Constipation is a common symptom for patients near the end of life. Constipation can have a significant impact on quality of life so preventing and treating it is important.
It’s best to prevent constipation whenever possible. Palliative care and hospice professionals are trained to ask about bowel movements frequently and it’s essential to be honest in your answers.
Prevention of constipation will depend on the risk of becoming constipated. For example, a patient who has abdominal cancer, diabetes and is taking regular opioid pain medication is at an extremely high risk of constipation. That's because abdominal tumors can compress or obstruct the bowel, diabetes damages sensory fibers and slows intestinal motility (movement), and opioids further slow gut motility and increase anal sphincter tone. Prevention for this patient would be more aggressive than a patient who only has, say, dementia.
Prevention focuses on adequate fluid intake, a proper diet, and activity (being active motivates the bowels).
Fluids, Proper Food and Exercise Are Prevention ToolsThese are often difficult things to increase in someone who is terminally ill, but even a small increase in fluid intake can be beneficial. Increasing food intake may cause more discomfort and shouldn’t be forced, but gently encouraging frequent small meals may be helpful. Increasing activity, even if it’s in the form of range of motion exercises by a health aid or physical therapist, can be very effective.
Stool softeners may be used to keep the stools soft, making them easier to pass. Stool softeners, such as senna, are particularly important for patients on opioid therapy.
When prevention isn’t enough and a patient becomes constipated, it’s important to start treatment promptly. Laxatives are usually used to treat constipation and are classified by their actions.
Bulk Laxatives. Bulk laxatives provide bulk to the intestines to increase amount of stool, stimulating the bowels to move. Dietary fiber is an example of a bulk laxative. Bulk laxatives may not be the answer for many palliative care and hospice patients because they require a lot of fluid intake to be effective. If a patient cannot maintain adequate fluid intake, bulk laxatives can cause more discomfort and further the problem. Bulk laxatives can also cause gas and bloating.
Lubricant Laxatives. Lubricant laxatives soften the stool and lubricate the stool's surface, making it easier to pass. Mineral oil is the most common type of lubricant laxatives. Mineral oil isn’t recommended for patients at risk for aspiration, or those taking docusate (Colace).
Surfactant/Detergent Laxatives. These laxatives, also commonly called stool softeners, reduce surface tension, thereby increasing absorption of water and fats into dry stools. Docusate, senna, and castor oil are examples.
Osmotic Laxatives. Osmotic laxatives are essentially sugars that can't be digested by the body and have an osmotic effect in the intestines. Lactulose and sorbitol are liquid forms of osmotic laxatives and are usually quite effective. The sweet taste of these medications is a drawback for many patients and they may cause bloating and gas. They can both be mixed with juice, tea, water, or other liquid to reduce the sweetness.
Glycerin suppositories are another example of osmotic laxatives. Glycerin suppositories may not be as effective as other methods in the chronically ill or elderly patient.
Saline Laxatives: Milk of magnesia is perhaps the most common form of this type of laxative. Saline laxatives increase gastric, pancreatic, and small intestinal secretions and intestinal motility. This medication can cause severe cramping and discomfort and is usually used as a last resort for chronically ill patients.
Suppositories and Enemas: Some laxatives are available in a suppository form, meaning they are inserted directly inside the rectum. Although the thought of using rectal medication may be unpleasant for patients and caregivers may cringe at having to insert them, suppositories are usually quick and effective. Bisacodyl (Dulcolax) is a bowel stimulant that works directly on the colon to induce peristalsis. Because it is a stimulant, cramping is a common side effect. Dulcolax isn’t always recommended for cancer patients and patients with liver disease because of it’s need to be metabolized, or broken down, in the liver.
Enemas are meant to be used infrequently and as a last resort in severely constipated patients. Saline enemas (Fleet Enema) loosen stool and stimulate bowel movement. If they are used frequently, they can cause metabolic imbalances such as hypocalcemia (a decrease in blood calcium levels) and hyperphosphatemia (an increase is blood phosphate levels).
Oil retention enemas can be helpful in patients who are impacted, meaning stool is so large and hard that it is obstructing the colon. If a patient is able to retain an oil enema overnight, that may be tried before a nurse manually dis-impacts them. An example of an oil retention enema is a milk-and-molasses enema.
Dis-impaction: If a patient is impacted and laxatives, suppositories, and enema’s aren’t working or aren’t recommended, a nurse may need to dis-impact them. This is an uncomfortable procedure where the nurse must insert her finger into the rectum to loosen and remove stool. You might cringe at even reading about his procedure. Rest assured that dis-impaction is only done when clinically necessary. Because it is uncomfortable and potentially very painful, patients should be premedicated with an opioid analgesic and perhaps an anxiolytic, such as lorazepam.
Constipation is a distressing symptom that dramatically impacts quality of life. It’s important to keep your health care provider informed about your or your patients bowel movements and alert them to any changes in patterns of bowel movements.
Bleser S, Brunton S, Carmichael B, Older K, Rasch R, Steele J. Management of chronic constipation: Recommendations from a consensus panel. J Fam Pract. 2005 Aug;54(8):691-8.
Ferrell, BR and Coyle, N; Textbook of Palliative Nursing, Oxford University Press, 2006.