RESUMEN
The assessment of constipation symptoms is based on history and physical examination. However, the experience is highly subjective perhaps explaining why palliative medicine doctors continue to use plain abdominal radiographs as part of routine assessment of constipation. Previous studies have demonstrated poor agreement between clinicians with this work in palliative care, limited further by disparity of clinicians' experience and training. The aim of this work was to explore whether there was less variation in the assessments of faecal shadowing made by more experienced clinicians compared to their less experienced colleagues. This pragmatic study was conducted across six palliative care services in Sydney (NSW, Australia). Doctors of varying clinical experience were asked to independently report their opinions of the amount of shadowing seen on 10 plain abdominal radiographs all taken from cancer patients who self-identified themselves as constipated. There were 46 doctors of varying clinical experience who participated including qualified specialists, doctors in specialist training and lastly, doctors in their second- and third post-graduate years. Poor agreement was seen between the faecal shadowing scores allocated by doctors of similar experience and training (Fleiss's kappa (FK): RMO 0.05; registrar 0.06; specialist 0.11). Further, when the levels of agreement between groups were considered, no statistically significant differences were observed. Although the doctors did not agree on the appearance of the film, the majority felt they were able to extrapolate patients' experiences from the radiograph's appearance. As it remains challenging in palliative care to objectively assess and diagnose constipation by history and imaging, uniform and objective assessment and diagnostic criteria are required. It is likely that any agreed criteria will include a combination of imaging and history. The results suggest the use of radiographs alone to diagnose and assess constipation in palliative care represents low value care.
Asunto(s)
Competencia Clínica , Estreñimiento/diagnóstico , Impactación Fecal/diagnóstico , Neoplasias/terapia , Cuidados Paliativos , Médicos , Radiografía Abdominal , Adulto , Australia/epidemiología , Competencia Clínica/normas , Competencia Clínica/estadística & datos numéricos , Estreñimiento/patología , Toma de Decisiones , Impactación Fecal/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/complicaciones , Neoplasias/diagnóstico , Neoplasias/epidemiología , Cuidados Paliativos/estadística & datos numéricos , Médicos/normas , Médicos/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Película para Rayos XRESUMEN
UNLABELLED: Constipation is common and sometimes distressing in palliative care patients. Laxatives are often prescribed, but there is little guidance as to the most appropriate time to cease these medications as death approaches. OBJECTIVE: To conduct a retrospective pilot review of usual prescribing of laxatives toward the end of life in a specialist palliative care unit. METHODS: The notes of all 92 inpatients who died over a 2-month period were reviewed, with the main outcomes of interest being the number and types of laxatives prescribed and the documentation of bowel movements in relation to time of death. RESULTS: On admission 70% of the patients were receiving laxatives, with a mean of two different types per person. The mean number of days before death that people had a bowel movement recorded by nursing staff was 3.8 (standard deviation (SD) 3.55). No differences were identified between those who had not received laxatives at any point, those who received laxatives until death, and those who ceased laxatives at distinct time points. However, differences were found between those who were commenced on an end-of-life care pathway (mean 4.30 days; SD 3.84) and those who were not (mean 2.50 days; SD 2.31) (P=0.01). CONCLUSIONS: The correct timing for cessation of laxatives as death approaches remains unclear. Further work is needed to understand how bowel function changes with disease progression and the subjective experiences of patients.
Asunto(s)
Estreñimiento/tratamiento farmacológico , Laxativos/administración & dosificación , Cuidados Paliativos , Cuidado Terminal , Adulto , Anciano , Anciano de 80 o más Años , Humanos , Pacientes Internos , Persona de Mediana Edad , Nueva Gales del Sur , Proyectos Piloto , Estudios Retrospectivos , Factores de TiempoRESUMEN
Opioids are major contributing factors to the problem of constipation in palliative care. Whilst this is without doubt, it remains unclear how much other factors also contribute to the problem. The aim of this audit is to review what other contributing factors are present when methylnaltrexone, the peripheral opioid antagonist is prescribed for constipation. The medical records of people prescribed methylnaltrexone over a four-month period were reviewed to examine certain characteristics of people including the whether the reason for constipation was charted, whether other factors that could contribute to constipation were considered and the effectiveness of methylnaltrexone. Over the study period, 10 people received methylnaltrexone, only 4 of whom had a bowel action less than 24 hours after administration with 3 not having any bowel actions reported 6 days after administration. Whilst all were receiving opioids, the opioids doses were in the moderate range (61-200 mg morphine equivalent). However, all had other factors that could contribute to constipation including impaired functional status and medications with anti-cholinergic effects (mean anti-cholinergic load 4.5). In conclusion, methylnaltrexone is targeted treatment for the management of opioid-induced constipation. However, there is a percentage of people who fail to respond. The impact of other factors on the problem of constipation requires greater clarification.