What do you recommend for a end-stage cancer patient (metastasis to the bone and brain) who is constipated from narcotics for pain control but throws up almost all her oral medications? The doctors keep prescribing "bowel protocol" but I am doing all I can to get her to swallow and keep down the most essential of her medications. Getting 3 Dilantins down takes 30 minutes of TLC. After being off for several days, I see that she is now suffering from fecal impaction which the doctor manually dealt with. We are not an oncology or pallative care unit but I believe the patient has refused hospice care and for some reason, the hospital sees fit to leave her on the gyn/women's health unit. I have completely bonded with this lovely lady and don't want to see her suffer more than she has too but know that by relieving her cancer pain, I am causing GI issues that also cause pain. I guess at some point, senna and colace need to be the priority meds but when looking at the choices, I still start with the anti-seizure and a few other meds that need to stay at even levels to work. Help?
Mar 25, '17
If she has had to be manually evacuated then supps could work. I've also seen metoclopramide given for constipation with opioids when all else fails, which can be given IV. Just a few thoughts.
Mar 25, '17
I think that the first thing that needs to be done here is a Goals of Care discussion and revisit having Palliative Care or Hospice see this patient. One of the great things about hospice (and palliative care) is our ability to control symptoms and your lady sounds like she needs some routine nausea medications (Haldol would probably work great for her as it is used for nausea at low doses), and can be given orally or via IV or even subcuteanously . Also, there needs to be some consideration of how much oral intake is she consuming- if she is eating at least one meal a day (and the nausea/vomiting is controlled) she should probably be on oral stool softners; if she's just eating bites over a day, she may just need a scheduled suppose. every 2-3 days. (Darn it- I can't see the original post--so I'll just throw out there that depending on where her cancer is- she may need scheduled reglan also). Thanks for advocating for your pt !
Mar 26, '17
Get a palliative care consult first and foremost. The average hospital doc has no idea what they're doing when it comes to palliative medicine. You need an expert on board. Palliative care is about symptom management and quality of life - it doesn't at all mean she has to agree that she's dying or give up on curative treatment if that's what she wants.
If getting PO meds in is that much of a trial, it's time to switch routes. Most meds are available SC or IV. Switch whatever you can to that. Consider suppositories or enemas for her bowels, or if she wants to keep trying to get her bowel meds PO, go with sennosides. Colace is useless unless you're getting adequate fluids which she almost certainly isn't. Consider discontinuing meds that, at this point, would be futile (nobody needs a statin or vitamin D or whatever at this stage in the game).
She'll also need her vomiting addressed, which the palliative consult will help with.
Apr 5, '17
Thank you for responding. Pt was getting zofran and reglan and they didn't seem to help. I think the only thing she was getting orally at the time was a few bites of sherbet to take the important oral meds and she still could barely keep this down. She was admitted over the weekend and it was in the notes that one particular doctor was going to talk to her again about palliative care. I didn't have her again before discharge but someone said she was able to eat some before she went home (was sent to postpartum for several days). I didn't know about haldol being used in that capacity, so I will look it up for future reference. I am sure they did eventually use suppositories if she allowed them to (pride can be a dangerous thing). I also didn't know that about colace versus senna so that will help me when a patient will only take one or the other. I tended to go with the colace because it is easier to swallow. (Her fluids were IV only).
We didn't even waste time with statins and her BP was such that she didn't need those meds. My priority was her anti-seizure meds because she did have a brain mass to go with bone mets.
Last edit by blackribbon on Apr 5, '17
Apr 13, '17
Lactulose helps keep things moist to slide through. Just another idea next time.