D.V., a 35-year-old man with gastric cancer metastasized to the esophagus with periaortic involvement, is hospitalized. He was diagnosed 10 months ago, and his disease has progressed despite multiple courses of chemotherapy (most recently, irinotecan and cetuximab). A double-lumen, peripherally inserted central catheter line has been inserted. He has lost 65 pounds since diagnosis, weighs 150 pounds at 6 feet tall, and presents with abdominal pain, severe nausea, vomiting, obstipation (intractable constipation), and general malaise. D.V. describes his pain as a 7 of 10 in intensity and as “burning like a knife through my stomach.” He uses 50 to 75 patient-controlled analgesia (PCA) bolus doses every 24 hours. He has no other medical problems. D.V. is referred to hospice care because he and his wife have agreed to stop chemotherapy and do not want to go back to the hospital. He states a history of allergic reactions to morphine, ondansetron, and diphenhydramine, although these reactions are not noted. He is presently receiving hydromorphone 2 mg/hour in an IV infusion with 1 mg PCA bolus dose every 5 minutes, hydromorphone 4 mg orally every 4 hours as needed for pain, fentanyl transdermal 275 mcg/hour every 3 days, ketamine 20 mg orally every 3 hours, senna two tablets twice daily, docusate sodium 250 mg twice, PEG 3350 17 g daily, lactulose 15 mL as needed for constipation, lorazepam 2 mg orally every 4 hours as needed for nausea or vomiting, metoclopramide 10 mg orally every 6 hours as needed for nausea or vomiting, promethazine 25 mg IV every 4 hours as needed for nausea or vomiting, baclofen 10 mg every 8 hours as needed for hiccups, and pantoprazole 40 mg once daily. What is your assessment of his medication regimen?
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