What is the recommended treatment for bowel obstruction in a hospice setting?

Treatment of Bowel Obstruction in Hospice Setting

The recommended treatment for bowel obstruction in hospice patients should focus on pharmacological management with opioids for pain control, anticholinergics to decrease GI secretions, and early initiation of octreotide, with surgical interventions generally avoided in patients with limited life expectancy. 1

Assessment and Diagnosis

• Bowel obstructions in hospice patients are typically diagnosed clinically and confirmed with plain film radiography 1
• CT scans should only be considered if surgical intervention is contemplated for patients with longer life expectancy 2, 1
• Assessment should be tailored based on estimated life expectancy:
  • Years to months: Evaluate for potentially reversible causes
  • Months to weeks: Focus on symptom management
  • Weeks to days: Prioritize medical management over surgical approaches 1

Pharmacological Management

First-line Medications

• Opioids: Essential for pain control and reduction of intestinal secretions 1
• Anticholinergics: Use scopolamine or hyoscyamine to decrease GI secretions and peristalsis 2, 1
• Octreotide: Recommended early in treatment (starting with 150 mcg SC BID, up to 300 mcg BID) due to high efficacy in reducing GI secretions 2, 1
• Antiemetics: Consider haloperidol, ondansetron, or olanzapine for nausea control 1

Second-line Medications

• Corticosteroids: Consider dexamethasone (up to 60 mg/day), but discontinue if no improvement in 3-5 days 1
• If using octreotide with good effect in patients with life expectancy >1 month, consider depot formulation once optimal dose is established 2

Important Medication Cautions

• Avoid prokinetic agents like metoclopramide in complete obstruction as they can worsen symptoms 2, 1
• For patients with partial obstruction, metoclopramide may still be beneficial 2

Non-Pharmacological Interventions

Hydration and Nutrition

• Consider subcutaneous or intravenous hydration if dehydration is present 1
• Total parenteral nutrition (TPN) may be considered only for patients with life expectancy of many months to years and when quality of life improvement is expected 2, 1

Decompression Options

• Nasogastric tube drainage: May be considered if other measures fail to reduce vomiting, but is often uncomfortable 1
• Venting gastrostomy: Options include percutaneous endoscopic gastrostomy (PEG) tube or venting gastrostomy tube inserted by interventional radiology 2, 1, 3
• Percutaneous transesophageal gastrostomy (PTEG): Consider when standard venting gastrostomy is contraindicated 3

Treatment Algorithm Based on Life Expectancy

Patients with Years to Months to Live

• Consider surgical intervention after CT scan if patient has good functional status 2
• Discuss surgical risks with patients and families 2
• Consider venting gastrostomy for symptom management if surgery is not appropriate 1, 3

Patients with Months to Weeks to Live

• Focus on pharmacological management with opioids, anticholinergics, and octreotide 1
• Consider venting gastrostomy for symptom relief 2, 1
• Formal palliative care consultation improves symptom management and quality of care 4

Patients with Weeks to Days to Live

• Prioritize medical management over surgical approaches 2, 1
• Focus on comfort with opioids, anticholinergics, and antiemetics 1
• Home support with hydration and gastric venting can be a humane alternative to hospitalization 5

Pitfalls to Avoid

• Delaying symptom management while pursuing diagnostic workup 1
• Using prokinetic agents like metoclopramide in complete obstruction 2, 1
• Pursuing surgical intervention in patients with poor functional status or very limited life expectancy 1
• Failing to involve specialized palliative care services early 1, 4
• Overlooking the importance of discussing goals of care and end-of-life preferences 4

Quality of Life Considerations

• A formal palliative care service significantly improves symptom management, end-of-life discussions, and appropriate hospice referrals for patients with advanced cancer and bowel obstruction 4
• Home support with fluids and gastric venting can provide a cost-effective and humane alternative to hospitalization for selected patients 5
• The goal of care should focus on symptom control rather than resolution of obstruction 1