Palliative Consult

Patient ID

74 yo M with metastatic pancreatic adenocarcinoma (PHN: 9841-230-492)

Reason for Consult

"Pain and symptom management"

History of Present Illness (HPI)

Pt presents for palliative consult regarding worsening epigastric pain, nausea, and progressive functional decline. Diagnosed with Stage IV pancreatic adenocarcinoma with liver mets on 12/11/2025. Completed 4 cycles of FOLFIRINOX; stopped 15/02/2026 due to poor tolerance and disease progression on repeat CT. Experiencing constant dull epigastric pain radiating to back (7/10), poorly controlled on current PRN opioids. Discussed transition to comfort-focused care and home symptom management.

Hx of Whipple procedure (10/2024) for initially localized disease, complicated by delayed gastric emptying.

Currently taking hydromorphone, paracetamol, ondansetron, pantoprazole, and senna. Using CBD oil 10 mg PO daily for sleep.

Lives with wife in a 2-storey house in Vancouver. Wife is primary caregiver but experiencing mild burnout. Ex-smoker (30 pack-years, quit 2010), no ETOH.

Allergic to penicillin.

Past Medical History (PMHx)

• Stage IV pancreatic adenocarcinoma with hepatic metastases (diagnosed 10/2024, recurrence 12/11/2025)
• T2DM (05/2015)
• HTN (2012)
• GERD (2010)

Medications

• hydromorphone (Dilaudid®) 2 mg PO q4h PRN (using 5-6 doses/day; increased from 1 mg last week)
• paracetamol (acetaminophen, Tylenol®) 1,000 mg PO TID
• ondansetron (Zofran®) 4 mg PO q8h PRN
• pantoprazole (Pantoloc®) 40 mg PO daily
• sennosides (Senokot®) 17.2 mg PO QHS
• metformin (Glucophage®) 500 mg PO BID (held recently due to poor PO intake)

Allergies

Penicillin (maculopapular rash)

Preferred Pharmacy

Shoppers Drug Mart #2214, West Broadway, Vancouver, BC

Palliative Review of Systems (ROS)

Constant dull epigastric pain radiating to T10-T12, 7/10 severity, worse supine. No neuropathic features.

Intermittent nausea, 4/10, worse after meals. No emesis.

Denies SOB, cough, or orthopnea.

Low mood and situational anxiety regarding prognosis and burden on wife; denies SI.

Anorexia present; intake < 50% of normal meals. Weight loss of 6 kg over past 2 months.

Spend > 50% of waking hours in bed/chair. Requires assistance with bathing and dressing. Ambikates short distances with 4-wheeled walker.

Constipated; last BM 4 days ago, hard stool (Bristol Type 1).

Normal voiding, continent, no dysuria or retention.

Social History

Lives with spouse (Margaret, 71, Substitute Decision Maker) in an owned 2-storey home; bedroom and bath on main floor. Daughter lives in Victoria, visits biweekly. Anglican faith, finds comfort in local parish support. Enrolled in BC Palliative Care Benefits (Plan P) as of last week; no financial barriers to meds. Vancouver Coastal Health (VCH) Home Health nursing initiated 1x/week; needs increase in home support worker (HSW) hours.

Code Status

DNR / MOST Level M2 (Medical care, no ICU, no CPR, transfer to acute care only if symptoms unmanageable at home).

Objective

Cachectic, frail-appearing elderly male lying in bed, mild distress from pain, jaundiced sclerae, alert and oriented x3.

BP 112/68 mmHg, HR 88 bpm, RR 16/min, Temp 36.6 °C, SpO2 97% on RA. Weight: 58 kg.

HEENT: Scleral icterus, dry mucous membranes. Chest: Clear to auscultation bilaterally. CV: Normal S1/S2, no murmurs. Abd: Soft, moderate tenderness to palpation in epigastrium, palpable nodular hepatomegaly 4 cm below costal margin, hypoactive bowel sounds. Ext: 1+ bilateral pitting pedal edema, no calf tenderness.

Labs (20/03/2026): Hb 98 g/L, WBC 6.2 x 10^9/L, Plt 145 x 10^9/L, Cr 82 µmol/L, eGFR 78 mL/min, Bilirubin 64 µmol/L, ALP 310 U/L, ALT 85 U/L. CT Chest/Abd/Pelvis (10/03/2026): Progression of multiple hepatic metastases, stable primary pancreatic bed mass, mild ascites, no bowel obstruction.

Assessment

74 yo M with progressive metastatic pancreatic adenocarcinoma, experiencingnociceptive visceral pain, opioid-induced constipation, and cancer-related cachexia/nausea. Prognosis estimated at weeks to a few months.

1. Metastatic pancreatic adenocarcinoma
2. Uncontrolled cancer-related visceral pain
3. Opioid-induced constipation
4. Anorexia/cachexia syndrome

PPS: 50%

Plan

• Pain: Start long-acting hydromorphone controlled-release (Hydromorph Contin®) 3 mg PO BID. Continue hydromorphone (Dilaudid®) 1 mg to 2 mg PO q1h PRN for breakthrough pain.
• Nausea: Switch ondansetron to metoclopramide (Maxeran®) 10 mg PO QID AC and QHS (addresses both nausea and gastric stasis, avoids worsening constipation).
• Constipation: Start macrogol 3350 (polyethylene glycol, RestoraLAX®) 17 g PO daily. Continue sennosides 17.2 mg PO QHS. Add bisacodyl (Dulcolax®) 10 mg PR daily PRN if no BM for 3 days.
• Deprescribing: Permanently d/c metformin given low PO intake and goals of care.

Reviewed goals of care; pt wishes to remain at home as long as possible and pursue a home death if feasible. Completed BC No Cardiopulmonary Resuscitation form for home chart.

Requested VCH Home Health to increase nursing visits to 2x/week for symptom reassessment and HSW daily for personal care. RTC in palliative clinic via telehealth in 1 week (03/04/2026 at 10:00).

Educated pt and wife on scheduled vs breakthrough opioid dosing, expected mild transient drowsiness, and constipation protocol. Provided 24/7 VCH Palliative after-hours contact numbers.