Constipation (Palliative Care) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Constipation related to advanced disease

This guidance does not cover:

  • Patients under 18 years of age

Assessment

Overview
  • Anticipate constipation; ask about previous bowel function, medications and other possible causative factors.
  • Remember that constipation can sometimes present as overflow diarrhoea.
  • Exclude malignant intestinal obstruction; abdominal palpation, auscultation and digital rectal examination are needed for proper assessment of constipation.
  • Investigations may be needed to guide treatment
    • Abdominal x­ray is rarely required.
    • Calcium level to exclude hypercalcaemia.
  • Constipation is characterised by difficult or painful defaecation, associated with infrequent bowel evacuations, and hard, small faeces.
  • It is a very common cause of distress in palliative care patients. It is better to prevent it than to wait until treatment is needed.
  • When opioids are commenced, it is almost always appropriate to start a laxative. Relatively high doses of laxative may be needed; the dose should be increased as the dose of opioid increases.
  • Constipation in patients with progressive disease is usually multifactorial
Causes to consider
  • Drug induced – review medication; consider prophylactic laxative Dehydration ­ encourage fluids; review diuretics
  • Reduced mobility ­ ensure ready access to toilet; attention to privacy, raised toilet seat for comfort Altered dietary intake ­ review and advise as appropriate
  • Hypercalcaemia – consider treatment i/v fluids and bisphosphonates
  • Neurological e.g. spinal cord compression; autonomic neuropathy
  • Intestinal obstruction
Effects of chronic constipation
  • Anorexia
  • Vomiting
  • Colic
  • Tenesmus
  • Overflow diarrhoea
  • Urinary retention
  • Agitation

Management

  • Most palliative care patients are too debilitated to tolerate the dietary measures needed to combat constipation and to tolerate laxatives such as bulking agents. High fluid intake, fruit and fruit juice (especially prune juice) all help.
  • Assess the cause and treat where possible.
  • Laxative doses should be increased until constipation is controlled and may need to be higher than in other patients.
  • Review laxatives every 2 days and titrate as required.
  • There is limited research about the management of constipation in palliative care patients, and therefore no evidence to support a particular medication regime.
  • Use oral drugs first line.
  • Patient preference is likely to dictate choice of laxative – this can have a significant impact on adherence.
  • Patients will usually require a combination of:
    • A stool softener: docusate, lactulose, Movicol ®, Laxido ®, magnesium salts
    • A stimulant: senna, bisacodyl, sodium picosulphate
  • Mixed preparations of softener and stimulant e.g. co­danthramer, keep medications to a minimum but may reduce flexibility of titration
    • Danthron containing products (co­danthramer and co­danthrusate) have been restricted to constipation in terminally ill patients of all ages due to the theoretical risk as a carcinogen.
    • Do not use co­danthramer or co­danthrusate in patients who are incontinent of faeces, danthron can cause excoriation/burning of the skin. Danthron may also colour the urine red.
  • Any bowel stimulant can cause colic, avoid if this is present.
  • Lactulose can cause excessive flatulence and bloating.
  • Do not prescribe laxatives in complete bowel obstruction without specialist advice.
  • If bowels have not moved in 3 days a rectal examination may be appropriate. If there is evidence of hard stool then rectal measures may be required.
  • Manual evacuation should be the last resort and may need sedation or analgesia. Please seek specialist advice.
  • Seek specialist advice for the management of opioid induced constipation
    • Some opioids (Fentanyl or Buprenorphine) may be less constipating
    • Peripheral acting opioid antagonist could be considered. E.g. Subcutaneous methylnaltrexone bromide, Targinact ® (oxycodone and naloxone) or oral Naloxegol ®. However, there are some prescribing restrictions on the use of these products given their relative cost, and they should only be prescribed under specialist advice.

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015.
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details and resources for further information

Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Supporting Informtation

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL4 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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