What are appropriate case‑management recommendations for a 64‑year‑old male nursing‑home resident with recurrent gastric and cecal carcinoma, recent severe abdominal pain suggesting tumor recurrence, schizophrenia and schizoaffective disorder with drug‑induced dyskinesia, who is refusing medical care, upset about missing clothing, and currently taking divalproex, ondansetron, pantoprazole, risperidone, polyethylene glycol, ergocalciferol, ferrous sulfate, acetaminophen, and oxycodone, with stable vital signs and no pain?

Case Management Recommendations for a 64-Year-Old Male with Recurrent Gastric Cancer and Psychiatric Comorbidities

This patient requires immediate palliative care consultation with integrated psychiatric support, focusing on symptom control and advance care planning rather than aggressive cancer treatment, given his recurrent metastatic gastric cancer, refusal of oncologic therapy, and complex psychiatric needs. 1

Immediate Priorities (Next 24-48 Hours)

1. Establish Goals of Care Through Advance Care Planning

• Initiate frank discussion about prognosis and treatment preferences immediately, as NCCN guidelines recommend active facilitation of advance directives when life expectancy is months to weeks 1
• Document specific preferences regarding: hospitalization, resuscitation status (DNR/DNI), artificial nutrition/hydration, and preferred location of death 1
• Address the patient's anger and feelings of loss of control by validating his autonomy while providing clear information about disease trajectory 1
• Given his schizophrenia and schizoaffective disorder, assess decision-making capacity; if intact, respect his treatment refusal while ensuring he understands consequences 1

2. Optimize Psychiatric Medication Management

• Continue risperidone 2 mg BID and divalproex 500 mg BID as these are controlling his psychotic symptoms and mood, which is essential for any meaningful care planning 1, 2
• The ondansetron 4 mg QID currently prescribed is appropriate for nausea but has potential benefit for negative symptoms of schizophrenia; maintain this regimen 3
• Monitor for drug-induced dyskinesia (already documented) but do not discontinue antipsychotics abruptly, as this would destabilize his psychiatric condition 2

3. Address Pain and Gastrointestinal Symptoms

• Current oxycodone 5 mg q6h PRN is inadequate for metastatic gastric cancer; transition to scheduled long-acting opioid with immediate-release breakthrough dosing 4
• Start morphine sustained-release 15 mg PO q12h with morphine IR 5 mg q2h PRN for breakthrough pain, as morphine is the opioid of choice for cancer pain 4
• Immediately intensify bowel regimen: increase Miralax to 17 gm TID and add senna 2 tablets BID, as constipation prophylaxis is mandatory with scheduled opioids 4
• Continue pantoprazole 40 mg daily for gastroesophageal reflux 1

Intermediate Management (Next 1-2 Weeks)

4. Palliative Care Consultation and Symptom Monitoring

• Refer to specialized palliative care team within 48 hours for difficult symptom control and end-of-life care planning 1
• Screen for distress using validated tools (Distress Thermometer) at every encounter; his agitation and anger suggest moderate-to-severe distress requiring intervention 1
• Assess for depression and anxiety using clinical interview, as cancer patients with pain have higher rates of psychiatric complications 5, 6
• Address his specific concerns about "stolen" clothes and autonomy, as these practical issues are contributing to his distress and refusal of care 1

5. Nutritional Support Decision-Making

• Do not pursue aggressive nutritional interventions (feeding tubes, TPN) as these do not improve outcomes in advanced cancer and may worsen symptoms 1
• Focus on small amounts of preferred foods and liquids for comfort rather than caloric goals 1
• Educate nursing staff and family that decreased oral intake is expected in advanced cancer and does not cause suffering 1

6. Consider Palliative Systemic Therapy Only If Patient Changes Mind

• If the patient reconsiders treatment, best supportive care with possible second-line chemotherapy (irinotecan or docetaxel) could provide modest survival benefit (median OS 4-5 months vs 2.4-3.8 months with supportive care alone) 1
• However, given his current refusal and psychiatric complexity, do not pursue this unless he explicitly requests it with clear understanding 1
• HER2 testing is not indicated at this stage given his treatment refusal 1

Ongoing Management (Weeks to Months)

7. Psychiatric Symptom Management in Context of Progressive Disease

• Monitor for delirium, which is common in advanced cancer and will worsen his baseline psychiatric symptoms 1
• If delirium develops: increase haloperidol or risperidone dosing, add lorazepam for refractory agitation, and eliminate unnecessary medications 1
• Provide family education about expected behavioral changes as disease progresses 1

8. Social Work and Practical Support

• Immediate social work intervention to address his concerns about missing belongings and feelings of being "stolen" from his home 1
• Arrange for return of personal items and involve him in decisions about his care environment to restore sense of control 1
• Assess financial concerns and insurance coverage for hospice services 1

9. Transition to Hospice Care

• Initiate hospice referral discussion now, as he likely has <6 months life expectancy with metastatic gastric cancer refusing treatment 1
• Hospice can provide: in-home or facility-based care, 24/7 symptom management, psychiatric medication continuation, family support, and respite care 1
• Frame hospice as "intensive symptom management" rather than "giving up" to align with his desire to "take care of himself" 1

Critical Pitfalls to Avoid

• Do not force treatment discussions when patient is agitated; wait for calmer moments and use his stated desire for autonomy as a bridge to care planning 1
• Never discontinue psychiatric medications in attempt to "simplify" regimen, as this will cause decompensation and make all other care impossible 1, 2
• Avoid NSAIDs (he is not currently on any) given his gastric cancer, GI bleeding risk, and potential renal effects 4, 7
• Do not use metoclopramide if bowel obstruction develops, as it will worsen symptoms; use octreotide 150-300 mcg SC BID instead 1, 4
• Recognize that his "noncompliance" and anger are normal responses to loss of control and terminal diagnosis, not purely psychiatric symptoms 1, 5

10. Regular Reassessment Schedule

• Daily nursing assessment of pain (0-10 scale), bowel function, nausea, and psychiatric symptoms 4
• Weekly case management review to reassess goals of care as clinical status changes 1
• Immediate palliative care consultation if: uncontrolled pain, new delirium, family conflict about care decisions, or patient requests treatment reconsideration 1