More than 1.7 million patients received hospice care annually in the United States. In the hospice setting, narcotics, often known as opioids, play an essential role in relieving pain and shortness of breath for our loved ones with a terminal illness. The use of narcotics in hospice care is generally safe and effective. However, healthcare providers, patients, and their families must understand the potential risks of using these medications.
Benefits and Risks of Narcotics in Hospice Care
Narcotics offer many benefits, including the management of severe pain and shortness of breath that hospice patients often experience. Decreasing pain and discomfort can significantly improve their quality of life in several ways, allowing them to engage more fully in everyday activities. Available dosage forms include tablets, liquid, patches, and injections, allowing for flexibility based on each patient’s needs.
While opioids can be highly effective in controlling pain, side effects can also negatively impact the patient’s quality of life. Common side effects to consider are sedation, constipation, nausea, and confusion. Constipation caused by opioid medications is extremely common and can sometimes limit the use of higher doses that may be needed to successfully manage pain.
The Importance of a Bowel Regimen
Because all narcotics cause constipation, this is a significant side effect that we must address. Unlike other gastrointestinal side effects from narcotics, which may improve over time, opioid-induced constipation is persistent. Without a proactive bowel regimen, constipation can become chronic, increasing the risk of complications such as bowel obstructions.
A bowel obstruction occurs when a blockage in the intestine prevents the normal movement of food and waste through the digestive system. Narcotics can slow the movement of the intestines, leading to a buildup of food and waste. This may eventually cause a blockage. Fortunately, bowel obstructions in hospice care are relatively uncommon, occurring in about 3% to 5% of patients.
A bowel regimen typically includes the use of stimulant or osmotic laxatives, stool softeners, and dietary changes to help prevent and manage constipation. Stimulant laxatives can help stimulate bowel movements, while stool softeners can help soften the stool, making it easier to pass. Increased fluid intake and dietary fiber can also promote regular bowel movements.
How Serious is a Bowel Obstruction?
A bowel obstruction in a hospice patient can be a serious condition. If left untreated, a bowel obstruction can lead to complications such as bowel perforation, infection, or sepsis, which can be life-threatening.
The common symptoms of a bowel obstruction include:
- Severe abdominal pain
- Nausea and vomiting
- Bloating
- Inability to pass gas or have a bowel movement
How Do You Treat a Bowel Obstruction?
Managing bowel obstructions in hospice patients can be challenging. Treatment should include a multidisciplinary approach that focuses on providing comfort and relieving symptoms. In some cases, surgery may be needed to remove the blockage, but this is often not possible in hospice patients due to the risks involved.
Non-surgical treatments are typically used to decrease the degree of blockage, stimulate the bowel, and manage symptoms. These treatments may include the following:
- Adequate pain relief with opioids or antimuscarinic/anticholinergic drugs
- Antiemetics to relieve nausea and vomiting
- Stool softeners to make stool easier to pass
- Suppositories or enemas to empty the rectum
- A nasogastric (NG) tube, which is inserted through the nose into the stomach to empty the stomach, reduce pressure, and ease symptoms
- Metoclopramide, which may be considered in partial bowel obstructions, and should be stopped immediately if it causes increased abdominal cramping or vomiting
The use of narcotics in hospice care is an essential part of managing pain and improving the quality of life for patients with a terminal illness. While bowel obstruction is a hospice patient is a serious condition, the use of a consistent bowel regimen is an important step in reducing this risk. Clinicians and caregivers alike must be aware of the signs of bowel obstruction in hospice patients and, if they suspect a problem, seek medical attention quickly. By promptly recognizing and treating bowel obstructions, we can alleviate symptoms and improve patients’ comfort in their last days.
References:
- https://oig.hhs.gov/reports-and-publications/featured-topics/hospice/
- Tradounsky G. Palliation of gastrointestinal obstruction. Can Fam Physician. 2012 Jun.;58(6):648-52. , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3374686/#:~:text=Functional%20and%20partial%20obstructions%20require,increased%20vomiting%20or%20abdominal%20cramping.
- Sizar O, Genova R, Gupta M. Opioid-Induced Constipation. [Updated 2023 Aug 7]. https://www.ncbi.nlm.nih.gov/books/NBK493184/
