The importance of constipation and its management in palliative care Essay Example

it may not cause significant discomfort for healthy individuals, constipation can lead to distressing symptoms like pain, confusion, nausea, vomiting, faecal impaction and urinary retention in these patients according to Groenwald et al (1996). This can negatively impact an individual's physical, social and psychological well-being as stated by Groenwald et al (1996).

According to Lewis (1985), constipation is frequently disregarded in cancer patients despite being a troubling symptom. Nonetheless, Winney (1998) contends that evaluating and comprehending bowel function can mitigate the effects of constipation. To provide optimal care for this condition, medical professionals, pharmacists, occupational therapists, social workers and dieticians must adopt a comprehensive approach although nurses play a vital role in supporting patients.

According to the Department of Health (DOH) (2000), over one-third of England's population will develop cancer during their lifetime, and the cancer plan aims to provide appropriate care, treatment, and support for those affected. Multiple international studies have found that constipation affects 20% to 50% of elderly community members (Harari et al, 1996; Petticrew et al, 1997; Chiarelli et al, 2000). Mrs. Andrews was admitted as an inpatient at a London hospice with a total capacity of 29 beds which houses a community palliative care team and day care unit. This hospice assists up to 420 patients per year.

Within the hospital, there are three wards that consist of bays and side rooms. Gender segregation is implemented in the bays, but bed allocation is not fixed throughout the wards. The care team employs both team nursing and named nurse methods and includes various staff members such as nurses, social workers, ward clerks, physiotherapists, pharmacists, research practitioners, complementary therapies coordinators, art therapists, psychiatrists and medical

professionals.

Mrs Andrews, who is 80 years old, has been dealing with breast cancer that has spread for the past 15 months. She lives alone in a council flat with just one bedroom since her husband passed away from prostate cancer. Although she relies on state benefits, she can manage to cook and shop for herself. Mrs Andrews frequently gets visited by a social worker, district nurse, and Macmillan nurses.

Initially, she spent the majority of her time indoors watching TV and chose to remain silent about her constipation. She resorted to using non-prescription laxatives but eventually developed diarrhea. Eventually, she contacted the district nurse to express her worries concerning her loose bowel movements.

Mrs. Andrews reported experiencing unexpected leakages, and was eventually prescribed multiple laxatives such as Senna, Lactulose, and Novical after admitting to constipation. She informed a district nurse about her condition, but it took a month for laxatives to be prescribed. Due to vomiting and severe pain during defecation, the nurse referred Mrs. Andrews to hospice care. Upon admission assessment, it was determined that Mrs. Andrews was malnourished and dehydrated, with significantly reduced mobility.

Following a pain assessment, Mrs Andrews was prescribed 10 mg of oramorph due to the ineffective nature of her previous medication, cocodamol. Additionally, the medical team administered glycerine suppositories after performing a rectal examination. Furthermore, Emma, Mrs Andrews' named nurse, referred her to several healthcare professionals, including the ward dietician, physiotherapist, social worker, community palliative care team and occupational therapist. Emma also invited the district nurse to attend a multidisciplinary meeting regarding Mrs Andrews' care at the hospice.

Despite the district nurse being unavailable, various healthcare professionals took action to improve Mrs Andrews's

care. The physiotherapist introduced exercises, the dietician suggested a high fibre diet, and the social worker expanded her care package to include assistance with cooking. Additionally, the community Palliative care team planned to provide follow-up visits after her discharge. Mrs Andrews made considerable progress within three weeks, and both her general practitioner and district nurse were notified of her impending discharge two days beforehand. Prior to leaving the hospital, an occupational therapist visited Mrs Andrews's home and advised the installation of a raised toilet seat, handrails, and a commode. It may have been beneficial for Mrs Andrews to have undergone an abdominal X-ray during her hospice stay in order to investigate any potential obstructions or identify the extent of faecal impaction and loading (Groenwald 1996).

According to Groenwald (1996), the primary objective in managing constipation should be prevention. Groenwald (1996) suggests that laxative treatment should aim to facilitate defecation and not necessarily to achieve daily bowel movement. Furthermore, Groenwald (1996) recommends maintaining a bowel diary at home. Fallon and O'Neil (1997) report that Mrs. Andrews experienced symptoms commonly associated with constipation, including abdominal pain, bloating, and incomplete evacuation. Symptoms of complications resulting from constipation include overflow diarrhea, nausea, and vomiting.

According to Fallon and O'Neil (1997), patients with advanced cancer are more likely to experience constipation compared to those with other terminal diseases. This symptom can often be mistaken for features of the underlying illness. It is reported that around 50% of patients admitted to specialist palliative care units suffer from constipation and approximately 80% require laxatives. Fallon and O'Neil (1997) also state that bacterial degradation of hard stools can cause leakages without warning. As part of

the admission assessment, Mrs. Andrews' named nurse obtained a thorough background history.

According to Gabriel (2001), effective management of constipation requires an accurate history. Gabriel identifies several potential causes of constipation including cancer, depression, poor nutrition, poor fluid intake, and opioids. Fallon and O'Neil (1997) suggest that Mrs Andrews may be experiencing depression due to her husband's death and cancer. It is unclear why Mrs Andrews was prescribed oramorph while in hospice care as opioids are commonly known to cause constipation (Corner and Bailey 2001). However, even when advice is given regarding dietary fiber, fluid intake, and exercise, Annels and Koch (2002) note that successful management of constipation is not always achieved. This may be due in part to common constraints faced by older individuals that prevent them from utilizing these options.

Annels and Koch (2002) noted examples such as the cost of fruit and vegetables, a tendency towards urinary incontinence, and not feeling safe to take walks alone when widowed. Mrs Andrews may have begun purchasing over-the-counter laxatives as a holiday preparation, as some practice nurses recommend (Goldman 1999). Gates and Fink (2001) suggest that increasing fluid intake can keep stools soft, while raised toilet seats, footstools, and bedside commodes are believed to be beneficial for constipated patients.

Emma should have notified the district nurses about Mrs Andrews' impending discharge earlier, ideally more than just two days before. According to Pateman et al (2003), research indicates that district nurses are particularly concerned that patients with actual or potential palliative care needs may not be referred to them early enough. Mrs Andrews' activity levels put her at risk for constipation, which is the most frequent complication of

immobility (Taylor 1990). Despite mentioning drinking 2-3 cups of tea and two glasses of water per day, Mrs Andrews' fluid intake of about 600ml falls short of the recommended 2-3L per day, with a minimum intake of 1-2L per day necessary for maintaining regular bowel habits (Cameron 1992; McFarland and McFarlane 1989).

According to Whitney (1998), research indicates that a team approach involving various medical professionals - including dieticians, social workers, psychologists, dentists, nurses, and physicians - is essential in managing constipation. This is particularly relevant to Mrs. Andrews, who was given opioids for acute pain while at the hospice; opioids are recognized as a common cause of constipation (Gates and Finch 2001). At the same time, increased awareness of pain under-treatment has led to a growing use of opioids (Bates et al 2004). With this in mind, it is crucial to differentiate true diarrhea from fecal impaction-related overflow when treating patients with a history of diarrhea (Fallon and O'Neil 1997). Other signs of constipation may include malodorous breath or the smell of fecal leakage (Fallon and O'Neil 1997).

The management of constipation in palliative care extends beyond the use of laxatives. Other symptoms such as pain and factors including diet, fluid intake, mobility, and toileting must also be considered for an effective outcome (Corner and Bailey 2001). It is important to understand that older people may have a different understanding of constipation, so healthcare providers should explore their understanding of the term (Annels and Merilyn 2002). Patient management for constipation should be individualized and take into account the patient's willingness to make changes (Vikery 1997). Establishing a routine for elimination and lifestyle changes can take time

and require support from healthcare professionals and family members (Vikery 1997). Overall, it is crucial to recognize the significance of constipation management in palliative care.

The topic choice has been justified, along with an explanation of the clinical setting and presentation of a patient profile. The analysis contains a thorough examination of research evidence and provides recommendations for practice. The importance of holistic care and the multidisciplinary team in managing constipation is highlighted.