What interventions are recommended for an unconscious palliative patient in inpatient hospice with no bowel movement for 6 days, indicating constipation?

From the Guidelines

For an unconscious palliative patient in inpatient hospice with no bowel movement for 6 days, intervention is generally recommended only if there are signs of discomfort or distress, and a gentle approach such as glycerin suppositories or a small-volume enema may be considered. The goal in hospice care is comfort, not normalizing bowel function, and constipation management becomes less aggressive as patients approach end of life 1. If the patient appears comfortable, observation may be sufficient as bowel care becomes less important in end-of-life care. However, if intervention is needed, it's essential to focus on relieving discomfort rather than adhering to regular bowel protocols.

Some key considerations for managing constipation in palliative care include:

• Assessing the cause and severity of constipation, and ruling out impaction, obstruction, and other treatable causes 1
• Using a bowel stimulant and stool softener, and titrating the dosage to achieve the desired effect 1
• Avoiding oral laxatives in unconscious patients due to aspiration risk
• Considering manual disimpaction if there is evidence of fecal impaction causing discomfort
• Documenting the assessment and rationale for either intervening or not intervening

It's also important to note that the NCCN Guidelines for Adult Cancer Pain recommend considering 0.15 mg per kilogram of body weight of methylnaltrexone every other day for patients experiencing constipation that has not responded to standard laxative therapy 1. However, this should be considered in the context of the individual patient's needs and circumstances. Ultimately, the focus should be on providing comfort and relieving discomfort, rather than aggressively managing constipation.

From the FDA Drug Label

The usual adult, oral dosage is 2 to 3 tablespoonfuls (30 mL to 45 mL, containing 20 grams to 30 grams of lactulose) three or four times daily. The dose of lactulose for this purpose is the same as the recommended daily dose When the adult patient is in the impending coma or coma stage of portal-systemic encephalopathy and the danger of aspiration exists, or when the necessary endoscopic or intubation procedures physically interfere with the administration of the recommended oral doses, lactulose solution may be given as a retention enema via a rectal balloon catheter Three hundred mL of lactulose solution should be mixed with 700 mL of water or physiologic saline and retained for 30 to 60 minutes. Lactulose enema may be repeated every 4 to 6 hours. This product generally produces a bowel movement within 12 to 72 hours.

For an unconscious palliative patient in inpatient hospice with no bowel movement for 6 days, indicating constipation, lactulose 2 can be given as a retention enema via a rectal balloon catheter. The recommended dose is 300 mL of lactulose solution mixed with 700 mL of water or physiologic saline, retained for 30 to 60 minutes, and repeated every 4 to 6 hours as needed.

• Key considerations:
  • The patient's unconscious state may increase the risk of aspiration, making rectal administration a safer option.
  • The goal of treatment is to relieve constipation and prevent further complications.
  • Docusate 3 may also be considered, but its effectiveness in producing a bowel movement within a shorter timeframe (12 to 72 hours) may not be sufficient for this patient's urgent needs.

From the Research

Assessment and Diagnosis of Constipation

• Constipation is a common problem in palliative care patients, causing significant suffering and discomfort 4, 5.
• The diagnosis of constipation can be challenging, especially in unconscious patients, and a diagnostic algorithm has been proposed to address this issue 6.
• The algorithm includes objective and subjective symptoms, such as days since last bowel movement and frequency of bowel movements, to diagnose constipation in palliative care patients 6.

Treatment Options for Constipation

• The combination of a softener and stimulant laxative is generally recommended for the treatment of constipation in palliative care patients 4.
• Various laxatives, including senna, lactulose, and polyethylene glycol 3350, have been used to treat constipation in palliative care patients, but there is limited evidence to support the use of one laxative over another 7, 8.
• Newer agents, such as methylnaltrexone, linaclotide, and lubiprostone, are available for the treatment of opioid-induced constipation, but their use is not widespread in hospice organizations 7.

Management of Constipation in Unconscious Patients

• The management of constipation in unconscious patients requires a comprehensive approach, taking into account the patient's individual needs and circumstances 5, 6.
• The use of laxatives, such as senna and lactulose, may be effective in managing constipation in unconscious patients, but the evidence is limited and more research is needed to determine the best approach 8.
• A bowel protocol, including the use of laxatives and other interventions, may be beneficial in preventing and managing constipation in unconscious patients in hospice care 7.