This page looks at aspects of bowel management near the end-of-life and links to supporting literature. There is further information on CareSearch with a focus on the needs of people dying with cancer.
It has been estimated that constipation affects 74% of nursing home residents. Constipation reduces quality of life and can cause serious complications.
Constipation may cause:
- changes in behaviour
- urinary retention
- faecal impaction, or
- faecal incontinence.
There are many factors that predispose aged care residents to constipation, significant causes near the end-of-life include:
- medications especially opioid analgesics and anticholinergic medications
- limited mobility
- in the very immobile, gut transit time may be up to 3 weeks (normal is 3 days).
- not recognising urge to defecate or lack of assistance to access toilet when urge occurs
- neurological Illnesses especially the dementias, strokes, depression, Multiple Sclerosis and Parkinson’s Disease
- general disability, and
- low caloric intake due to reduced appetite.
An individualised bowel management program based on a thorough history and assessment of bowel function is the basis for maintaining regular bowel activity.
Daily monitoring of bowel function and use of appropriate scale, for example the Bristol Stool Chart, allows for consistent recording and evaluation of interventions.
Where possible the bowel management plan should reflect the resident’s preferred method of preventing constipation. It should also be consistent with the current goals of care for the resident. Is the goal living well with a palliative approach or comfort care at the end-of-life?
General principles of bowel management toward the end-of-life
- A medication review to identify and where possible cease medications that contribute to constipation
- Increase fluid intake
- Increase dietary intake and give supplemental fibre intake if necessary
- Assist with toileting needs including use of a timed toileting program
- Increasing exercise
Morphine is a useful analgesic, but it commonly causes constipation. A laxative should always be considered when morphine is commenced (unless death is very close).
Use of laxatives as treatment for constipation
- There is limited evidence for the superiority of one laxative over another.
- The evidence that is available may be derived from younger populations and non-palliative care settings.
- A recent review  has shown polyethylene glycol (PEG) preparations to be more effective and better tolerated than lactulose.
- Another study found that lactulose, senna and PEG preparations are equally effective in relieving opioid induced constipation. 
Choice of aperient for palliative care residents will be influenced by many factors including:
- if the resident is close to death then further intervention is not appropriate
- ability of the resident to safely swallow tablets or thin fluids will affect choice of aperient
- if dietary intake is poor, increasing fluids and fibre content of diet may not be realistic
- use of fibre based aperients requires adequate fluid intake
- liquid paraffin carries a risk of lipid pneumonia from aspiration and is not recommended.