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Addressing constipation in hospice care
Having regular bowel movements is something we can take for granted in life. But for those with chronic constipation, particularly patients in hospice care, the inability to eliminate with ease can be extremely dangerous.
Constipation in elderly patients, especially with dementia diagnoses such as Alzheimer’s disease can lead to worsening confusion, irritability, anxiety, agitation, and sometimes aggression.
Hospice patients, in particular, are at an increased risk of constipation. Constipation is such an important issue in hospice that The Centers for Medicare & Medicaid Services (CMS) made it part of the Hospice Item Set (HIS Section N0520) that must be completed on all admissions to hospice.
Causes and side effects of constipation in hospice patients
Constipation is common amongst hospice patients due to multiple factors, including inactivity, decreased intake of fluids and dietary fiber, and the necessary use of opioids, anticholinergic, antipsychotic, and antihypertensive drugs.
Constipation causes discomfort regardless of a person’s age, but for older adults, especially those with dementia or Alzheimer’s, it can lead to worsening confusion, irritability, anxiety, agitation, and sometimes aggression.
Common side effects include:
- Hemorrhoids
- Rectal swelling
- Anal fissures
- Abdominal pain
- Fecal impaction
Constipation typically is treated with a regimen of stool softeners, laxatives, suppositories, and enemas, safeguarding patients against fecal impaction.
Fecal impaction is particularly dangerous for hospice patients. Complications caused by fecal impaction are less common, but when untreated, can prove fatal. Treating fecal impaction in hospice patients can be an invasive and potentially dangerous process.
Treatment and preventative measures
Residential care facilities, nursing homes, and hospice providers acting proactively can easily prevent fecal impactions. Parentis Health facilities and health care providers have strict protocols in place to safeguard patients. Staff routinely monitors all patients, employing natural interventions such as encouraging fluids, offering prune juice, and movement of the patient. Even something as simple as transferring a patient from a bed to a wheelchair can promote better regularity and prevent constipation in hospice patients.
If these efforts are unsuccessful, our hospice care team opts for gentle, over-the-counter remedies like water-based laxatives and milk of magnesia. We purposefully avoid potent laxatives to minimize discomfort and the potential for perforation. We can also use suppositories and enemas as needed. Enemas are warmed to the body temperature. This is because heat stimulates the rectal mucosa, which in turn promotes bowel movements.
Communication is equally important to the treatment of constipation and the prevention of fecal impaction. The team communicates clearly to patients and family members the potential disruptions to regular bowel movements. Collaboration between the skilled nurses who visit the patient, the RN Case Manager, facilities, and the hospice physician is an integral part of keeping a regular defecation schedule.
Coordinated, transparent efforts prevent a simple bodily function from becoming a serious medical complication. We keep our patients comfortable and regular as long as possible, until such time as the interventions mentioned above will no longer be appropriate.
3 Merck Manuals Consumer Edition, https://www.merckmanuals.com/home/fundamentals/death-and-dying/symptoms-during-a-fatal-illness, Accessed 4 November 2021
4 Tracey, James MD. “Fecal Impaction: Not Always a Benign Condition”, Journal of Clinical Gastroenterology, April 2000, Volume 30, Issue 3, pgs. 228-229.