Background

Constipation is identified by unsatisfactory defecation due to infrequent stools, difficulty passing stools, or the sensation of incomplete emptying [1]. This contributes to considerable physical and psychological suffering for patients and their families [2]. It is one of the most frequent gastrointestinal complications encountered in clinical practice in Western societies [3], with prevalence rates increasing in older adults across community [4] nursing homes [5], and specialist palliative care [6] settings. Whilst constipation affects approximately 40% of patients receiving palliative care [7], this figure increases in specialist palliative care (SPC) to greater than 66% [6]. Mercadante [6] assessed the change in prevalence of constipation in patients with advanced cancer after one week of receiving support from SPC. Patients with low bowel function (bowel function index ≤28) experienced worsening of their symptoms, and patients with normal bowel function at initial assessment saw a worsening in their condition due to lack of prevention or subsequent under-treatment. A systematic review of constipation in SPC settings identified challenges for the assessment and management of this symptom, including a lack of standardised assessment, an overemphasis on pharmacological intervention, and lack of preventative and non-pharmacological intervention [8]. Constipation (Advanced pharmacology) – Assignment Example. Fragmented approaches to constipation management were highlighted in a European Report on the burden of constipation in an ageing population [9], and similar challenges have been identified in previous hospice-based studies, identifying a need to improve the overall clinical practices of assessment and management of this symptom [10].

To guide clinical practice, a review of guidelines identified twenty-two generic clinical guidelines for constipation across North America, Europe, and Asia [11]. It was found, however, there was only one guideline developed specifically for palliative care, developed according to the principles of the ADAPTE¹ process [12] (Additional file 1). These guidelines provide a useful starting point for evidence-based practice as their recommendations are well supported by the research literature. Such recommendations include: the need for a comprehensive assessment using the Rome III criteria [13]; a complete documentation of medical history; and the use of physical examination as part of the comprehensive assessment process [14–17]. In order to ensure effective management of constipation, it is recommended that equal attention is paid to optimised toileting, lifestyle modifications, and adjustment of activity levels, alongside pharmacological management [18]. Very recent clinical guidelines have been developed by the European Society for Medical Oncology for the diagnosis, assessment, and management of constipation [19], and similar key recommendations are made compared to the previous guidelines. This includes the need for a comprehensive assessment, and a balance of strategies for prevention and self-care and prescribed laxative therapy. It is noteworthy that despite a systematic review of clinical trials highlighting no evidence to support the use of one laxative over another [20], previous research in both the UK and USA identified preferences for specific laxatives, such as Senna and Sodium Docusate [10, 21]. It is also noted that clinical record keeping is an integral component in the delivery of quality healthcare [22, 23], and essential to ensure high quality care. Whilst key areas have been identified by the guidelines and supported by the literature, questions exist for these specific guidelines but also more generally across oncology guideline implementation around the extent of their implementation, HCP compliance to the guidelines across patients, and impact in clinical practice [24]. There is a dearth of real-world, patient-level, clinical evidence regarding the management of constipation for people with advanced cancer in SPC settings. Constipation (Advanced pharmacology) – Assignment Example.

Methods

Results

Discussion

This study examined the recorded clinical practices of the assessment and management of constipation for patients with advanced cancer in three SPC inpatient units, and identified variations within and across sites in one organisation in both assessment and management practices from clinical guidelines recommendations.

Approximately three quarters of patients in this study received a comprehensive assessment, and other related symptoms such as nausea and vomiting were also recorded, demonstrating good clinical practice and a holistic approach to assessment. Globally it is advocated in both clinical guidelines and research that the assessment of constipation should combine the following elements: use of the Rome III criteria [13]; a medical history; and a physical exam [14–18]. Constipation (Advanced pharmacology) – Assignment Example. In the hospice population, great diversity in the physical capacity of individuals (33.3% independent and 21.3% bedbound), calls for assessment to consider not just the patient’s bowel movements, but also a full history of their general health, needs, and circumstances as part of person-centred, holistic palliative care [32]. However, the findings showed no evidence of the use of standardised documentation for assessment or any further follow up, therefore, this may contribute to subjectivity in the assessment process and potentially overlooking patients who are constipated but their symptoms not appropriately documented to help reach a diagnosis.

The guidelines identify best practice as both constipation assessment and management delivered within a MDT with a clearly identified clinical lead and active communication between all team members [18]. Furthermore, a recent meta-synthesis of qualitative evidence identified the key coordinating role of the nurse in palliative care between the patient, family, and other HCPs as a fundamental aspect of their overall role [33]. In line with the guidelines and this meta-synthesis, the nurse had a leading role in the assessment and management of constipation, with variable involvement from other members of the MDT as appropriate and when required. Possible reasons for variability may be attributable to limits in guideline diffusion within the SPC unit, or to perceived role in constipation assessment and management, or due to staffing availability, therefore, additional signposting may support other roles within the SPC setting to identify when their expertise is required across the assessment and management process.

Despite the clinical guideline’s recommendation of the use of DRE, only 25% of patients received a DRE after three days without a bowel evacuation, however, clinical judgment is key to consider when interpreting this finding. Given the clinical pathology of many patients within SPC such as reduced mobility, reduced oral intake, and pharmacology, the cause of constipation can often be identified without an invasive procedure such as a DRE. In addition, almost half (n = 65; 43.3%) of the patients included in the chart review were admitted for end of life care. The guidelines state that when caring for a patient who is at the end of life, rectal intervention is rarely necessary [18], therefore, it was appropriate to see limited use of this intervention. Constipation (Advanced pharmacology) – Assignment Example.

A palliative care approach calls for symptom management to be addressed as a multidimensional experience, considering the non-physical aspects of pain within assessment and management [34]. Pharmacological management was well developed and aligned to the guidelines, which state that the medication with lowest cost base should be used where there is no evidence to differentiate between medications in terms of efficacy, tolerability and side effect profile [18]. A Cochrane review of clinical trials highlighted no evidence to support the efficacy of one laxative over another [20], therefore, laxatives with a lower cost base should be selected. In the UK, Senna, lactulose, and docusate are the three oral laxatives with the lowest cost base (£0.80, £1.30, and £1.95 per 14 day treatment respectively [35]), and these options were used as primary laxatives for approximately half of patients (46.0%), mirroring findings from previous hospice-based research in the UK and USA [10, 21]. However, findings highlighted that pharmacological strategies were more likely to be documented, resulting in a lack of evidence that non-pharmacological interventions were utilised and questioning the use of a holistic approach to care [36]. Best practice is based on a balance between strategies for prevention and self-care and prescribed oral and rectal laxative therapy [19], however, this is not reflected in the current study. Conversations around the prevention of constipation, which were a key element within the guidelines, were only recorded on 20% of patient charts. Whilst equal attention should be paid to optimised toileting, lifestyle modifications, and adjustment of activity levels [18] as well as pharmacological management, non-pharmacological interventions were only documented in 53% of case-notes, compared to 96% documenting pharmacological intervention. These findings call for a greater awareness of the holistic approach necessary in the prevention and management of constipation in palliative care. Whilst patients may be implementing these independently of their hospice plan of care, preventative and non-pharmacological strategies are of equal relevance to pharmacological care and therefore should also be discussed by HCPs and recorded alongside pharmacological intervention.

Previous studies have shown that only a small proportion of the cost of managing constipation in a SPC inpatient unit was related to drug expenditure (13%), compared to 85% of cost for staff time [37]. The cost to older adults can be seen in terms of the reported negative impact on physical, psychological, and social well-being in everyday life [38]. This cost to older adults was also found in a recent systematic review within SPC settings, therefore, it is essential that this symptom is well managed [8]. Constipation (Advanced pharmacology) – Assignment Example. Good clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare, and would enable enhanced communication within the MDT, reducing the staff time required to manage constipation [22, 23, 39]. Effective assessment and management of constipation through adherence to clinical guidelines along with good documentation of all aspects of assessment and management may assist in minimising the burden to both staff and patients.

Interpretation of the findings must be undertaken cautiously, due to the inability to differentiate between data that were not recorded, and clinical activities that were not undertaken. Non-recorded data limits the ability to provide a full picture of what happens in this setting regarding the assessment and management of constipation. However, this study is able to provide useful insights into data recording and some ways in which the problem of constipation is it being managed within this practice setting. Strengths of this research are also acknowledged. Through the use of Gilbert’s [25] evaluative criteria, the methodological approach has been conducted in a rigorous manner, in particular the training and follow up verification with data abstractors after collecting five case-notes. This rigorous approach has increased the replicability of the study and reliability of the findings.

Conclusions

This study provides an insight into the recorded clinical practices of constipation assessment and management in inpatient SPC settings. Despite existing clinical guidelines, clinical records show great variability within and between sites. Whilst comprehensive, holistic assessments were evident for 73% of patients, a lack of standardised documentation or evidence of follow up may result in the identification, diagnosis, and subsequent treatment of constipation being missed for some patients within this setting. The nurse, supported by standardised documentation procedures, plays a key coordinating role in identifying and assessing constipation. Application of pharmacological interventions appeared to adhere to clinical guidelines, but prevention and non-pharmacological interventions requires further attention. Accurate documentation is essential for not only identifying areas of practice that require improvement, but areas of good practice. Further education is needed to equip HCPs with the knowledge and skills to perform not only a full assessment, but also to use appropriate non-pharmacological and preventative strategies. Owing to gaps in recording, it is vital that SPC settings consider ways to support the implementation of new documenting and recording strategies which are readily available to the MDT to enable transparency of care and maintain good clinical standards. Future research should consider identifying staff knowledge of constipation, and the use and effectiveness of non-pharmacological interventions across clinical settings for this group of patients. Constipation (Advanced pharmacology) – Assignment Example.

Additional files

Acknowledgements

Abbreviations

Authors’ contributions

All authors made substantial contributions to the conception and design of the work. AF and LGW facilitated the acquisition of data, SM, DM, EB, PS, and FH led on interpreting and drafting the work, all authors revised it critically, and all authors read and approved the final version of the manuscript.

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Funding

This work was supported by a research grant awarded to Professor Sonja McIlfatrick by Marie Curie UK (REF MCCC-RP-16-A20993). The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.Constipation (Advanced pharmacology) – Assignment Example.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Office for Research Ethics Committees Northern Ireland (ORECNI) (RECA Reference 16/WM/0352). Permission to access patient notes for the purpose of this study was obtained from each hospice. Approval was also obtained from the Hospice Research Governance Committees in each location. Data collection was conducted by hospice staff who routinely access patient notes, and all data was anonymised prior to sharing with the research team. Constipation (Advanced pharmacology) – Assignment Example.