Constipation in palliative care

Key points

• In palliative care emphasis is on prevention of constipation; anticipatory prescribing is often indicated.
• An active and proactive approach to the assessment and treatment of constipation is important as constipation may cause extreme distress and suffering.
• The stage of a patient’s illness, their prognosis and their goals should be considered. For example the goal of care for patients at the end of life may be maintaining comfort, not necessarily relieving constipation.

What is constipation?

Assessment

Causes & management

What is constipation?

Constipation is defined as a decrease in bowel movements to fewer than three times per week. [1] Constipated stools, Type 1 on the Bristol stool chart, are usually hard, dry, small in size, and difficult to eliminate. [2] Other signs of constipation may include pain on bowel movement, straining, bloating and often the sensation of a full bowel.

The physiologic processes of continence and defecation are not completely understood. It is thought that there is interplay between the voluntary processes of the central nervous system (CNS) and internal involuntary reflex mechanisms. Constipation occurs when problems arise from external disorders involving the CNS, disorders of the colon, rectum, or anal sphincters or from a combination of these mechanisms. [3]

It is estimated that between 50-95% of people with cancer will experience constipation. The highest incidence is in those who are taking opioids. Opioid-induced constipation may be a distressing symptom for both the individual and their family. [4]

Assessment

A comprehensive assessment of constipation enables identification of the causes of constipation and forms the basis of an appropriate management plan.

Assessment includes:

1) Taking a thorough patient history and physical examination including:

• a rectal examination to reveal either soft or hard faeces
• an abdominal x-ray to rule out impaction or obstruction.

2) Discussion and documentation of:

• characteristics of bowel habits
• individual meaning of & response to constipation
• impact on the individual.

Characteristics of bowel habits
It’s important to gain a clear understanding of the individual’s normal bowel habits.

Ask the patient about the timing, amount, frequency & consistency of their stools. Document the patient's responses.

If the patient is experiencing pain associated with defecation, include the following additional pain assessment points: position, quality, radiation, severity, timing.

Individual meaning of constipation
Identify sources of psychological and social distress as these may lead to poor eating & hydration habits.
Ask the individual to explain what their constipation means to them and the impact it has on their comfort and daily life. e.g. Does your constipation worry or concern you?

Encourage the individual to think about this in terms of their physical, psychological, and social well-being.

Individual response to constipation
Ask the individual to explain what makes their constipation worse and what (if anything) helps.
Ask them to explain in their own words how they are managing to cope with their constipation i.e. what actions are they taking.

Impact on level of function
Ask the patient to explain how their constipation affects their ability to perform their activities of daily living. [5,6]

Causes & management

Individuals with a life-limiting illness are often lacking in some or all of the following factors required for normal defecation. These include:

• a fibre-rich diet
• adequate fluid intake
• normal peristalsis
• adequate abdominal & pelvic muscle power
• normal rectal and perianal sensations
• adequate physical activity. [5]

In palliative care the main goals of constipation management are:

• To identify the cause of the constipation of to enhance quality of life, where possible, through regular reassessment of symptoms, ensuring that the strategies are appropriate for the stage of the individual's illness
• to anticipate constipating effects of pharmacological agents such as opioids
• to relieve pain and any gastro-intestinal symptoms that may be causing discomfort or distress
• to consider the patient's goals and preferences when developing a management plan. [6]

The goals of management may be achieved using a combination of pharmacological and non-pharmacological interventions. Table 1 outlines some common causes of constipation and possible pharmacological/procedural interventions whilst Table 2 details the non-pharmacological approaches to constipation management

Table 1

Table 2

Management of constipation in the dying patient
During the last days of life it is important to maintain regular, comprehensive symptom assessment. Constipation is less likely to be a problem in the last days of life, as the individual deteriorates and becomes comatose. The priority of symptom management for the dying patient is to relieve symptoms and maintain comfort. [6]

REFERENCES

1. National Digestive Diseases Information Clearinghouse (NDDIC). (2007). Constipation. Retrieved November 10, 2010, from http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/

2. Continence Foundation of Australia. (2010). Bristol stool chart. Retrieved November 10, 2010, from http://www.continence.org.au/pages/bristol-stool-chart.html

3. McCrea, G.L., Miaskowski, C., Stotts, N.A., Macera, L., Varma, M.G. (2008) Pathophysiology of constipation in the older adult. World Journal of Gastroenterology. 14(17): 2631–2638. Retrieved November 10, 2010, from http://www.wjgnet.com/1007-9327/14/2631.pdf

4.Lentz, J., McMillan, S.C. (2010). The Impact of Opioid-Induced Constipation on Patients Near the End of Life: Perspectives of Patients, Family Caregivers, and Nurses. Journal of Hospice & Palliative Nursing. 12(1):29-38. Retrieved November 10, 2010, from http://journals.lww.com/jhpn/Fulltext/2010/01000/The_Impact_of_Opioid_Induced_Constipation_on.10.aspx

5. Palliative Care Expert Group. (2010). Gastrointestinal symptoms. In: Therapeutic guidelines: palliative care. Version 3. Melbourne: Therapeutic Guidelines Limited

6. Larkin, P.J, Sykes, N.P., Centeno, C., Ellershaw, J.E., Elsner, F., Eugene, B., Gootjes, J.R.G., Nabal, M., Noguera, A., Ripamonti, C., Zucco, F., Zuurmond, W.W.A., on behalf of The European Consensus Group on Constipation in Palliative Care. (2008). The management of constipation in palliative care: clinical practice recommendations. Palliative Medicine. 22:796. Retrieved November 11, 2010, from http://pmj.sagepub.com/content/22/7/796

7. National Comprehensive Cancer Network. (2010). NCCN Practice Guidelines in Oncology: Palliative Care. Retrieved November 11, 2010, from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

8. Thomas, J., Karver, S., Cooney, G.A., Chamberlain, B.H., Watt, C.K., Slatkin, N.E., et al. (2008) Methylnaltrexone for opioid-induced constipation in advanced illness. New England Journal of Medicine. 358: 2332–2343.

9. Candy, B., Jones, L., Goodman, M.L., Drake, R., Tookman, A. (2011) Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD003448. DOI: 10.1002/14651858.CD003448.pub3.

10. Mehta, R., Arnold, R. (2011) Evaluation of Spinal Cord Compression. Fast Facts and Concepts. #237. Retrieved, 31 March, from http://www.eperc.mcw.edu/EPERC/FastFacts/ff_237.htm

11. Mehta, R., Arnold, R. (2011) Management of Spinal Cord Compression. Fast Facts and Concepts. #238. Retrieved, 31 March, from http://www.eperc.mcw.edu/fastFact/ff_238.htm