Larkin, P.J., Sykes, N.P., Centeno, C., Ellershaw, J.E., Elsner, F., Eugene, B., . . . European Consensus Group on Constipation in Palliative Care. (2008). The management of constipation in palliative care: Clinical practice recommendations. Palliative Medicine, 22, 796–807.

To raise awareness of constipation in palliative care; to provide guidance on the assessment, diagnosis, and management of constipation; and to encourage research in this area.

Databases searched were PubMed and the Cochrane Library (2001-2006).

Search keywords were constipation, laxatives, palliative care, terminal care, terminally ill, hospice, guidelines, recommendations, ​and systematic reviews.

Four publications were found for consideration. They were graded according to the UK National Service Framework for Long Term Conditions and the Oxford Quality Scale. A pan-European work group of healthcare professionals with experience in management of constipation in palliative care was assembled to debate and reach consensus on best practice.

• Constipation was defined as “passage of small, hard feces infrequently and with difficulty.”
• Estimates of the prevalence of constipation in palliative care range from 32% to 87%.
• The costs of constipation are as follows.
  • The cost of laxatives per year in England among older adults is 43 million pounds.
  • An economic study of US nursing homes identified costs of $2,253 per long-term resident annually.
  • A UK study found that 80% of community nurses spend up to half a day per week treating patients with constipation.
  • A study reported that 5.5% of calls to a UK district nursing service were directly related to constipation.
• Pharmacologic agents, metabolic factors, neurologic disorders, structural physical abnormalities, and function factors such as diet and environment contribute to constipation.

Key approaches to the prevention of constipation include

• Ensuring privacy and comfort
• Increasing fluid and fiber intake
• Encouraging activity and increasing mobility
• Anticipating constipating effects of agents such as opioids and providing laxatives prophylactically.

Principles of treatment include

• Oral laxatives should be used in preference to rectal treatments.
• Arachis oil is derived from peanut oil, and allergy may prevent its use.
• A combination of a softener and stimulant is recommended. A comprehensive table with types of laxatives, dosage, mechanism of action, speed of action, possible side effects, contraindications, and starting dose is provided.
• An algorithm for management is provided for
  • First-line treatment: oral combination of a softener (e.g., polyethylene glycol, lactulose, electrolytes) and stimulant (e.g., senna, sodium picosulfate)
  • Second-line treatment: rectal suppositories, enemas, and consideration of opioid antagonist if patient is taking opioids
  • Third-line treatment: manual evaluation and consideration of opioid antagonists if patient is taking opioids
  • Ongoing monitoring and patient education.

• Little evidence was found in this area, current research is poor, and additional research is needed on many aspects of assessment, diagnosis, and management in palliative care.
• Although the authors suggest prophylactic approaches, the algorithm provided begins only at patient complaint of constipation.

This guideline provides a practical algorithm for constipation management based on consensus, rather than actual evidence. Specific choices of oral laxatives are not recommended; however, substantial evidence-based information for comparison of available oral laxatives agents is given.