Management of constipation in palliative care

Management of constipation in patients with palliative care needs depends on the cause and type of constipation. Consider the potential benefits and burdens of management and the patient’s preferences—see Principles of symptom management in palliative care.

The key aspects of management of constipation are to:

Identify and address reversible causes, such as
- lack of privacy
- pain when defecating (eg due to an anal fissure)
- poor mobility
- dehydration
- drug adverse effects (eg opioids, anticholinergics)
- concurrent conditions (eg hypercalcaemia).
Identify the type of constipation to help inform the choice of laxative therapy:
Treat as for undifferentiated constipation if the cause cannot be identified—see Undifferentiated constipation in palliative care.
Use nonpharmacological management, which involves the same measures used to prevent constipation.

Specific management is required for stomal constipation and constipation in patients with spinal cord compression or injury.

Note: Address the multifactorial causes of constipation whenever possible.

The causes of constipation are usually multifactorial. Encourage patients to use any methods or treatments they have used previously to successfully manage constipation.

Laxatives used in palliative care lists types of laxatives used in palliative care; for further information on laxatives, see Overview of laxatives used in adults in the Gastrointestinal guidelines.

Table 1. Laxatives used in palliative care
Class of laxative [NB1] [NB2]	Examples of laxatives
stool softener	docusate glycerol (suppository only) [NB3]
osmotic [NB4]	macrogol 3350 lactulose [NB5] sorbitol+sodium citrate+sodium lauryl sulfoacetate (enema only) (eg Microlax)
stimulant	bisacodyl senna sodium picosulfate methylnaltrexone (for opioid-induced constipation only)
lubricant	glycerol (suppository only) [NB3]
Note: NB1: Bulk-forming laxatives (eg bran, ispaghula, psyllium, sterculia) may not relieve constipation in patients with palliative care needs, and often worsen it. The increased bowel transit time and the patient’s poor fluid intake produce hard dry faeces. These laxatives have no role in preventing constipation in patients who are not ambulant, have decreased oral intake, or in patients taking opioids or other drugs that can cause constipation. NB2: For further information on laxatives, see Overview of laxatives used in adults in the Gastrointestinal guidelines. NB3: Glycerol suppositories have a softening and lubricating action. NB4: Patients may object to the sweetness of lactulose or the saltiness or particular flavour of individual macrogol 3350 preparations, affecting adherence to therapy. NB5: Do not use lactulose for patients with poor fluid intake