NCG Guidelines – Palliative Care Management of Symptom Cluster - Constipation

Palliative Care Package for Constipation

Name of the protocol: Palliative Care Management of Constipation

Indication- Constipation > 5 days with distress

Regimen/ protocol: Obstipation in cancer patient

Content of the regimen: Consultation, evaluation, nursing procedures, medicines, observation and review until regular passing of

motions, Supportive Care, OPD follow-up of minimum 2 review consultations over next month.

Cost of the package including investigations included) – consultation, medicines, procedural charges, paramed MDT professional

charges, cost for admission and follow-up consultations

Duration of each package – 1 months

Maximum number of times package will be utilised – 6 times

Cost for day care – Yes

Any investigations needed before package – if symptoms/signs necessitate, Electrolytes, TSH levels, upright X-ray abdomen/ USG

and when required CT to identify malignant bowel obstruction

Dose: drugs and doses are listed below – (A)

Investigations during therapy – Nil

Cost of supportive care - Physiotherapist, occupational therapist, dietician, assist aids – (B) & procedural charges (C)

Admission/ administration cost – Yes, when the patient is in obstipation

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 NCG Guidelines – Palliative Care Management of Symptom Cluster - Constipation

Constipation in cancer patient - Clinically

assessment with History, Examination

Medication Constipation
Look for systemic Local Recent onset
history, Look for  Is there without above
causes - S. Calcium, concerns- constipation with
and modify colic, vomiting mentioned issues
potassium - treat pain on urinary retention,
drugs that may abdominal
reversible defecation, lower limb weakness
contribute to distension?
conditions Ileus, rectal, suggesting spinal cord Constipated < 5 days
constipation Rule out
colonic compression in a
pathology, Bowel patient with Prostate,
Dehydration E.g. Modify the
dose or the stoma Obstruction breast, lung Per Rectal evaluation
due to diuretics, related with a
inadequate drug,
standing X-Ray Rectum Other
intake ondansetron, Rectum empty
Abdomen Urgent referral filled with findings -
anticholinergics, & collapsed
antidepressants, Surgical to evaluate/ soft stools details
Hypo/hypercalce others referrals manage spinal below
mia, hypokalemia Refer to cord
compression Use Regularise
Stop / modify the NCG stimulant
dose of opioids / Manage guidelines Stimulant
laxative per laxatives Per
Is patient hypothroid - consider opioid tenesmus, on oral or as
Refer and activate rotation. other managing oral + stool
suppository softener +
internal medicine contributors Bowel + softener +
care-pathways and to pain on obstruction Supportive
Stimuant laxative Supportive Care
packagea defecation, Care
and softner adjusted
to achieve bowel review
review
movement atleast
Is patient depressed?
once in 2-3 days
Refer and activate
psychology/psychiatry
care-pathways and
packagea

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 NCG Guidelines – Palliative Care Management of Symptom Cluster - Constipation

Is it flaccid Manual removal of

Full bowel egime - Bulk laxatives, bowels? Faeces; check &
softners 12 hours prior. Plan motion (LMN) repeat if necessary
20-30 minutes after warm fluid
PR Examination,
intake. Abdominal massage along the Is it irritable,
digital stimulation -
colnic length to stimulate movement. reflex bowel
Paraparetic/ 15-20 sec- check &
(UMN)
paraplegic/ long-term repeat if necessary
Asdmit if there bed-bound patient?
is nausea, Supportive care - Education on Bowel routines, adjust diet. Loperamide may
bloating, be used with very close monitoring to manage consistency of stools - to keep
abdominal the stool firm, but not hard.
discomfort -
Constipation > 5 Obstipation
days, without Rectal intervention (bowel regime) every 1 to 3 days to avoid impaction
above listed Lack of privacy,
issues Patient/family education,environmental adjustment (bed-side
mobility, inadequate
commode, walker, occupational therapy)
dietary fibre
Day-care admission for evaluation and procedures E.g. Enema,
Rectum full -
manual evacuation + stimulant laxative + softener laxative,
hard stools
education + supportive care
Per rectal
examination Day-care admission for evaluation and procedures - high up
Rectum dilated
enema + stimulant laxative suppository, followed by oral
& empty
laxatives, education and supportive care.

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 NCG Guidelines – Palliative Care Management of Symptom Cluster - Constipation

Drugs (A)

Stimulant laxatives Softening laxatives Others

• Bisacodyl – Tab: 5-10 mg at night to 10 mg TDS; • Syp.Lactulose 15 ml HS to30 ml • Look for and modify impact of Drugs
• Bisacodyl Suppository 10mg TDS which cause constipation- opioids,
• Senna 15 mg HS – 30 mg/ Day • Docusate Sodium antacids, anticholinergics, ondansetron,
• Glycerol 4g • Cremaffin.- antidepressants
• Sodium Picosulphate– 5 mg–30 mg / Day • Opioid induced constipation, intractable
• Poly Ethelene Glycol sachet – Peglec –1 sachet dissolved in not < Osmotic / Bulk Forming with other treatments - S/C
125ml of water. Upto 3 sachets may be used with proportionate • Macrogols 1 sachet Methylnaltrexone 8 mg on alternate days
volume of water. Intended volume is taken orally in < 4 hours. • Ispaghula (C.I - Bowel Obstruction) – is evidence
Used in patients with prolonged, severe constipation. who can based option – if accessible regionally.
take in large volumes of fluids orally and mechanical issues / • Local application agents – Lignocaine
bowel obstruction is completely ruled out. ointment/gel

Supportive Care * (B)

Education/ communication MDT - Referrals Supportive Equipment

Discuss issues with privacy/ comfort in the environment, regularity of Diet – high fiber; hydration; special Position support during defecation with knees
daily rhythm, toilet seating/ positioning (knee above hip for improved diet if on tube feeding- whole cereal above hip-joints - Foot-stool
dynamics); hydration meals (wheat, oats, rice), pulses, Access to commode / Railings for support
Elicit and address fears - of bleeding per rectum, withholding fluids, nuts, vegetables, fresh/dried fruits, Walker
food – due to anxiety about being dependant on others for defaecation natural juice,
Elicit and respond to dignity concerns Physiothereapy/ occupational therapy
Physical range of movement
exercises, energy conservation
techniques, positioning

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 NCG Guidelines – Palliative Care Management of Symptom Cluster - Constipation

Procedures (C)
Nursing Procedures – Rectal procedures are avoided if there is neutropenia, thrombocytopenia
This may require day care admissions.

Regular Enema
Minor procedure: Enema fluid is placed into the rectum using a lubricated end of Sodium Phosphate Enema sachet

High-up enema
Minor procedure - Enema fluid is placed high up beyond the rectum using a lubricated simple 16G catheter. 2 sachets of Sodium Phosphate Enemas

Manual Evacuation
Minor procedure - Local anaesthetic gel, gloves, day-care admission + suppository + enema

Drug administration- Subcutaneous injections / infusions, P/R suppository

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