanced heart failure. 1
• Use CPAP machine nightly for obstructive sleep apnea management, as untreated OSA worsens heart failure outcomes. 1
• Maintain adequate nutrition despite nausea; consider small, frequent meals and nutritional supplementation if oral intake is poor. 1

Pain Management Considerations

• Celiac plexus blockade should be discussed with interventional radiology if opioid tolerance develops or side effects become intolerable, as this can provide 50-90% analgesic response lasting 1 month to 1 year. 1
• Consider palliative radiotherapy consultation if pain control remains inadequate despite optimal medical management, as hypofractionated radiotherapy can improve pain control and reduce analgesic consumption. 1

Palliative Care and Prognosis Discussion

• Reassess overall prognosis and appropriateness of advanced care planning given stage IV pancreatic cancer with multiple comorbidities and recent hospitalizations. 1
• Consider referral to palliative care specialists for comprehensive symptom management and goals-of-care discussions, particularly given the complexity of managing both advanced cancer and heart failure. 1
• Discuss advance directives and end-of-life preferences if not already established, ensuring alignment between patient wishes and treatment plan. 1

Comorbidity-Specific Management

Atrial Fibrillation

• Ensure rate control is adequate with target heart rate discussed with cardiologist; monitor for symptoms of rapid ventricular response. 1
• Verify anticoagulation status and ensure appropriate therapy given CAD, HFrEF, and atrial fibrillation. 1

Diabetes Management

• Intensify glucose monitoring given poorly controlled T2DM and potential for medication adjustments affecting glycemic control. 1
• Coordinate with endocrinology or primary care for optimization of diabetes medications, particularly if SGLT2 inhibitors are part of heart failure regimen. 1

Coronary Artery Disease

• Continue antiplatelet therapy as prescribed unless contraindicated by bleeding risk. 1
• Maintain statin therapy for secondary prevention unless contraindicated. 1

Common Pitfalls to Avoid

• Do not discontinue GDMT medications without cardiology consultation, even if blood pressure seems low, as these medications improve survival in HFrEF. 1, 2
• Avoid NSAIDs completely as they can cause sodium and water retention, worsening heart failure and increasing risk of hospitalization. 4
• Do not delay seeking care for worsening symptoms, as early intervention can prevent full decompensation requiring hospitalization. 1
• Avoid excessive fluid restriction that could lead to dehydration and prerenal azotemia, particularly in the setting of poor oral intake from nausea. 1

Coordination of Care

• Ensure all providers have updated medication list including changes made during hospitalization, with clear documentation of which medications were held and which were newly started. 1
• Provide written discharge instructions addressing activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen. 1
• Establish clear communication pathway between oncology, cardiology, and primary care teams to coordinate complex management decisions. 1