Constipation

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 In Tip of the Month
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Constipation can be a common occurrence in individuals with life-limiting illnesses and can often be a source of pain or discomfort to those receiving palliative or end-of-life care. Constipation is the infrequent or difficult passage of stools from the digestive system leading to fewer bowel movements than an individual is used to. This decreased bowel motility causes more fluid to be absorbed from the digestive tract, causing dry and hard stool.

What Causes Constipation?

Constipation can be caused by many different reasons in people receiving palliative care:

  • Medications (Opioids, antacids, diuretics, anti-depressants, iron supplements)
  • Immobility
  • Decreased food, fluid, and fibre intake
  • Dehydration
  • Medical conditions (e.g., Crohn’s disease, irritable bowel syndrome, tumours in the bowel)
  • Conditions causing neurological deficits (e.g., spinal cord injuries, diabetes, multiple sclerosis)
  • Metabolic causes (hypokalemia, hypercalcemia)
  • Psychological (e.g., use of a bed pan or commode)

It is important to remember that even in the absence of food or fluid intake, the body will continue to produce a small amount of stool. Therefore, constipation should be considered as a possible concern in individuals receiving end-of-life care.

Assessment

As constipation can be so common, regular screening of all individuals should be performed. Asking individuals if they are having abdominal discomfort or pain, excessive straining with bowel movements, or changes in the type, frequency, and consistency of stool can help assess for constipation.

Remember to do a physical exam including a full abdominal assessment: visual inspection, auscultation of bowel sounds, and palpation. A rectal exam or abdominal x-rays may also be helpful in some cases.

Cancer Care Ontario provides valuable resources on the assessment and management of constipation. The Bristol Stool Chart can be used as an assessment tool to classify the shape and consistency of feces into seven types. Types 1 and 2 occur with constipation.

Prevention and Management

Considerations for the individual’s functional status is essential in determining interventions for the prevention and management of constipation. The Palliative Performance Scale could be used to assess for a person’s functional status.

Opioid medications are widely used for pain management in people receiving palliative or end-of-life care. Opioid-induced constipation is a known side effect of opioid use and should always be prevented. It should never be a reason to avoid opioid medications.

Prior to initiating constipation interventions, it is important to rule out a bowel obstruction!

Non-Pharmacological Interventions

  • Maintain adequate fluid intake while minimizing caffeine and alcohol
  • Encourage adequate fibre intake
  • Provide privacy during times of toileting
  • Encourage movement, if tolerated (e.g., ambulation)
  • Elevating the head of the bed to support the defecation process
  • Consult with other interdisciplinary team members for additional mobility/ positioning techniques or dietary recommendations

Pharmacological Interventions

  • Stimulant laxatives (e.g., Senna, Sennosides, Cascara)
  • Osmotic laxatives (e.g., Lactulose, Polyethylene Glycol [PEG])
  • Rectal suppositories (e.g., Bisacodyl)
  • Enemas
Resources

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