Management of Bowel Obstruction in Elderly Hospice Patients

Assessment and Diagnosis

The National Comprehensive Cancer Network recommends that bowel obstructions in hospice patients are usually diagnosed clinically and confirmed with plain film radiography, which is typically sufficient to establish the diagnosis 2
The National Comprehensive Cancer Network suggests that CT scan should only be considered if surgical intervention is contemplated, as it provides more detailed information about the cause of obstruction 3
Assessment for underlying causes should be based on estimated life expectancy, with evaluation for malignant causes for patients with years to months of life expectancy, focus on symptom management goals for patients with months to weeks of life expectancy, and prioritization of medical management over surgical approaches for patients with weeks to days of life expectancy 3

The National Comprehensive Cancer Network recommends opioids for pain control and to reduce intestinal secretions 2
Anticholinergics, such as scopolamine or hyoscyamine, are recommended to decrease GI secretions and peristalsis 1, 4
Octreotide is recommended to be considered early in treatment, starting with 150 mcg SC BID, up to 300 mcg BID or via continuous subcutaneous infusion, due to its high efficacy and tolerability in reducing GI secretions 2, 4, 6
Corticosteroids, up to 60 mg/day of dexamethasone, may be considered, but should be discontinued if no improvement is seen in 3-5 days 3, 4
Antiemetics, such as haloperidol, ondansetron, or olanzapine, should be considered for nausea control, but metoclopramide should be avoided in complete obstruction 2, 5, 6

Hydration, either subcutaneously or intravenously, should be considered if there is evidence of dehydration 3, 4
Nasogastric tube drainage may be considered if other measures fail to reduce vomiting, but its use is usually uncomfortable and increases the risk of aspiration 3, 4
Venting gastrostomy, such as percutaneous endoscopic gastrostomy (PEG) tube or venting gastrostomy tube inserted by interventional radiology, may be considered to relieve symptoms and improve quality of life in the absence of extensive peritoneal disease 2, 4
Total parenteral nutrition (TPN) may be considered if there is expected improvement in quality of life with a life expectancy of many months to years, but should be discussed with a gastroenterologist-led nutrition team early 3, 4

The goal of care should focus on symptom control rather than resolution of obstruction, with prioritization of reduction of nausea/vomiting, pain control, and overall comfort 3
Unnecessary hospital attendance should be avoided, as patients in the last phase of life often have poor experiences with limited benefits 4
Early referral to specialized palliative care services is beneficial for additional support 4
Decision-making for partial or complete bowel obstruction is complex and requires specialist advice 4

Prokinetic agents like metoclopramide should not be used in complete obstruction, as they can worsen symptoms 2
Surgical intervention should be avoided in patients with poor functional status or very limited life expectancy 3
Symptom management should not be delayed while pursuing diagnostic workup 2
Most malignant bowel obstructions are partial, allowing time to discuss appropriate interventions with the patient and family 3