We all poop...until we don't

There are many things we take for granted in life  

We don't know how important they are until we lose the ability to do them with ease.  

One such thing is "pooping".  

We can call it bowel movements (B.M), feces, defecating, number two, whatever we call it. If we face difficulty in this area of normal bodily functions it can bring great discomfort. 

"Every visit we assess the three Ps: Pain, pooping, and P.O intake" as pointed out by Kristin Marquez RN BSN, Preceptor at Parentis Hospice.  

Constipation is an important issue in hospice, so important in fact that The Centers for Medicare & Medicaid Services (CMS) makes it part of the Hospice Item Set (HIS section N0520) that must be completed on all admissions to hospice. 

What are some of the causes of constipation in hospice patients? ?

As stated in the Merk Manual professional version under -Care of the dying patient: "Constipation is common among dying patients because of inactivity, use of opioids and drugs with anticholinergic effects, and decreased intake of fluids and dietary fiber. " as well as many antipsychotics and antihypertensive drugs. 

What type of complications can arise from constipation? 

• Constipation may lead to swollen veins in the anus (hemorrhoids),  
• swelling of the rectum,  
• torn skin in the anus (anal fissures),  
• abdominal pain,  
• fecal impaction.  
• Constipation in elder adults, especially with dementia diagnoses such as Alzheimer's disease can lead to worsening of confusion, irritability, anxiety, agitation, and sometimes aggression. 

 "The complications of a fecal impaction are, fortunately, not common but include:  

• urinary tract obstruction,  
• perforation of the colon,  
• dehydration,  
• electrolyte imbalance,  
• renal insufficiency,  
• fecal incontinence,  
• decubitus ulcers,  
• stercoral ulcers, and  
• rectal bleeding. 

 Because fecal impactions tend to occur in the elderly and chronically ill patients, these complications can prove fatal.  

The treatment of a fecal impaction usually requires the digital fragmentation and extraction of the stool. Lubricating enemas and suppositories may be helpful. Sedation or anesthesia, local or general, may occasionally be needed. Surgical removal of the impaction may be necessary in refractory cases. Potent laxatives should be avoided because they may increase pain and may contribute to perforation if there is a significant obstruction" 

Wrote Dr. Tracey, James, M.D. in an article in the Journal of Clinical Gastroenterology: April 2000 - Volume 30 - Issue 3 - p 228-229 where he shed some light on the complications of fecal impaction.  

How does hospice treat constipation? 

 Every patient as previously stated is screened on admission for medications that can potentially constipate them. If a patient is taking a scheduled opioid (meaning taking an opioid drug on a routine basis) or on a PRN opioid (taking an opioid drug on an as-needed basis) then we must address a bowel management regimen. 

1. In a conversation with Julia Chacon RN CO DPCS, she stated that "it is best to first look at natural interventions such as encouraging fluids, offering prune juice and movement of the patient. Even as simple as transferring a patient from bed to wheelchair can promote peristalsis".  
2. However, if natural interventions do not work Dr. Melissa Siew indicated that her "first drug of choice is Miralax because it uses the body's own fluid to bulk up the stool while also encouraging the patient to consume 8 Oz of fluid at the same time". 
3. Dr. Robert J Wielenga recommends Senna (sennosides) 8.6mg one tab by mouth twice per day for bowel management. A very common escalation of laxatives should the patient not have a bowel movement in three days is Milk of Magnesia (magnesium hydroxide, 1200 mg of magnesium in 15 mls ) give 30 ml by mouth once per day as needed for constipation.  
4. Should the latter intervention not work then hospices commonly use Dulcolax (bisacodyl) suppository 10mg one suppository per rectum once a day as needed. Nurses should take this opportunity to check for fecal impaction. Should the suppository be ineffective then hospice physicians commonly prescribe Fleet enema (sodium phosphate) one daily per rectum as needed.  

It is important to point out that warming the enema solution to body temperature may be beneficial as heat stimulates the rectal mucosa. Dougherty and Lister (2004) recommend a solution temperature of 40.5-43.3 degrees C for non-oil-based enemas. Cold solutions should be avoided as they may cause cramping. 

Moving on 

Having a bowel movement is a very important function, the collaboration, and communication of the skilled nurses who visit the patient, the R.N Case Manager, the family, the patient him/herself, the caregivers, facilities, and the hospice physician is an integral part of keeping a regular defecation schedule so we may prevent a simple bodily function from becoming a serious medical complication.  

There are times when a patient will no longer be able to produce urine nor feces, mainly 1-2 days before passing away and the interventions mentioned above will no longer be appropriate...  

but until that time comes we must be diligent and responsible as nurses in collaborating with the attending physician to start a bowel management regimen as soon as we start any type of constipating drug like an opioid, and we must maintain open communication with our patients and families to avoid unnecessary discomfort due to "poop" or the lack thereof

My name’s Jose Escobar……..Executive Director/Administrator for Parentis Hospice.

a lot of people ask me why I love Hospice ... let me tell you my story:

When I was a teenager, as I was going through nursing school, I saw, lived, and experienced someone close to me die in pain, suffering, his family was ill-prepared.

Not only was the ending very hard for everyone who loved him, but the entire disease process was painful..." just let me go" he told his mom. I do not want anyone to have to go through that alone.

My passion in life is to help as many people as I can alleviate the pain and suffering of chronic and terminal illness; provide support and education.

The unknown creates fear, not knowing what resources we have available makes us fight a battle alone....when we don't have to.