Standard of Care Developed for Cancer Patients With Constipation

SAN DIEGO—A multidisciplinary group of nurses at New York’s Memorial Sloan-Kettering Cancer Center have developed a standard of care for cancer patients suffering from decreased quality of life due to constipation.

Anne Walsh, RN, MS, OCN, a clinical nurse at the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering, presented her team’s strategy at the 26th Annual Conference of the Oncology Nursing Society (abstract 99).

"The project started several years ago," Ms. Walsh said. "We tried to identify a quality-of-life issue that affected prac-tices throughout ambulatory care. We identified constipation as a problem that affected all patients in approximately 95% of their treatment of disease at some point."

The primary causes of constipation, she said, include decreased physical activity and inadequate dietary fiber and fluid intake. Additional causes can be attributed to age; opioids, vinca alkaloids, and other constipating medications; and a variety of other medical conditions, such as intestinal obstruction, spinal cord compression, electrolyte imbalance, and depression.

Constipation can result not only in a physical discomfort that negatively affects quality of life but also in excessive use of health care resources with unnecessary visits to the emergency room.

The group realized the issue was more multidisciplinary than they had anticipated, and so they brought in the ser-vices of pharmacy and patient management, which included pain management, a physician liaison who would approve the protocol, and other nurse experts.

"We found very little research literature on constipation management that was noteworthy, but there was a lot of anecdotal information available," Ms. Walsh pointed out. "So, from the beginning, even though it was a utilization review project, it really became a practice project for patient improvement."

Ms. Walsh and her team established a protocol using algorithms based on patient needs. "We created a standard of care now used throughout the hospital," she said. Patients receive a constipation management fact card and fiber fact card. Staff members carry a pocket-sized laminated card providing the algorithm for the initiation and titration of specific laxatives. The card provides directives for what to do once a normal bowel pattern returns or if it does not—which can include increases in medications or an assessment for obstruction or impaction. The care standard also includes phone follow-ups by the nursing staff.

The program was implemented in October 2000, and, according to Ms. Walsh, several hundred people have benefited from it to date.