What is the best approach to manage bowel obstruction symptoms in an elderly hospice patient?

Management of Bowel Obstruction in Elderly Hospice Patients

For elderly hospice patients with bowel obstruction, medical management focusing on symptom control rather than surgical intervention is strongly recommended to optimize quality of life during end-of-life care. 1

Assessment and Diagnosis

• Bowel obstructions in hospice patients are usually diagnosed clinically and confirmed with plain film radiography, which is typically sufficient to establish the diagnosis 1
• CT scan should only be considered if surgical intervention is contemplated, as it provides more detailed information about the cause of obstruction 1
• Assess for underlying causes based on estimated life expectancy:
  • Years to months: Evaluate for malignant causes (tumor mass, carcinomatosis) 1
  • Months to weeks: Focus on symptom management goals (decreasing nausea/vomiting, allowing patient to eat, decreasing pain) 1
  • Weeks to days: Prioritize medical management over surgical approaches 1

Pharmacological Management

First-line medications:

• Opioids for pain control and to reduce intestinal secretions 1
• Anticholinergics to decrease GI secretions and peristalsis:
  • Scopolamine or hyoscyamine for secretion control 1
  • Glycopyrrolate as an alternative anticholinergic 1
• Octreotide: Consider early in treatment (start 150 mcg SC BID, up to 300 mcg BID or via continuous subcutaneous infusion) 1
  • Recommended early due to high efficacy and tolerability in reducing GI secretions 1
  • May consider depot form if helpful and patient has life expectancy of at least 1 month 1

Additional medications:

• Corticosteroids (up to 60 mg/day of dexamethasone, discontinue if no improvement in 3-5 days) 1
• Antiemetics:
  • Important: Do NOT use antiemetics that increase GI motility (like metoclopramide) in complete obstruction 1
  • Metoclopramide may be beneficial only in partial/incomplete obstruction 1
  • Consider haloperidol, ondansetron, or olanzapine for nausea control 1

Non-Pharmacological Interventions

• Hydration: Consider subcutaneous or intravenous fluids if evidence of dehydration 1
  • At-home intravenous hydration may be considered for symptom management 1
• Nasogastric tube drainage:
  • Use only if other measures fail to reduce vomiting 1
  • Usually uncomfortable and increases risk of aspiration 1
  • Only insert if the patient wants to try this and other measures have failed 1
• Venting gastrostomy:
  • Palliative venting gastrostomy can relieve symptoms and improve quality of life in the absence of extensive peritoneal disease 1, 2
  • Options include percutaneous endoscopic gastrostomy (PEG) tube or venting gastrostomy tube inserted by interventional radiology 1
• Total parenteral nutrition (TPN):
  • Consider only if expected improvement of quality of life with life expectancy of many months to years 1
  • If the patient has good performance status, consult a gastroenterologist-led nutrition team early 1

Special Considerations for Hospice Patients

• Goals of care: Focus on symptom control rather than resolution of obstruction 1
  • Prioritize reduction of nausea/vomiting, pain control, and overall comfort 1
• Avoid unnecessary hospital attendance as patients in the last phase of life often have poor experiences with limited benefits 1
• Early referral to specialized palliative care services is beneficial for additional support 1
• Decision-making for partial or complete bowel obstruction is complex and requires specialist advice 1

Management of Constipation (Often Preceding Obstruction)

• Prophylactic laxative therapy is essential when prescribing opioids 3
• Recommended laxatives:
  • Stimulant laxatives (senna, bisacodyl) 1, 4
  • Osmotic laxatives (polyethylene glycol, lactulose) 1, 4
• For opioid-induced constipation: Consider methylnaltrexone 0.15 mg/kg subcutaneously every other day, but avoid in patients with bowel obstruction 3

Pitfalls to Avoid

• Do not use prokinetic agents like metoclopramide in complete obstruction as they can worsen symptoms 1
• Avoid surgical intervention in patients with poor functional status or very limited life expectancy 1
• Do not delay symptom management while pursuing diagnostic workup 1
• Recognize that most malignant bowel obstructions are partial, allowing time to discuss appropriate interventions with patient and family 1

By following this approach, clinicians can effectively manage the distressing symptoms of bowel obstruction in elderly hospice patients while maintaining focus on quality of life and comfort during end-of-life care.