Bowel disturbance common until the end

By Sarah Guy

Patients treated by palliative care services experience bowel disturbances until the end of life, with severe problems increasing as death approaches, report Australian researchers.

Their findings also show that bowel problems are weakly - but significantly - associated with other symptoms including nausea, fatigue, and pain, and that there are no significant differences between patients diagnosed with cancer, and those with other diagnoses.

"It is worrying that all these problems exist in people under the care of teams whose main role is to minimize the impact of symptoms," say Katherine Clark, from Calvary Mater Newcastle Hospital in Waratah, New South Wales, and co-investigators.

The team assessed 7772 palliative care patients' self-reported symptom scores using the Symptom Assessment Scale over a collective period of 6 years.

Patients were seen an average 22.5 times between referral to palliative services and death, over an average 98.6 days, and the majority (94.0%) had a cancer diagnosis - most commonly arising from outside the gastrointestinal tract.

A total of 42.2% of patients reported disturbed bowel function at time of referral, of whom 7.2% described it as severe.

Both the proportion of patients with bowel disturbances and those with severe problems appeared to decrease after initial referral to palliative care; however, Clark and colleagues' results show that these numbers rose as time to death approached.

Specifically, at 90 days before death, 26.8% of patients reported bowel symptoms, of which 2.3% were severe, while at 60 days, the respective figures were 28.2% and 2.5%. By 30 days before death, these figures were 33.7% and 3.9%, respectively, and at seven days before death, 35.2% of patients reported bowel disturbance, of which 4.1% was severe.

A bivariate analysis revealed weak but significant associations between bowel disturbance and other symptoms, except breathing problems, which showed no relationship.

Not surprisingly, says the team in the Journal of Pain and Symptom Management, this was a symptomatic group of people with the most frequently reported symptom being fatigue, regardless of time before death.

Clark and co-authors suggest that better understanding of the physiology of the colon and how other structures of defecation change with progressive illness is needed.

"There is still very little understanding of how much changed bowel function reflects the use of medications and how much other factors such as diet and functional status impact the problems that people experience," they highlight as an example.

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