No bowel movement in ovarian cancer patient

[nputte]

I have a 70y/o female with ovarian cancer with mets. She has not had a bowel movement in over a week. I checked her rectally, she has no stool, is not impacted. She has no nausea or vomiting so I do not suspect that she is obstructed...yet. She is having increased pain. There is noncompliance with medications. She's on 62mcg of Fentanyl, 5-20mg of oral Morphine every hour for breakthrough pain, Lactulose 60mL daily, Senna S 2-4 tablets BID, Dulcolax suppositories once a day. She is becoming more distended. She is suffering and I don't know what to do. I have educated and educated the family on pain management but it's a crazy family situation. We know that her tumor is so large that it's pressing on her bowels because she's been in the hospital for this previously. She can't eat...I'm at a loss!! Any ideas or suggestions?? She doesn't want to go to the hospital but I feel like her symptoms are in no way being managed in the home.

[leslie :-D]

all the laxatives and stimulants in the world, will not help this lady if tumors are compressing her lg bowel.

she needs much more aggressive pain mgt...

i'd up the patch to at least 100mcg, and give mso4 40 mg q4h, WITH a prn for breakthrough.

ovarian ca is rough...esp with the complication of bowel compression.

depending on pt presentation, tumor debulking is also a temporary but highly palliative measure.

leslie

[ErinS, BSN, RN]

You may also be getting to the point where a different delivery of medicine needs to be considered. I would likely start continuous narcotic and possibly a lorazepam infusion, and be discussing the possibility of needing palliative sedation in the near future. A pump may cut down on the noncompliance issues. Unfortunately, sometimes our patients just get to where nothing will make them have a bm- we need to either aggressively manage with meds or decompression. Make sure that you are discussing this with your MD and manager. We have a very strict protocol before starting palliative sedation.

[leslie :-D]

You may also be getting to the point where a different delivery of medicine needs to be considered. I would likely start continuous narcotic and possibly a lorazepam infusion, and be discussing the possibility of needing palliative sedation in the near future. A pump may cut down on the noncompliance issues. Unfortunately, sometimes our patients just get to where nothing will make them have a bm- we need to either aggressively manage with meds or decompression. Make sure that you are discussing this with your MD and manager. We have a very strict protocol before starting palliative sedation.

thanks, erin.

and that is precisely why i recommended aggressive pain mgmt...

knowing that her condition is going to become unbearable.

as it stands, continuing to give these bowel meds, will only serve to exacerbate her suffering.

not all hospices do pall sedation...

ours did, and as you stated, only in dire circumstances.

leslie