Everyone’s normal bowel habits are slightly different. Some people have a bowel movement every day and some people can go every other day, every 3rd day, or even once a week. Fun fact, your small and large intestines are 15 to 25 feet in length!

 

As a person is declining and their eating habits change, disease progresses, and they become more immobile, it becomes more difficult for the stool to make that journey through the many twists and turns it takes from beginning to end. However, even at end of life, the body still produces waste and the lining within the colon is constantly regenerating. So even if someone is not eating well, they should still be passing a stool at least every 3 days.

 

Constipation is a very common symptom at end of life. Decreased oral intake, decreased mobility, medication side effects, and certain disease processes can cause constipation and lead to distressing symptoms.

What are signs of constipation? 

  • No BM for 3 days
  • Inadequate amount
  • Abdominal pain, cramping, or discomfort
  • Abdominal bloating
  • Tenderness to the abdoment
  • Hemmorhoids
  • Nausea
  • Vomiting
  • Straining while trying to pass stool
  • Small, hard stools
  • Restlessness
  • Confusion or Delirium
  • Diarrhea or liquid stool oozing – this could indicate a blockage of the formed stool contents and the liquid is seeping around the blockage.

What causes constipation? 

  • Decreased fluid intake – it is normal for hospice patients to drink less, however even though increasing fluids can assist with constipation, you should not force people to drink more especially if it is not safe to do so.
  • Decreased fiber intake – in a healthy individual, fiber will assist with bulking up the stool and needs to be combined with a decent intake of water, about 24 oz. When nearing end of life, both eating and drinking is affected and therefore increasing fiber without the ability to drink enough fluid, can cause stools to become difficult to pass.
  • Immobility – when a person’s activity level decreased, digestion is also decreased
  • Medication side effects – narcotics such as morphine, oxycontin, oxycodone, hydromorphone, and the like, can cause constipation. These medications can decrease intestinal motility. For this reason, doctors will often prescribe a stool softener or a laxative regimen with the narcotic medication to prevent constipation. You do not want to wait until you are already constipated to start. Aside from narcotic medications, other medications can also cause constipation such as antihistamines, antidepressants, anticonvulsants, and more.
  • Fear – if someone is already constipated or has issues such as hemmorhoids, they can become fearful of the pain it could cause.
  • Neurological conditions – certain neurological conditions such as MS, ALS, Parkinsons or strokes can interfere with the contractions in the intestinal tract.

Assessment and Monitoring

To assess for constipation, the hospice nurse may ask about last BM date, color, consistency, and amount. They may also listen to the patient’s abdomen to assess bowel sounds, or if needed, perform a rectal check to determine if there is any stool there and if it is hard or stuck.

The nurse will also take into consideration how much the person is eating, drinking, moving, and any medications or medical conditions the patient may have.

 

As a caregiver, it is helpful to keep track of bowel movements to prevent constipation or further complications or discomfort.

 

Treatment of Constipation

  • Laxatives such as Senokot (senna)
  • Stool softeners such as Colace (docusate)
  • Laxative plus stool softener (senna + docusate)
  • Osmotic Laxative (Miralax) – pulls water from the body into the stool and must be mixed with four to eight oz of water, or other beverage.
  • Suppositories – softens the stool and lubricates the passage
  • Enema – softens the stool and lubricates the passage
  • Lactulose – this an oral medication that is metabolized in the colon and can be used as a laxative if other measures were not effective. This medication can be used with patients who have liver disease to assist with pulling ammonia from the blood stream into the colon to be excreted as waste when the liver is unable to breakdown the ammonia on its own.
  • Increase fluid intake – water is great, but if someone is unable to drink an adequate amount of water, encouraging things like soups, popsicles, ice chips, and fruits
  • Increase fiber intake – whole grains, legumes, and vegetables increase bulk in the stool and speed up the transit of food in the digestive tract to help prevent constipation
  • Increase fats and oils in the diet – fats such as olive oils and butter can help with lubrication
  • Power Pudding – a recipe that can be made to assist with constipation includes a half cup each of applesauce, bran flakes, and prunes. Eating a few tablespoons to a ¼ cup of this recipe in the morning can get things moving and can be kept in the refrigerator for up to a week. Adding a bit of cool-whip can also help with the taste.
  • Activity – even if someone is unable to go for a walk, some type of mobility will assist with getting the GI tract moving.
  • Laying on the left side – by laying on the left side, this uses gravity to help move waste through the ascending colon into the transverse colon and then into the descending colon.

 

Prevention of constipation is important at end of life to promote comfort and avoid complications. By having a bowel movement at least every three days, discomfort and distressing symptoms can be avoided. If your loved one has not had a bowel movement in three days or is experiencing any of the above-mentioned symptoms, contact your hospice nurse!