Constipation

End-of-life constipation and how to relieve it

Hospice nurses are obsessed with bowel movements. Bowel movements are also known as stool, feces, BMs, or poop. Every patient has a different normal when it comes to having a bowel movement. Some patients have a bowel movement every day, some have a bowel movement every three days, and some patients have a bowel movement once a week. 

Hospice nurses freak if their patient does not poop at least every three days. Constipation can cause pain, nausea, vomiting, confusion or delirium, impaction, or an abdominal obstruction which is why hospice nurses can get pretty aggressive and annoying when it comes to dealing with constipation. Here are some answers to the frequently asked questions about bowel movements and constipation.        

What is constipation? 

A patient is constipated when they have one or more of the following symptoms: 

• too few bowel movements in a week 

• difficulty having a bowel movement (straining)

• the production of small, hard bowel movements (an incomplete bowel movement) 

• the inability to have a bowel movement altogether 

Understanding the physiology of the bowel can help us further understand what is happening in the body when a patient is experiencing constipation. 

Together your small intestine and large intestine are approximately 15-25 feet long which is equivalent to the length of 3-5 queen size mattresses in a row!

Together the small intestine and large intestine are approximately 15 feet to 25 in length. That is three to five queen size beds in a row. Imagine the hairpin turns your poop has to make to actually get out of your body — when the body is in the process of dying, these turns get more difficult for the patient, especially as their habits around food, liquid, and movement change. 

Even if patients are not eating or drinking much, it is often likely that there is some residual poop somewhere in those 25 feet of hairpin turns. The lining of the colon is also constantly regenerating which adds to the toxic waste. The longer it stays in there, the harder and more difficult it is to pass.  

What causes constipation? 

It is quite normal for a hospice patient to experience constipation. When someone is ill, they may not have a robust appetite and may crave different foods. These dietary changes alone can cause a disruption to one’s normal bowel habits. 

Other potential causes include the following. 

Medications. There are many medications that can actually cause constipation. Many hospice patients are on opioids for pain relief such as hydrocodone, oxycodone, morphine, hydromorphone, fentanyl, Oxycontin, or MS contin. Opioids are a major cause of constipation because they slow the motility of the intestine and this always leads to constipation. 

Generally when someone starts an opioid, the doctor will prescribe a bowel regimen simultaneously (some type of laxative and/or stool softener). You do not want to wait until you are constipated to start the bowel regimen.

Other medications that may cause constipation are anti-depressants, antihistamines, anti-seizure meds, and many more.

A decrease in fiber. The patient may not be able to tolerate that daily bowl of oatmeal followed by 24 ounces of water which typically helps them have their daily bowel movement. Fiber needs to be matched with an ample amount of fluid to be beneficial, otherwise it will aggravate the constipation.

A decrease in fluids. Hospice patients may drink less than they normally do. An increase in fluids can help, but you do not want to force a hospice patient to eat or drink as their body is naturally doing what it needs to do.

Inactivity. Inactivity and immobility can also lead to constipation.

Fear. When patients are constipated, it may be painful to evacuate the bowels which can lead to fear and apprehension about going to the toilet. 

Colon cancer. Patients with colon cancers may have difficulty having bowel movements because the cancer may mechanically disrupt the flow of feces.

Neurological conditions. Certain neurological conditions such as a stroke or Parkinsons can affect the neural pathways that innervate the colon.

What symptoms can you expect as a result of constipation? 

Hospice patients may experience any of the following symptoms when they are constipated. 

• Bloating

• Inadequate evacuation — after you have a bowel movement, you do not feel like it was complete

• Straining when you try to have a BM

• Small stools — no offense, but we do not count a small bowel movement as a bowel movement  

• Hard stool or stool that looks like rabbit pellets

• More than three days with no BM

• Abdominal pain, cramping

• Abdomen tender to the touch

• Nausea and vomiting

• Diarrhea or oozing stools could signal that the patient  stool and the body is doing a work-around

• Confusion and delirium — a sudden state of confusion that waxes and wanes 

How often should one have a BM?

At least every three days. Three days means, if the last bowel movement was on December 1st, you will need to administer a suppository on December 4th. The more days that pass, the stool will get harder and more difficult to pass. 

How can you assess the health of a patient’s BMs? 

Keep track of bowel movements. Honestly, when you are the primary caregiver, you will forget what day it is and when that last BM was, and even when you showered last. Every day merges together into foggy weeks. Come up with a system where you can easily jot down the date, the BM, and the size of the BM. 

Hospice nurses help with assessing the health of the patient’s bowel movements. They will always ask about bowel movements. Hospice nurses will also listen to the patient’s bowel tones. They may have to evaluate the patient's rectum to determine if there is any hard stool in there, or any stool at all. That will determine the next course of treatment. If there is stool in their rectum, they may obtain an order for a suppository.

What are the likely pharmaceutical interventions that may help with constipation? 

Senna / sennosides (Senokot). This medication is a laxative. 

Docusate (Colace). This is a stool softener. In my experience, used alone, this is not very effective.

Senna + docusate (Senokot S). This medication has both the benefit of a stool softener and laxative. Together, they are quite effective.

If the patient is having a hard time swallowing pills, one can crush the Senokot S and offer it with yogurt or applesauce. It will taste like dirt and applesauce mixed together. Liquid senna exists, but they often have to swallow a large amount of the medicine to be effective. It also tastes like dirt.

Polyethylene glycol (Miralax). Miralax is an osmotic laxative and works with the water in their body to soften and ease the passage of stool. Mix in four to eight ounces of their favorite beverage. This may be too much fluid for a patient to consume, but in theory, it has no real taste to it, though I have had some patients complain about the texture.

Lactulose (Enulose). Although this tastes disgusting and sugary sweet, it is often used with patients who have liver disease. Lactulose helps to eliminate the ammonium from their body when the liver cannot. A build-up of ammonium can lead to confusion for patients with liver disease. 

Bisacodyl (Dulcolax). This medication comes in either an oral tablet or suppository and works to help with constipation by stimulating your bowel muscles.

Suppositories. A suppository is a medication that is designed to be inserted into the rectum. Hospice nurses may administer a bisacodyl (Dulcolax) suppository after three days with no BM. If the patient is in the home, the caregiver will need to do this task. Suppositories are not recommended for certain types of cancers or if a patient has potential for bleeding. If you have any questions, please call your hospice team.

Sodium phosphates (Fleets enema). An enema can be very effective if nothing else is working. It increases fluid in the small intestine, but can get a little messy. The patient can lie on their left side while the nurse administers approximately eight ounces of fluid into the rectum. The patient should then hold it in for one to five minutes, and then let the water go. You will definitely need pads or chux underneath the patient for this. This can also be done while the patient is on the toilet.

Tap water enemas. This too can be a bit messy, but a nurse may administer warm water through the rectum. It softens and lubricates the lining of the colon which may help a patient to have a BM.

What non-pharmaceutical interventions aid in constipation relief?

Increase fluids. If a patient has a poor appetite altogether and is unable to drink large volumes of fluids, encourage fluid-y foods like watermelon, popsicles, and soups.

Drink warm fluids. Heat up prune juice or apple juice, or both mixed together. You can even add a tablespoon of margarine. Mmmmmm. There are also teas that stimulate the bowels.

Eat more fiber. But make sure to talk to the hospice nurse to determine if fiber is doing more harm than good.  When a hospice patient is immobile and not able to drink much fluid, fiber can create a cement like effect.

Eat prunes. Prunes help speed up digestion and bulk up the food already in the process of digestion as they are high in insoluble fiber.

Increase fats/oils in the diet (margarine, butter, olive oil). This helps to “grease the skids.”

Movement. Any kind of movement will help food move through the patient’s system. 

When should you call the hospice nurse?

Make sure to call in extra help when the patient is experiencing cramping, severe pain, blood in stool, sudden bloating, sudden confusion and/or no BM in two to three days.  Or call anytime you have any questions or concerns.

Constipation is a very aggravating symptom for hospice patients because they may feel like their body is failing them and the attention around it can be humiliating. Unfortunately, it is a very normal part of this process. Always remember, though, that patients know their body better than the nurses, so advocate for what the patient needs and wants. It is ok to refuse medications and treatments at the end of life. After 10 years of administering suppositories, I had some patients refuse bowel meds altogether, and I was surprised they died so peacefully without having a bowel movement the week before they died. The most important thing is the patient’s comfort and dignity.

Blessings.