Hospice symptom management
Hospice constipation management
Constipation is nearly universal in hospice patients on opioids, and it is under-treated. A prophylactic bowel regimen (stimulant + softener) started at the same time as any scheduled opioid — and titrated with each opioid escalation — prevents most constipation and its downstream complications (fecal impaction, anorexia, nausea, delirium).
Educational content only. Individual clinicians must confirm current dosing and drug availability against their hospice medical director and current formulary. This is not a substitute for your hospice’s policies or your medical director’s clinical judgment.
Quick framework
- Start a prophylactic bowel regimen with every scheduled opioid: senna 8.6 mg PO QHS + docusate 100 mg PO BID.
- Titrate up as needed to achieve a soft, formed bowel movement every 1–3 days.
- Ask about last bowel movement at every visit and every phone triage.
- Escalate for no bowel movement > 3 days: add bisacodyl 10 mg PO QHS or PR suppository.
- For persistent no BM ≥ 5 days: disimpact digitally after adequate analgesia + consider polyethylene glycol (PEG) 17 g PO QAM.
Pharmacology
- 01Senna 8.6 mg PO 1–2 tabs at bedtime, titrate up to 4 tabs BID.
- 02Docusate 100 mg PO BID — softener, works synergistically with a stimulant but is weak alone.
- 03Bisacodyl 10 mg PO QHS or 10 mg PR for rescue.
- 04Polyethylene glycol (Miralax) 17 g PO daily titrated to effect; excellent second-line, low-side-effect profile.
- 05Methylnaltrexone 8–12 mg SC every other day for opioid-induced constipation refractory to a full escalated bowel regimen; peripheral μ-antagonist that does not reverse analgesia.
- 06Lactulose 15–30 mL PO BID as a third-line osmotic option, particularly if hepatic encephalopathy is a concurrent concern.
Non-pharmacological approaches
- Encourage fluid intake as tolerated with the plan of care (do not force in dying patients).
- Encourage movement / ambulation if tolerated.
- Warm liquids in the morning (coffee, tea, hot water) can stimulate the gastrocolic reflex.
- Position on toilet or commode with feet elevated on a stool (Squatty-Potty style).
- Privacy and unhurried time.
When to escalate
- No BM for 5+ days despite escalated regimen — assess for impaction (digital rectal exam).
- Abdominal pain, vomiting, and no flatus — evaluate for bowel obstruction; involve hospice medical director.
- Overflow diarrhea in a constipated patient — often indicates impaction; disimpact rather than treat as diarrhea.
- Refractory to full regimen + methylnaltrexone — reconsider goals of care and involve IDG.
Documentation example
A composite narrative illustrating a defensible chart entry (identifying details fictionalized):
Patient started on morphine ER 30 mg PO q12h + IR 10 mg q4h prn for cancer pain. Simultaneously started senna 17.2 mg PO QHS + docusate 100 mg BID. On day 5, patient reports last BM 4 days ago, mildly uncomfortable. Added bisacodyl 10 mg PO. Bowel movement produced within 12 hours. Escalated senna to 17.2 mg PO BID going forward. Family instructed to notify RN if no BM in 2-day increments.
FAQ
Why not just use docusate alone?
What is methylnaltrexone?
Should we stop opioids to treat constipation?
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Educational content only. Not a substitute for your organization’s policies, your medical director’s clinical judgment, or current hospice formulary.