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Guidelines for the Management of Constipation in Palliative Care

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Guidelines for the Management of Constipation in Palliative Care Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines Guidelines for the Management of Constipation in Palliative Care D Monnery,1 M Cooper,1 R Ayre,2 S Cureton,2 L Devlin,3 T Cookson,3 C Owens,3 S Schofield,3 G Sudworth,3 C Hyland,3 L Edmunds,1 L Waters,1 A Scott.4 (Guideline Development Lead). 1 The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK. 2Bridgewater Community Healthcare NHS Foundation Trust, Wigan, UK. 3Willowbrook Hospice, Prescot, Merseyside, UK. 4Marie Curie Hospice, Liverpool, UK. Summary of Main Recommendations Diagnosis Constipation is a very common symptom in palliative care patients which can adversely affect their quality of life. Patients and healthcare professionals often differ in their assessment.3 [Level 3] It is important to explore the views of the patient and whether they believe themselves to be constipated. 3 [Level 3] The Bristol Stool Chart may be useful in helping to make a diagnosis of constipation. Assessment Before starting any laxative medicine clinical assessment should exclude bowel obstruction. It may be appropriate to check the patient’s blood biochemistry and perform a digital rectal examination. Health professionals should assess for any factors potentially contributing to the constipation including: opioids;14 [Level 2+] mobility; fluid / dietary intake and environmental factors such as equipment needs.15 [Level 4] Symptom Control Always give advice about non pharmacological measures. Further guidance on dietary advice can be found in Section 4.4 of this guideline. Laxative monotherapy should be used where possible, as it may avoid tablet burden and improve quality of life for the patient.25 [Level 4] The evidence base for the use of some laxatives is limited. Senna and lactulose have been shown to be effective when used as single agents and in combination.4,24 [Level 1] Other laxatives may also be considered. Please see Figure 1 and Table 3 in the guideline. If constipation persists despite the optimisation of oral laxatives, rectal interventions may be considered. A digital rectal examination will help to determine the most appropriate rectal intervention to use. Please see Figure 2. For patients with malignant spinal cord compression, rectal intervention should be given on alternate days and combined with an alternate day stimulant oral laxative such as senna.15 [Level 4] Please see Figure 2. Communication Patients should be offered information about constipation at the time of diagnosis, and when starting any medicines which increase the risk of constipation e.g.opioids.15 [Level 4] Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021 Page 1 Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines Section 1: Introduction Constipation is a very common symptom in palliative care patients.1 It has been shown to result in significant physical, psychological, social and existential problems affecting quality of life.2 Defining constipation is complicated by conflicting perceptions between patients and clinicians. Patients frequently describe constipation as an experience of bowel movements. Clinicians may define constipation based on the frequency of bowel movements.3 In general, the various definitions of constipation refer to: infrequent, difficult or incomplete bowel evacuation that may lead to pain and discomfort; stools that can range from small hard ‘rocks’, to a large bulky mass; and a sensation of incomplete evacuation.4 Due to the difficulties in defining constipation, the incidence is difficult to determine but has been estimated at between 18% and 90% of patients receiving palliative care.5-7 The prevalence of contributory factors is estimated at between 25% and 90% of patients.1,8 The lack of a clear definition of constipation can contribute to difficulties and delays in reaching a diagnosis.9 No tools or criteria have been demonstrated to be consistently effective in helping to make an accurate diagnosis of constipation in patients receiving palliative care. Causes of constipation in the palliative care population are often multifactorial and include: poor dietary intake; physical inactivity; disease related and treatment related.4 The prevention and treatment of constipation is often related to the cause.4 Constipation in the majority of people receiving palliative care has the potential to be drug-induced and so management to promote satisfactory bowel movements commonly involves laxative administration.4,10 The benefits of treatment must be balanced against potential side effects. Many laxatives can contribute to discomfort by exacerbating colic or causing diarrhoea. Use of rectal interventions has implications for dignity and may not be acceptable to some patients. Management options should be discussed with the patient and /or those important to them, taking full account of their views and preferences. This guideline aims to give advice about the diagnosis, assessment and use of pharmacological and non-pharmacological measures which can be offered to relieve constipation in patients receiving palliative care. It is an update of “Guidelines for the Management of Constipation in Palliative Care” last reviewed in 2010.1 Management of bowel obstruction in palliative care is available separately and not covered in this guideline.12 Section 2: Scope and Purpose This guideline aims to inform practice in the assessment, diagnosis and management of constipation in patients receiving palliative care. Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021 Page 2 Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines The guideline is aimed at specialist palliative care professionals including doctors, nurses, pharmacists and allied health professionals and generalists involved in providing palliative care e.g. general practitioners, district nurses, hospital doctors and nurses.This guideline is an update of Guidelines for the Management of Constipation in Palliative Care, 2010.11 Due to differences in approach and treatment, management of bowel obstruction is not covered in this guideline. There is a separate regional guideline for the medical management of malignant bowel obstruction in palliative care.12 The guideline aims to answer the following questions:- 1. What is the best method to assess patients for the presence of constipation in palliative care? 2. What methods of management are recommended in patients diagnosed with constipation in palliative care? Table 1 summarises the scope and purpose of this guideline. Table 1 Scope of Guideline People aged over 18 years with constipation receiving Population palliative care People under 18 years Populations not covered People not receiving palliative care Community care Secondary care Healthcare setting Tertiary care Hospice care Diagnosis and assessment of constipation in palliative Topics care Management of constipation in palliative care Bowel Obstruction Topics not covered Section 3: Methods This guideline is based on the AGREE II criteria, which can be found in the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual.13 Guidelines for the Management of Constipation in Palliative Care Date of Production: July 2018 Date of Review: July 2021 Page 4 Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines 3.1. Clinical Questions and Interventions The clinical questions were derived from the previous guideline developed in 2008 and updated in 2010.11 These were refined by the Guideline Development Group which has authored this guideline. The clinical questions used to guide the literature review in PICO (Patient, Intervention, Control, Outcome) format are:- 1. In patients receiving palliative care and suffering from medication-induced constipation (P), is one method of management (I) superior to other methods or no formal method (C) in relieving constipation (O). 2. In patients receiving palliative care and suffering from non-medication-induced constipation (P), is one method of management (I) superior to other methods or no formal method (C) in relieving constipation (O). 3.2. Outcomes To maximise patient comfort by ensuring the best assessment and treatment methods for patients with constipation receiving palliative care through:- improved knowledge of the assessment and diagnosis of constipation improved knowledge of the non-pharmacological and pharmacological interventions available promotion of education and training for all staff involved in caring for patients with constipation 3.3. Literature Search Systematic electronic database searches were undertaken to find potentially relevant articles. MEDLINE, Embase, CINAHL and Cochrane databases were searched in July 2017. A full outline of the search strategy, results and appraisal of evidence can be found in Appendix 1. The grading of the level of evidence and recommendations follows the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual and uses SIGN criteria.13 Section 4: Guideline Recommendations 4.1. Assessment and Diagnosis of Constipation Assessment of constipation is complicated by a difference in perception and definition between patients and clincians.14 Health professionals’
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