Bowel movements and the hospice patient

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Specializes in Corrections, Cardiac, Hospice.

The midnight nurse and I had a debate the other night, not a fight, a debate. She came from an intensive care unit recently and I think she still has the acute care mentality, she thinks I am too layed back about this... We have a patient who is end of life. He hasn't eaten anything except bites here and there since admit 6 days ago. On morphine sulfate 5 mg Q6 hours around the clock. No BM in that time. He is absolutely going to die within the next 48-72 hours. She wanted to start a bowel prep on him. His belly isn't distended, still soft with +sounds X 4 quads. Already had a dose 2 days ago of MOM and a rectal suppository of Dulcolax the night before. The nurse who gave it told me she didn't feel anything when she put it in. I say it is awful to give a person something that makes them poop constantly the whole day they are trying to die. She has done this before, given people R/S at night and checked for impactions then they spend the whole day and afternoon of the day they die being incontinent. Am I crazy? or is she?;)

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dang, i've been in this specialty for over 11 yrs, and even i won't guesstimate when a pt will die.

i've been wrong too many times.

in the absence of any evident restlessness/discomfort, i would monitor closely.

the noc nurse's concerns, are valid.

even w/o po intake, 20mg of morphine daily, combined w/immobility, probable dehydration and a failing circulation, it is trouble waiting to happen.

but if nothing is felt digitally, abd soft/nt, and pt appears perfectly comfortable, then again, monitor closely.

very closely.

neither one of you is right or wrong.

every pt has a different presentation.

but if i was going to go by my 'book' knowledge, i'd be sharing the same concerns as the other nurse.

leslie

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Specializes in Acute Care Cardiac, Education, Prof Practice.

I would agree that a bowel prep would be beyond the realm of comfort I would expect in a hospice situation. I hope some day to work in hospice and I don't think (considering the other options and assessments you listed) that I would go this route with this patient.

Tait

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Specializes in Corrections, Cardiac, Hospice.
dang, i've been in this specialty for over 11 yrs, and even i won't guesstimate when a pt will die.

i've been wrong too many times.

I don't guesstimate either, this happened Thursday night and he died late Saturday- early Sunday sometime;)

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I don't guesstimate either, this happened Thursday night and he died late Saturday- early Sunday sometime;)

i'm usually right w/my estimations.

but there are some pts who have really surprised me.

it's humbled me a bit.

you'll see. ;)

leslie

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Specializes in Cardiac Telemetry, ED.

End of life care is about comfort. You have to look at the patient. This is an area where clinical judgment comes into play. I'm not sure there's a right answer here. But, from the picture you've painted, I'd probably not be doing aggressive bowel care here either.

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I think it depends on the patient. If he was showing no signs of discomfort then I would just have monitored him. If there were signs of discomfort then I would have implemented out facility protocol. I have had patients that were hospice and not eating go for many days without a BM. One was given an enema and still had no BM.

When my father was hospice he went nine days without eating and did not have a BM. No signs of discomfort or anything. Now when he did finally have a BM, it was a huge one. And he was not constipated, it was just like any BM anyone would have. He also did not have signs of distress or pain. No abd distension or anything. BS were fine.

I guess this is where critical thinking comes into play. Each situation is different.

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