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  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
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  • 10. Common Symptoms
  • 11. Withholding Treatment
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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

     
    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Constipation Diarrhea
    Anorexia/Cachexia
    Fatigue/Weakness
    Fluid Balance/Edema
    Skin
    Odors
    Insomnia

    Constipation

    Case Example

    AR is a 46-year-old mother of 2 with advanced ovarian cancer widespread within the abdomen. Ascites is present on examination. Bowel sounds are present. Pain is well controlled with transdermal fentanyl 25 mg/hour. However, she complains of persistent constipation.

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    Definition/Description

    • "Discomfort associated with reduced frequency of bowel movements"
    • Usually associated with an increase in stool consistency that leads to difficulty in defecating
    • Often neglected symptom
      • Often not carefully assessed
      • If left unmanaged, it can lead to considerable patient distress
      • Consequences of unmanaged constipation

        • Abdominal pain
        • Bloating
        • Nausea and vomiting
        • Overflow incontinence
        • Tenesmus
        • Fecal impaction
        • Bowel obstruction

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    Causes

    • Decreased mobility, ileus, mechanical obstruction
    • Metabolic abnormalities
    • Spinal cord compression
    • Dehydration
    • Autonomic dysfunction
    • Malignancy
    • Medications
      • Opioids
      • Calcium-channel blockers
      • Anticholinergics

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    Management

    General Measures

    • Tailor examination, investigation, and treatment to presentation, stage, and context of the person and illness
    • Correction of the underlying pathophysiological cause of constipation often not possible or appropriate for many patients at the end of life
    • Establish what is "normal"
      • Wide range of "normal" number of bowel movements per day or per week, consistency, color, and volume
    • Regular toileting
      • Have the patient toilet regularly at the same time each day
    • Gastrocolic reflex
      • Take advantage of the gastrocolic reflex that occurs after eating (strongest peristalsis is in the early morning)

      • Have the patient sit upright if possible
    • Medical management
      • Notes
        • Suggested cathartics are listed in order of usual preference in patients with advanced illness, poor mobility, and decreased oral intake

        • Clinicians frequently fail to dose-escalate a particular modality

        • This leads to the sense that "nothing works" when, in fact, nothing has been tried to its maximal therapeutic dose
    • Stimulents
      • Prune juice 120–240 ml q d or bid
      • Senna 2 PO q hs, titrate (up to 9 or more per day)
      • Casanthranol 2 PO q hs, titrate (up to 9 or more per day)
      • Bisacodyl 5 mg PO, PR q hs, titrate
    • Osmotics
      • Lactulose 30 cc PO q 4–6h, titrate
        • sorbitol is cheaper alternative

      • Milk of magnesia 1–2 tablespoons 1–3 times per day
        • or other Mg salts

      • Magnesium citrate
    • Detergents
      • Stool softeners
        • Sodium docusate 1–2 po q d–bid, titrate
        • Calcium docusate 1–2 po q d–bid, titrate

      • Phospho-soda enema prn
    • Lubricants
      • Mineral and peanut oil
      • Glycerin suppositories
    • Large-volume enemas
      • Warm water - distends colon to soften stool and induce peristalsis
      • Soap suds - irritates colon to induce peristalsis
    • Prokinetic Agents
      • Metoclopramide 10–20 mg PO q 6h
      • Cisapride 10–20 mg PO q 6h

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    Constipation From Opioids

    • Occurs with all opioids
    • Prophylactic measures
      • Consider prophylactic measures

      • Easier to prevent than treat

      • Reasonable in the elderly, debilitated patient who may have other coexisting causes of constipation

      • Effective regimen to maintain bowel function will enable patients to have both pain relief and normal bowel movements
    • New-onset abdominal pain and/or nausea and vomiting in a patient taking opioids may be due to unrecognized constipation
    • Abdominal x-rays may be needed to confirm the diagnosis
    • Warn radiologist that you are looking for the volume of stool present, not just signs of obstruction
    • Pharmacological tolerance developed slowly, or not at all
    • Dietary interventions alone are usually not sufficient
    • Combination stimulant/softeners are useful first-line medications
      • Casanthranol + docusate sodium
      • Senna + docusate sodium
    • Avoid bulk-forming agents in debilitated patients
    • Prokinetic agents helpful in management
    • While opioids cause constipation, they are not the only medication to do so
      • Calcium-channel blockers
      • Any medication with anticholinergic adverse effects (such as tricyclic antidepressants)
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