Guidelines for a Palliative Approach in Residential Aged Care

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constipation, increased vigilance by the aged care team is required. A daily assessment of bowel function is required and should include the resident’s preferences for treatment, history of bowel habits, and management [234] (Level QE). Assessment could include consideration of issues such as whether the resident expresses a desire to defecate, whether they are showing signs of discomfort, whether they are eating and drinking, whether the rectum is full, and whether there are skin problems caused by bowel leakage due to overflow from constipation. Any symptoms of constipation should be considered, as the cause dictates the treatment. Symptoms may include: [236] • nausea or vomiting; • straining during defecation; • infrequent bowel movements; • feelings of incomplete emptying after bowel movements; • frequent small amounts of diarrhoea; • rectal pain on defecation; • stomach pain, distension or discomfort (stimulant laxatives, i.e. lactulose, can cause these • problems, so it is important to assess if the laxative itself is causing the symptom); • hard stools; and • faecal incontinence. 6.11.2 Management Pharmacological management Managing constipation requires determining the type of constipation. It may be either primary (or ‘simple’, i.e. associated with inadequate fibre intake, dehydration, reduced mobility, or withholding faecal evacuation and a reduction in muscle tone), or secondary, which may occur as a result of disease or drug therapy. [236] The most significant factor for residents receiving a palliative approach is opioid-induced constipation [234] (Level QE). Laxatives have been considered as first line treatment for incontinence by RACF staff; however, a recent study involving 21 RACFs found that the use of irritant or osmotic laxatives alone was unsuccessful in this regard [237] (Level QE). Instead, the authors found that the use of bulk laxatives (i.e. fybogel or regulan) when combined with suppositories were associated with the lowest rates of faecal incontinence. The authors recommended that suppositories be used after bowel clearing to prevent recurrent constipation [237] (Level QE). Additionally, no evidence was found to support the view that bulk laxatives were contraindicated when used for chronic constipation in older, immobile persons [237] (Level QE). A causal relationship between laxative use and diarrhoea in the immobile older person was found, with a recommendation for the additional use of a bulking agent to reduce the incidence of diarrhoea [234] (Level QE). If a laxative must be prescribed for a resident, then a discussion between the doctor and aged care team members to decide on the most appropriate laxative is encouraged [237] (Level QE). Guidelines for a Palliative Approach in Residential Aged Care 107
Brocklehurst and colleagues (1999) [237] found that the two most commonly used laxatives in RACFs were lactulose (36%) and senna (29%). Senna was considered to be significantly more effective and less expensive, despite the popularity of lactulose; therefore, it is recommended that the cheaper laxative be trialled first [235] (Level II). If a laxative is used, compensatory measures for dehydration and electrolyte depletion should also be considered [237] (Level QE). Non-pharmacological management A study of 100 palliative care patients (average age 67) was conducted to determine assessment procedures for bowel care and patient preferences [234] (Level QE). The results of the study indicated that patients preferred non-pharmacological approaches for their bowel care such as diet, regular gentle exercise, abdominal massage or administration of a hot pack as firstline interventions whereas nurses preferred to use medication (either oral or rectal) [234] (Level QE). Despite this patient preference for non-pharmacological bowel care management, the effectiveness of most of these approaches has not been validated [235] (Level II) with the exception of one RCT involving exercise. An RCT was conducted to examine whether an intervention that combined low-intensity exercise and incontinence care (both urinary and faecal) would be beneficial and result in cost savings to the RACFs [238] (Level II). The RCT involved 190 incontinent residents from four nursing homes who were randomly assigned to the intervention (Functional Incidental Training [FIT]) group or the control group. In all cases, the intervention group performed significantly better than the control group. For example, the number of residents with constipation or faecal impaction in the control group was significantly higher than for the intervention group for the same periods. This finding indicates that low-intensity exercise combined with incontinence care may be beneficial in reducing the incidence of constipation or faecal impaction for residents, although further research is required with older people who are receiving a palliative approach to their care. The use of the FIT intervention, although cheaper, did not result in significant cost savings compared with usual care methods. Guideline: Bowel Care 36. Eliciting information that includes a history of residents’ bowel habits and their preferences for treatment, an awareness of complementary methods of bowel care (e.g. low-intensity exercise, abdominal massage and hot packs) and better documentation procedures, will improve bowel management and residents’ well-being. 37. Discussion between the doctor and nursing staff about the most appropriate laxative for use with a resident will enhance management decisions regarding bowel care. 38. The combined use of bulk laxatives and suppositories is associated with the lowest rates of faecal incontinence. The use of suppositories after bowel clearing can prevent recurrent constipation. 39. Where a laxative is required, it is recommended that a cheaper laxative be trialled first and that appropriate compensatory measures should be taken to avoid dehydration and electrolyte depletion. Ref No. Evidence level 235, 238 II 234, 237 QE 237 QE 237 QE 235 II 237 QE 108 Guidelines for a Palliative Approach in Residential Aged Care
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Guidelines for a Palliative Approac
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NHMRC APPROVAL These guidelines wer
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4 ADVANCE CARE PLANNING 55 4.1 Impl
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16 MANAGEMENT’S ROLE IN IMPLEMENT
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17 Ann and Mr Wells’ family Helpi
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IMPORTANT NOTICE On 8 December 2005
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achieved for these guidelines from
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facets of a palliative approach are
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Additional levels of evidence The N
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Guidelines Ref No. Evidence level A
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Guidelines Ref No. Evidence Cachexi
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Guidelines Ref No. Evidence Anxiety
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Guidelines Ref No. Evidence 70. Und
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1.1.1 Aims The aims of the systemat
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Table 1: Search terms Terms Aborigi
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1.1.5 Exclusion Criteria Although t
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in the methodology that may invalid
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To ensure the reliability of the re
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1.2.2 Methodology When the first re
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1.4.2 Method When feedback was requ
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Several Working Party members conve
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or disagreed with each stakeholder
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All the feedback received was colla
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CHAPTER 2 A PALLIATIVE APPROACH A s
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• Profound weakness • Trouble s
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• Has the resident had a recent d
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in the RACF rather than transferrin
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palliative care teams is more appro
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or ageing progression (see Table 4)
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Table 7: A practical model of socia
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Vignette 2: Robert’s story Robert
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CHAPTER 4 ADVANCE CARE PLANNING Car
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Page 74 and 75: CHAPTER 5 ADVANCED DEMENTIA Advance
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Page 78 and 79: 5.3.2 Acute illness One study found
Page 80: Vignette 5: Anna’s story Anna was
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Page 87 and 88: Table 8: Common myths about pain ma
Page 89 and 90: 6.2.4 Breakthrough pain The term
Page 91 and 92: Pain can lead to behavioural change
Page 93 and 94: Vignette 7: Mrs Harris’ story Mrs
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Page 101 and 102: The reasons for malnutrition in old
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Page 105 and 106: To assist in such a discussion, a d
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Page 109 and 110: Guideline: Hydration 24. Recommenda
Page 111 and 112: 6.7 NAUSEA AND VOMITING Nausea is t
Page 113 and 114: • Do you have any problem control
Page 115 and 116: 6.9.1 Assessment A thorough oral as
Page 117 and 118: 6.10 SKIN INTEGRITY The major skin
Page 119: Wounds can occur in residents for a
Page 123 and 124: medication treatment along with non
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Page 130 and 131: CHAPTER 7 PSYCHOLOGICAL SUPPORT A r
Page 132 and 133: 7.1.1 Death statements and depressi
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Page 136 and 137: 7.2.2 Management Non-pharmacologica
Page 138 and 139: Table 17: Distinguishing delirium f
Page 140: is recognised that in many rural an
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Page 145 and 146: 8.4 FAMILY INVOLVEMENT The role of
Page 148 and 149: CHAPTER 9 SOCIAL SUPPORT, INTIMACY
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Page 152 and 153: 9.2.2 Management Imaginative progra
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Page 164 and 165: CHAPTER 12 SPIRITUAL SUPPORT Dein a
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Page 168: Guideline: Spiritual Support 68. A
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interpersonal and leadership skills
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CHAPTER 14 END-OF-LIFE (TERMINAL) C
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mood (61%), constipation (59%) and
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e relevant, and may even worsen sym
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Treatment involves changes in posit
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14.5 PREPARING FOR IMMINENT DEATH
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education of the aged care team and
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Table 21: Grief, loss and bereaveme
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• excessively avoiding tasks remi
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Vignette 18: Reflections When provi
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may have been able to contribute to
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CHAPTER 16 Management’s role in i
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REFERENCES 1. World Health Organiza
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31. Hanson, L. C., Danis, M. & Garr
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60. World Health Organization Quali
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89. McCarthy, M., Addington-Hall, J
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121. Saunders, C. M. (1998). Forewo
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150. Sindrup, S. H. & Jensen, T. S.
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177. Berry, E. M. & Marcus, E.-L. (
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208. Robinson, S. B. & Rosher, R. B
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237. Brocklehurst, J., Dickinson, E
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265. Barraclough, J. (1997). ABC of
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295. Brown, T. M. & Boyle, M. F. (2
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328. Kristjanson, L. J., Leis, A.,
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360. McGrath, P., Vun, M. & McLeod,
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392. Saunders, C. M. & Baines, M. J
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424. Rawlings, D. & Glynn, T. (2002
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Glossary acetaminophen Acetaminophe
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coordinator of volunteers coping A
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geropsychologist A geropsychologist
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opioids Opioid is a specific term u
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specialised palliative team A speci
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Ms Wendy Shiels Dr Jane Sims Dr Chr
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APPENDIX B The Australian Governmen
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APPENDIX F: Summary of the frequenc
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APPENDIX G: An example of how the g
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APPENDIX I: Resource list PALLIATIV
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Psychological Challenge Depression
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APPENDIX J: Examples of advance dir
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Schedule 1 MEDICAL POWER OF ATTORNE
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APPENDIX K An example of a Genogram
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INDEX Abbey Pain Scale 64, 71, 78 A
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evidence levels 5, 6, 20, 21, 22 ev
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andomized controlled trials 5, 21 R
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Palliative Care Australia PO Box 24
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Guidelines for a Palliative Approach in Residential Aged Care

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