Constipation in palliative care

Constipation is very common in people living with a terminal illness. When someone is living with a terminal illness, their eating habits, fluid intake, mobility and medication may change. These can all contribute to constipation. There are ways you can help manage a patient’s constipation.

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Constipation in people with a terminal illness

Constipation can be complex. It can be physically uncomfortable and emotionally distressing for patients. Constipation means different things to different people, so it’s important to find out what’s normal for the patient and find out what they or their carers mean by constipation.

Signs of constipation include:

• opening the bowels less frequently than usual
• passing hard stools
• having to strain when passing stools
• feeling like you haven't completely emptied the bowel.

Constipation can lead to other symptoms or issues, including:

• nausea and vomiting
• abdominal pain and bloating
• overflow diarrhoea
• faecal impaction (build-up of faeces in the rectum leading to blockage)
• bowel obstruction
• urinary retention
• embarrassment and anxiety
• confusion
• restlessness and agitation.

Causes of constipation

Different things can cause constipation and patients may have more than one factor:

Lifestyle factors include:

• low-fibre diet
• low fluid intake
• low physical activity, which leads to reduced muscle activity in the abdomen and reduced bowel activity
• environment - for instance, if patients don’t have easy access to a toilet or they need support getting to the toilet.

Lots of types of medication can contribute to constipation. Some of the most common are:

• opioids
• ondansetron (an anti-sickness medication)
• medication for Parkinson’s disease
• iron supplements
• antacids.

Cancer, especially bowel and ovarian cancer, can lead to constipation as a result of:

• external compression or internal obstruction of the bowel by a tumour
• raised level of calcium in the blood (hypercalcaemia), leading to dehydration
• bowel surgery.

Other illnesses can contribute to constipation, including:

• neurological disease including spinal cord compression
• diabetes
• hypothyroidism
• diverticular disease
• haemorrhoids.

Assessing constipation

Carry out a thorough assessment if:

• the patient tells you they have constipation
• someone looking after them tells you they have constipation
• you think they may have constipation.

The goal of the assessment is to:

• confirm what symptoms the patient is experiencing
• identify any reversible causes that can be treated
• identify any signs of emergencies which require specialist treatment, like bowel obstruction or spinal cord compression.

Read more about how to identify emergencies and what to do.

Talking to a patient about constipation

Constipation can be a sensitive and embarrassing issue for some people. If the patient can talk to you about their constipation, consider the following things before speaking to them:

• Think about their privacy and dignity. Ask them if they'd prefer to talk to you alone or with someone else, such as a family member or carer.
• Use clear, plain language and avoid slang words or medical jargon.

Some patients may be more comfortable talking about their constipation than others. Be aware that this may not be an easy conversation for them, and try to talk about it in a way which feels comfortable for them.

Carrying out an assessment

Check the patient’s care plan and take a history. Assess their symptoms and identify reversible causes with these causes:

• What's your normal bowel habit, and what's it like now? Have you noticed any changes in your bowel habit?
• Do you have any tummy pain or discomfort when you’re passing stool?
• Are you having to strain to pass stools?
• Do you have any other symptoms such as nausea and vomiting? Severe vomiting and abdominal swelling are red flag symptoms that should make you think of bowel obstruction.
• Do you have new back pain or leg weakness? These are red flag symptoms of spinal cord compression.
• What is your diet like?
• How much fluid do you drink each day?
• Have you started any new medications?
• Have you been prescribed any laxatives and are you taking them regularly?
• Have you been taking any over the counter medication?
• Do you have access to a toilet whenever you need it?

A rectal examination should be carried out by someone who is qualified, if appropriate and if the patient gives consent. This will help to identify faecal impaction, haemorrhoids, or any skin problems around the anus. If the patient has a stoma, someone qualified should examine the stoma to assess for faecal impaction.

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Managing constipation

The aim is for the patient to be able to open their bowels comfortably and at an acceptable frequency for them. The management plan will vary for each patient.

There are lots of ways you can help someone with constipation:

• Encourage the patient to have plenty of fluids. They can drink things other than water, as well as meals with lots of fluid, like porridge.
• Encourage the patient to eat regular meals. If appropriate, advise them to eat more fibre. High-fibre foods include fruit and vegetables, beans and pulses, and wholegrain cereals.
• Ensure your patient has access to toilet facilities. It may be harder for them to get out of bed if they have fatigue, are unwell, have reduced mobility or are disabled. It can help to have a routine or system for them to access toilet facilities.
• Make sure  they have privacy and ask if they need help going to the toilet. Ask them how they would like you to help them.
• Encourage exercise if it’s appropriate. Even gentle activity can help to stimulate the bowel.
• Massage the abdomen in a circular motion to encourage stimulation.
• If they have been prescribed laxatives, encourage them to take them regularly.
• Review their bowel habit regularly and talk to the district nurse, specialist nurse or GP if their symptoms don’t improve.

You can also advise them on posture when they use the toilet:

• Sit forward with forearms placed on thighs.
• Raise feet on a small footstool.
• Relax and allow plenty of time for the bowels to open.

Treatments for constipation

Patients who are prescribed opioids will commonly be prescribed laxatives at the same time. There are many different types of laxatives (also called aperients). The patient may require more than one type. It can take a while for them to work so reassure the patient during this time.

Monitor the patient's bowel habit carefully if they're taking laxatives as too high a dose can cause diarrhoea.

Suppositories and enemas may be given for severe constipation, especially if the patient is unable to take laxatives orally.

If someone has faecal impaction, a combination of laxatives, suppositories and enemas may be needed.

If a patient’s constipation is caused by opioids, they might not respond to normal laxatives. If their constipation is not improving, a specialist palliative care team can prescribe medicines which reverse opioids, like methylnaltrexone or naloxegol. This may affect how well the patient’s pain is controlled, so can only be given by specialists who will be able to manage the person’s pain.

If the patient is nearing the end of life and is agitated, assess their bowels and address any issues that can help them have a more comfortable and peaceful death. If the cause of their constipation is reversible, it’s important to identify it so it can be treated.

Read more about helping a patient to be comfortable at the end of life.

When to ask for help

Constipation can be a sign of something more serious, including bowel obstruction or spinal cord compression.

Some of the early signs of bowel obstruction include severe nausea or vomiting, stomach cramps and a swollen abdomen.

Signs of spinal cord impression include:

• pain in the back that can radiate round to the front of the chest
• pain that is worse lying down, coughing, straining or sneezing
• numbness and tingling
• difficulty passing wind
• bloating.

Read more about spinal cord compression.

If you suspect any of these, contact the patient’s doctor immediately.

If the patient’s constipation isn’t resolving, or they're having distressing symptoms as a result, speak to their district nurse, specialist nurse or GP as they may require more treatment. Distressing symptoms can include:

• nausea and vomiting
• agitation
• pain
• urinary retention.

Useful resources

NICE Clinical Knowledge Summary: Palliative Care - constipation  

Scottish Palliative Care Guidelines: Constipation  

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