Caring for the Patient with a Fecal or urinary diversion in Palliative

Caring for the Patient with a Fecal or urinary diversion in Palliative

Caring for the Patient with a Fecal or
Urinary Diversion in Palliative and
Hospice Settings: A Literature Review
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Charles Tilley, MS, ANP-BC, ACHPN, CCRN
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Abstract
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The number of people requiring palliative or hospice care who have a fecal or urinary diversion is increasing, but the literature about the number of persons with a stoma receiving end-of-life care, or research to help guide that care, is very
limited. A broader review of the literature and clinical experience indicate that several progressive changes will affect the
ability of persons with a stoma to provide self-care, including motor, sensory, vision, and cognitive deficits. It is important
for the wound ostomy continence nurse (WOCN) to anticipate these changes and take steps to address them. The latter may include simplifying the equipment or accessories used and identifying and teaching caregivers how to manage
the stoma or empty a continent diversion or neobladder. A thorough assessment and stoma care adjustment also are
needed when peristomal complications such as a change in the abdominal plane, mucocutaneous separation, or caput
medusa are observed. Medication absorption and its effect on fluid and electrolyte balances must be considered at all
times, especially in persons with an ileostomy, and the elimination side effects of commonly used medications in the palliative and hospice care environment must be monitored and addressed. The Advanced Practice WOCN with knowledge
about end-of-life care can help prevent complications and improve patient quality of life. Research is needed to increase
understanding about the scope of these problems and best practices to address them and to understand the experience
of patients with a stoma at end-of-life.
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Keywords: ostomy, palliative care, hospice, complications, advanced practice nursing
Index: Ostomy Wound Management 2012;58(1):24–34
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Potential Conflicts of Interest: none disclosed
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fter an average lifespan of 77 years, most Americans will
experience a slow, debilitating, progressive chronic disease that lasts an average of 3 years for women and 2 years for
men until death.1,2 During this time, palliative care provided
by skilled clinicians will help alleviate suffering.
The World Health Organization’s3 (WHO) definition of palliative care is generally accepted:“Palliative care is an approach
that improves the quality of life of patients and their families facingtheproblemsassociatedwithlife-threateningillnessthrough
the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial, and spiritual”. Palliative
careisnotdependentonprognosisandcanbedeliveredconcurrenttocurativetreatment.Thisdistinguishespalliativecarefrom
hospice care; the latter is a philosophy focused on terminally ill
patients—ie,peoplenolongerseekingcurativetreatmentswho
have a life expectancy of 6 months or less.
The National Consensus Project for Quality Palliative
Care4 contends the continuum of palliative care starts at the
“Diagnosis of Serious Illness,” continues with “Life-Prolonging Therapy,” and concludes with initiation of the “Medicare
Hospice Benefit”and death. It is imperative to appreciate this
potentially lengthy gamut of care; many practitioners and
laypeople perceive palliative care as a service reserved only
for the actively dying.
Davis et al5 emphasized this central point: “Palliative care
is integral throughout the course of advanced illness and is
not reserved only for the brief care of the imminently dying.”
This means that for millions of Americans, palliative care
may be offered to lessen the impact of incapacitating illness
and to improve quality of life at any point in their existence.
Given this probability, there are future implications not only
for advanced practice nurses in palliative care and hospice,
but also for wound, ostomy, and continence specialists from
Mr. Tilley is a Hospice Nurse Pratitioner, MJHS Hospice and Palliative Care, New York, NY. Please address correspondence to: Charles Tilley, MS, ANP-BC,
ACHPN, CCRN, 49 Park Avenue, #4B, New York, NY 10016; email: ctilley@mjhs.org.
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Ostomy Wound Management 2012;58(1):24–34
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Key Points
• As the population ages, the number of persons who
have undergone stoma, continent diversion, or neobladder surgery will increase.
• Unable to identify information to help the WOCN
provide optimal stoma care for patients with increasing disability and/or receiving palliative or hospice
care, the author reviewed the general literature in the
context of commonly observed problems in clinical
practice.
the stoma, putting on a new pouching system, and disposing
of the used pouching system. As taxing as this process can be
for an otherwise “well” person with a stoma, basic ostomy
care, supply ordering, pouch disposal, and trouble-shooting
leakage may be present an insurmountable challenge for persons with a life-limiting illness. Specifically, palliative care ostomy challenges may include the presence of motor, sensory,
vision, and cognitive deficits, as well as peristomal complications and pharmacological considerations.
Motor and sensory deficits. An overview of the chronic and often lethal diseases the advanced practice nurse
(APRN) will commonly encounter in palliative care and
hospice, as well as their potential effect on the person
with a stoma, must begin by reiterating the importance
of a obtaining complete patient history and performing a
physical assessment. It is essential to obtain a meticulous
individualized evaluation of the patient’s history of the
present illness, past or current medical or surgical treatments, medications (including herbal, over-the-counter,
and homeopathic remedies), and functional level. A psychosocial evaluation and an ostomy and/or continence assessment also must be performed.
For many persons living with chronic, debilitating illness or life-limiting disease, alterations in their physiological functioning and the often devastating sequelae of their
treatment regimens may lead to motor and sensory deficits.
Neuromuscular illness can affect people with stomas in numerous debilitating and often painful ways (see Table 1).10–16
Progressive neurodegeneration, peripheral neuropathies
(from either disease process or treatment modality), and autoimmune diseases may interfere with a person’s ability to
care for his/her stoma, requiring the expertise of the WOCN
to help modify the care routine or teach the caregiver how to
care for the stoma if accommodation is not possible. Key to
ensuring adherence to the treatment plan and stoma health,
as well as to maintaining the patient’s autonomy and selfesteem is the development of a realistic plan of care for the
esteem is the development of a realistic plan of care for the
palliative care or hospice patient.
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all areas of practice who will likely care for clients at the end
of their life in a variety of settings.
Information about the incidence of patients with an ostomy or continence-related problem in hospice is scarce. The
1999 National Home and Hospice Survey6 (conducted in
1996) reviewed 59,000 current and 393,000 discharged hospice patients to discern the presence of a urinary catheter,
stoma, or incontinence issue. The numbers were staggering;
60% of the current and 80% of the discharged patients had
incontinence, a urinary catheter, an ileostomy, or a colostomy.
Considering these statistics and the fact that the first of
the 78 million baby boomers turned 60 years old on January
1, 2006, it is easy to see that these numbers may have doubled or tripled since 1996.7 At the same time, no published
research specifically addresses the current prevalence, management, or quality-of-life aspects related to ostomy issues in
men, women, and children facing life-limiting illness.
The implications for life-changing contributions by
wound ostomy continence nurses8 (WOCNs), a newly recognized subspecialty within the American Nursing Association, to the rapidly expanding field of palliative care are at
the same time infinite and daunting. The number of WOCNs
currently practicing in hospice is unknown. The majority of
WOCNs in the US practice in acute care, with numbers ranging from 35.6% in New England to 60.8% in the West North
Central regions.9 Per the 2008 WOC Nursing Salary and
Productivity Survey,9 outpatient and home care are the next
largest practice sites identified; hospice and palliative care
were not included as a survey choice. The very likely limited
number of WOCNs in hospice and palliative care, coupled
with the projected increase in this population over the next
decade, is unsettling.
The purpose of this literature review is to explore the
complex and often multifactorial etiology of ostomy-related
concerns in palliative care and hospice and describe specific
management strategies the WOCN may employ.
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Method
Pubmed© and UpToDate© databases were searched for
studies and systematic reviews on ostomy prevalence, complications, and management at end-of-life using the following medical subject headings (MESH): ostomy, palliative care,
hospice. The search spanned 40 years (1970 to 2010) of English-language literature, targeting meta-analyses, randomized controlled trials, retrospective studies, and systematic
reviews. No studies specifically addressing these topics were
found, so more general ostomy, palliative care, and hospicerelated publications were used for use in this overview.
Ostomy Care Challenges
Pouching change procedures for either one- or two-piece
pouching systems can be complex and challenging and include essential tasks such as emptying and removing the
pouching system, washing and drying the skin, measuring
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Feature
Table 1. Neuromuscular debilities
General and stomaspecific considerations
Advanced Parkin- Loss of dopaminergic neurons and the
son’s Disease
appearance of Lewey bodies
Freezing, hypokinesis/akinesis,
dyskinesias, and dystonia10
Careful assessment to
ensure maximization of
dopa-minergic agents.
May necessitate collaboration with the prescribing neurologist
Multiple sclerosis
(MS)
Spasticity
Spasticity is usually
treated with baclofen or
tizanidine.
May respond to both pharmacologic and nonpharmacologic interventions.
Consider caregiver training early in the disease
process because recurring episodes may be
sporadic and debilitating
or increase in frequency
with increasing age
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Multifocal plaques of demyelination
within the central nervous system.10 If
diagnosed under the age of 40 years,
recurring episodes of neurologic
impairment followed by periods of
spontaneous remission are common
Pain syndromes have been
reported in up to 80% of
patients.10 Along with pain
syndromes, dysesthesias are
extremely common
Loss of both upper motor neurons
(UMN) in the motor cortex and lower
motor neurons (LMN) in the brainstem
and spinal cord10
Stroke
May affect sensory or motor function
and often both depending on location
and extent of injury. May be ischemic
(thrombotic, embolic), hemorrhagic (intracerebral, subarachnoid), or lacunar
Spasticity, slow movements,
hyperreflexia, and poor dexterity are sequelae of UMN
disease. Weakness, atrophy,
reduced tone, and hyporeflexia are due to LMN involvement
5,000 new cases of this
irreversible disease diagnosed each year, with an
average lifespan post diagnosis of 3 to 5 years.10
Persons with ALS and a
stoma will need caregiver
assistance, whether at
home or in a long-term
care setting, at some
point in their lifespan
Hemiparesis
Ataxia
Paresthesia
Presents the challenge of
caring for a stoma with
one, possibly the nondominant, hand.
Challenges utilizing or accessing toilet facilities.
Inability to feel a clip or
flange, or to recognize it
as such (stereognosis)
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Amyotrophic
lateral sclerosis
(ALS)
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Forpatientswithimpairedmotorskillssecondarytodisease
or treatments (see Table 1), it is important to realistically assess
patient functional status, enlist the help of a caregiver or staff
members if the patient is institutionalized, and recommend
options that simplify ostomy care. Velcro® pouches that eliminatetheneedtouseclips,one-pieceappliances,andtwo-piece
pouches that can be attached to a skin barrier with one hand
foreasyapplicationsmaybesuggested.ConvaTec’s© (Skillman,
NJ) moldable technology also may be an option for persons
with minimal manual dexterity, chronic metacarpal joint pain,
or polyneuropathies of the hands. These skin barrier products
do not need to be cut (eliminating the need to manage scissors), and they are molded to fit snuggly against the stoma,
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facilitating adaption to changing stoma size and shape. Colostomy patients may consider using a disposable, closed-end
pouch, thus eliminating the need for a clip, while urostomy patients may need to try various spouts and tabs to find the product easiest for them to use.17 The WOCN may need to refer a
patient to occupational therapy to assist in teaching manual
skills and to recommend needed adaptive devices.
A thorough assessment also may show that self-care is not
possible. In this instance, caregiver possibilities must be explored for providing daily stoma care or, in the case of a continentdiversionorneobladder,regularly-scheduledintubation.
If this resource does not exist or is not available, home care
agencies or long-term care placement may be necessary.
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Pathophysiology
Sequelae
General and stomaspecific considerations
Quadriplegia or
paraplegia
Spinal cord trauma, spinal stenosis,
or cord compression due to primary
tumor or metastasis
Injuries from C4 through C7
may effect shoulder and arm
musculature; C6 through C8—
forearm extensors and flexors;
and C8 through T1 — hand
musculature. Total cord transection syndrome results in
the loss of all types of sensation and motor function below
the level of the lesion11
May lack the physical
coordination to perform
majority of gross and/or
fine motor skills needed
to perform daily care,
depending on level of injury. Focus on modifying
a plan to accommodate
abilities or teach caregiver ostomy care
Peripheral
neuropathy
Common diseases causing polyneuropathies include diabetes, alcoholism,
shingles, HIV/AIDS, hepatitis C, rheumatoid arthritis (RA), end-stage kidney
or liver disease, and tumor invasion, as
in brachial plexopathy commonly seen
in metastatic lung cancer.12
Chemotherapy-induced peripheral
neuropathy (CIPN) is a well-known
side effect of cancer treatment
Symptoms may range in severity from minimal, transient
numbness and tingling in the
extremities to burning pain
and lack of coordination
Most notorious classes of
chemotherapeutic agents
responsible for CIPN are
the taxanes (paclitaxel,
docetaxel, abraxane),
vinca alkaloids (vincristine, vinblastine,
vinorelbine), and platinum
compounds (cisplatin,
carboplatin, oxaliplatin).13
Oxaliplatin, in combination with 5-FU and
leucovorin, is considered
first-, second- or thirdline therapy for metastatic colon and rectal
cancer; the recipient
commonly has either a
temporary or permanent
ostomy14
Rheumatoid
arthritis (RA)
Acute and chronic inflammation in the
synovium associated with joint tissue
destruction.15
Joint damage that results in disability often occurs early in disease (<2
years). In one study, in less than 2
years post diagnosis, patients had
joint space narrowing on plain radiographs of the hands and wrists and
two thirds of patients had erosions.15
Although the course of RA varies
and patients may have long clinical
remissions or intermittent disease, the
majority of patients have progressive
disease that can lead to joint destruction and instability16
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Vision deficits. Vision deficits are common among
palliative patients and are an often-overlooked complication of chronic illnesses. In ostomy care, compromised
eyesight can greatly hinder the ability of the ostomate
to measure the stoma for an appliance, note peristomal
complications, or empty the pouch. Ultimately, the potential inability to perform self-care may encroach on the
patient’s independence, which can negatively influence
body image.
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Illness/treatment modality
Loss of joint mobility and
dexterity, as well as crippling
pain, accompany RA
Must be diligent about
pain control during acute
flares or with end-stage
disease. The loss of hand
dexterity could impair
the patient’s ability to
apply and remove a clip,
cut a pattern, or empty a
pouch
Diabetic retinopathy from advanced diabetes is the principle cause of impaired vision in patients between 25 and 74
years of age.18 Patient’s with chronic kidney disease (CKD),
most commonly caused by diabetes, may suffer from diabetic retinopathy or may experience conjunctival erythema
(the“red eyes of uremia”), which may be noted when corneal
and conjunctival precipitation of calcium pyrophosphate is
induced by high plasma phosphate levels.19 The WOCN also
may encounter metastatic calcification in the eyes, associated
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Chemotherapuetic agent
Epiphora
Cyclophosphamide,
methotrexate, and 5-fluorouracil
Retinopathy
Cisplatin, etoposide,
tamoxifen, interferon
Corneal or conjunctival
damage
Carmustine, mitomycin
Glaucoma
Interferon
Cataracts
Tamoxifen, busulphan,
methotrexate
Optic nerve or oculomotor
nerve damage
Carmustine, vinblastine,
vincristine
Optic neuritis
Cisplatin, tamoxifen
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Ocular toxicity
Given the array of visual deficits and their multifactorial
etiologies, where does the practitioner start? O’Shea25 suggests using educational materials with larger font on blue
or cream-colored paper that reduces glare. Bright lights and
magnifying glasses also may be needed. Audiotapes with
step-by-step instructions that can be conveniently played as
frequently as the ostomate or caregiver require may be employed.26 In the absence of peripheral neuropathy, Lemiska
andWatterworth27 suggest focusing on the patient’s strength
and keen sense of touch. Changing the ostomy appliance
when the stoma is not functioning (ie, when there is no output) and utilizing a two-piece pouching system are recommended, because it is easier to center the skin barrier by feeling the stoma by touch.17 If the patient has an ileal conduit,
he/she may be taught to wick the urine with a tampon or
dental wick, both to keep the peristomal skin dry and to help
center the skin barrier.Tactile aides also have been developed
by Coloplast Corporation (Marietta, GA).
Cognitive deficits. Carmel and Goldberg17 note the successive stages of the cognitive learning process to include the
acquisition of knowledge, comprehension, application (in
ostomy care, the person can apply the knowledge to the ostomy procedure), synthesis, and evaluation (the person can
performtheostomy careindependently andrecognizeswhen
to ask for help). The adult learner must be evaluated for the
ability to achieve each component of the learning process
with the goal of developing a realistic plan of care.
Althoughmanydiseaseprocessesmaycausecognitivedeficits in the palliative care population, a commonly encountered diagnosis is dementia. Dementia may be the result of a
multitude of pathologies including Alzheimer’s disease (AD)
or Lewey body dementia seen in patients with advanced Parkinson’s disease.28
Results of a longitudinal study by Hely et al29 showed that
83% of patients with Parkinson’s developed dementia within
20 years of diagnosis. Considering the projected growth rate
of elderly population in the US and assuming no cure will
be found, an estimated 14 million Americans will have AD
by 2050.28 These figures have a profound impact on the advanced practice WOCN working in palliative care and hospice. Because dementia is progressive, the ostomy patient
diagnosed with either of these diseases will eventually experience loss of memory and cognition skills, as well as functional impairment. The APRN will need to be vigilant about
decline in any of these areas because of their impact on daily
ostomy care and the eventual added caregiver burden in the
later stages of the disease.
Ongoing assessment of cognitive function is critical; interventions by the WOCN must be directed at the patient’s
level of functioning. Many tools exist to assess cognition
and are commonly used by physicians and nurse practitioners in hospice and palliative care. The Mini-Mental Status Exam (MMSE) has a total possible score of 30; a score
<20 usually indicates cognitive impairment.29 As part of the
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Table 2. Chemotherapy and resultant ocular
toxicities
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with marked hypercalcemia.19 Rarely, the WOCN practicing in hospice may encounter patients with complete loss of
sight; according to Tyler,20 “Profound uremia may rarely be
complicated by transient cortical blindness.”
Although rare, primary brain tumors, such as ocular melanomas or optic pathways gliomas, can cause local destruction
of structures in the eye or the supporting anatomy. Fungating
wounds of the head and neck involving the orbit and/or eye
also can be devastating. The complexity of treating both the
malignant wound and the ensuing ostomy difficulties from
lack of vision can be doubly challenging for the WOCN.
Therapies aimed at treating various malignancies may
impair vision. Surgery, such as enucleation or local resection
and brachytherapy or external beam radiation, are also possible causes of blindness.21,22 Although relatively uncommon,
certain chemotherapy agents acting as either single agents or
in combination therapies are known to induce ocular toxicities (see Table 2).23
Secondary ocular manifestations of rheumatoid arthritis,
a debilitating chronic systemic inflammatory disease, may
include Sjögren’s syndrome and keratoconjuctivitis sicca
(KCS).24 Combined motor and sensory deficits, as well as the
chronic pain issues, add to the challenges of treating palliative patients.
Finally, although 80% of patients with multiple sclerosis
(MS) complain of vision problems, visual dysfunction often is
overlooked as a source of disability.10 This is an important point
for the APRN to remember before engaging in teaching ostomy
care to someone with MS. Each client should be evaluated for
the need for an eye exam before proceeding.
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The skin barrier should mirror the topography of the
peristomal plane.31 In the case of a protruding abdomen or
a peristomal plane with creases, wrinkles (as seen with excessive weight loss), or scars, a convex pouching system may be
considered.33 This system also may be used in patients with
uneven planes due to tumors; barrier paste can be used to fill
in uneven areas. An extended-wear barrier, left in place for up
to 7 days, may be chosen for a patient with a large abdominal
tumor burden who is experiencing pain to decrease frequent
changes and discomfort. Premedicating with a short-acting
opioid before the wafer change should be included in the
plan of care. In all cases, the back of the skin barrier should be
examined during each pouch change to ascertain undermining by effluent, and the skin should be assessed for irritant
dermatitis (see Figure 1).
Mucocutaneous separation. Mucocutaneous separation
is the detachment of the stoma from the surrounding skin
(see Figures 2 and 3). Prevalence information in the general
stoma population is limited and is unknown in hospice patients.34,35 Risk factors include administration of corticosteroids, a diagnosis of diabetes mellitus or malnutrition, the
presence of infection or stoma necrosis, and recurrence of
malignancy or any of the chronic, debilitating diseases mentioned throughout this paper.36 Steroids, a mainstay in the
treatment of pain, dyspnea, and cerebral edema, are used
routinely in palliative care settings. Diabetes and its sequelae,
coronary artery disease, stroke, and end-stage renal disease,
are all common comorbidities seen in persons with chronic
disease. Malnutrition and cachexia may be seen in several
chronic, debilitating illnesses such as acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary
disease (COPD), congestive heart failure (CHF), dementia,
tuberculosis, malaria, CDK, liver disease, and rheumatoid arthritis (RA).37 Cachexia occurs in up to 80% of patients with
advanced cancer.38 Infection, stoma necrosis, and recurrence
of disease due to the debilitating nature of chronic illness
may be anticipated.
Conservative management is key, because at end-of-life
the etiology of the complication most likely will not be correctable. Colwell36 suggests filling the separation between the
skin and stoma with an absorbent material such as skin barrier powder, hydrofiber, or calcium alginate dressing to absorb
drainage as well as to prevent excessive soiling from urine or
feces. The skin barrier then is fitted around the stoma and
over the area to protect from effluent. If the separation heals,
assessment for stenosis and retraction is suggested.36 A convex pouching system should be avoided because it may cause
deeper tissue destruction and impaired healing at the stoma/
skin junction.33
Caput medusae. Varices occurring at the site of the stoma may be seen in patients with portal hypertension and
end-stage liver disease (ESLD) either from malignancy or
cirrhosis. This condition, often referred to as caput medusae, accounts for between 1% and 5% of all variceal
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hospice eligibility criteria for AD and as a helpful tool for
the WOCN in deciding how to develop a plan of care for the
ostomate with this type of dementia, routinely assessing and
documenting the decline of the patient utilizing the Functional Assessment Staging (FAST) scale is key.30 The scale was
developedtoevaluatepatientsatmoderatetoseverestagesof
dementia when the MMSE is no longer able to reflect changes
in a meaningful, clinical way. At stage 5, early dementia, cognitive decline is moderately severe and the patient may no
longer survive without some assistance, including choosing
the proper clothing. At this stage, the patient is still continent and requires no assistance with toileting, but one could
extrapolate the routine yet sometimes complex care of an ostomy to possibly require assistance. Patients at stages 6 and
7, associated with severe cognitive decline, will require daily
care from a caregiver or institutional staff.
Early in the cognitive disease trajectory, it is prudent for the
APRN to identify one or more caregivers willing to learn about
and assist with the patient’s ostomy care. At early stages of
memory loss (FAST scores of 2 to 4), the patient may need visual reminders to prompt the ostomate to empty his/her pouch,
intubate a continent diversion, or order equipment. As memory
and cognition diminish, step-by-step instructions, coaching/
prompting, or visual aides may be considered. Simpler pouches,
such as pre-cut, one-piece appliances with Velcro® closures may
be suggested. Eventually, based on the relentless nature of dementia, the caregiver(s) will need to assume total daily care.This
will necessitate the development of a teaching plan for either
family or staff, depending on home care or facility placement.
The additional caregiver burden of providing stoma care or diversion intubation should be considered, and the need for respite care, support groups, or counseling routinely assessed.
Peristomal Complications
Although no statistical data or research directly describe
peristomal complication rates in hospice, the author has observed these issues may be more pronounced or prevalent in
the hospice population due to an increase in the frequency
and duration of risk factors.
Changes in abdominal planes. The peristomal plane is
the surface area under the solid skin barrier and adhesive of
the pouching system, extending out approximately 4 inches
by 4 inches from the base of the stoma.31 Assessing the plane
with the patient lying down, sitting, and standing helps the
practitioner decide on the type of skin barrier needed.32 The
skin surrounding the stoma should be assessed for firmness,
excessive softness, uneveness caused by subcutaneous tumors, the presence of fungating wounds, and rounded protrusion caused by ascites, scars from prior surgeries, or trauma. The type of barrier included in the plan of care may need
to be changed multiple times during the palliative to hospice
continuum as the disease process progresses and abdominal
tumor burden or ascites increases, weight loss occurs, or malignant bowel obstruction develops.
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Figure 1. Irritant dermatitis.
Figure 2. Mucocutaneous separation.
Photo used with permission from WOCN Image Library
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Photo used with permission from WOCN Image Library
Figure 3. Mucocutaneous separation.
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bleeding.39 A purple hue caused by dilation of mucocutaneous vessels and profuse bleeding may surround the
stoma if it is eroded or traumatized (see Figure 4). This
may be observed either in the pouch itself or at the time
of the wafer change.36
The APRN must first control bleeding by direct pressure,
cauterization with silver nitrate, the use of epinephrinesoaked gauze or gel foam, or suture ligation.39 It is important to educate the patient or caregiver about the need to
1) avoid using a two-piece ostomy appliance (the flange
may rub against engorged vessels) and 2) wear loose-fitting
clothing.36 Convex pouching systems should be avoided as
well because they may damage distended blood vessels at the
stoma/skin junction and cause bleeding.33 Lastly, the patient
and caregiver must be instructed to apply direct pressure and
seek medical attention if bleeding occurs.
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Figure 4. Caput medusae.
Photo used with permission from WOCN Image Library
Palliative Pharmacology: Implications for Patients
with a Stoma
Prescribing for patients with a stoma presents numerous
challenges for practitioners in palliative or hospice settings.
Many medications routinely used by APRNs in the general
population may cause problems in a patient with an ileostomy
orcolostomy,bepoorlyabsorbedandthereforesubtherapeutic,
cause constipation and blockage, induce diarrhea, or cause an
increased propensity for altered fluid and electrolyte balances.
The length of small bowel available for drug absorption
is the most important consideration when selecting medications for the person with a stoma.40 Patients with ileostomies or transverse colostomies associated with high output
should avoid enteric-coated and sustained-release products
because of their slow dissolution properties.41 This has profound implications for pain management; many long-acting opioids are sustained-release.Transdermal fentanyl may
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Feature
Table 3. Foods that can change stool consistency
Foods that can loosen stool
Foods that can block or thicken stool
Dried fruit
Corn
Baked beans
Bean sprouts
Fruits with seeds and skin
Cabbage
Celery
Bamboo shoots
Broccoli
Mushrooms
Applesauce
Milk
Nuts
Prunes
Bananas
Fried foods
Boiled Rice and Pastas
Cheese
Fresh fruits
Creamy peanut butter
Whole wheat bread
Raw vegetables
Tapioca pudding
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Fruit juices
(especially apple and prune)
Popcorn
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Potatoes
Marshmallows
Adapted from Floruta C. Nutritional resources. In: Colwell J, Goldberg M, Carmel J (eds.). Fecal and Urinary Diversions: Management Principles. St.
Louis, MO;2006:339–350.
a multitude of uses in palliative care, as well as for traditional
use in gastro-esophageal reflux disease (GERD).
Constipation and blockage, sometimes necessitating ileostomy lavage or colostomy irrigation, may be caused by a
multitude of medications used in palliative care and hospice,
nonpharmacological factors, or a combination of both. A
careful history may reveal the cause, so the importance of a
thorough history and physical examination cannot be sufficiently emphasized.When assessing the severity of constipation in a cancer patient, the National Cancer Institute’s Common Toxicity Criteria for Constipation44 may be extrapolated
to the ostomy population and help guide management. A
digital assessment of the stoma is an important and unique
component of a complete physical assessment that may be
overlooked by practitioners with limited stoma experience.
Careful insertion of a lubricated gloved finger is needed to
assess for impaction or blockage.
Patients report that opioid-induced bowel dysfunction, or
constipation, is the most common and debilitating adverse
effect of chronic opioid use.42 Although contraindicated in
ileostomy patients, stimulant laxatives such as senna may
be used in colostomy patients, along with stool softeners,
to combat this common side effect. Preventing constipation
is crucial, and the goal of care should include maintaining
daily ileostomy and once every 1 to 2 days distal colostomy
functioning. The NP may educate patients with constipation
on increasing their intake of foods that can loosen stool and
avoiding foods that can cause blockage or thicken the stool
(see Table 3).45 Other medications that may cause constipation in persons with a stoma include tramadol (Ultram,
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be considered in this case, with short-acting opioids in solutions or uncoated tablets for breakthrough pain.Transdermal
fentanyl also has been shown to lessen the severity of constipation as compared to oral opiods and may require less laxative use.42 Someone with a distal colostomy will probably not
experience medication absorption problems, so long-acting
oral pain medications may still be an option.
Divalproex Na (Depakote, Abbott Laboratories, Abbott
Park, IL) usage for seizure control or as an adjuvant analgesic, digoxin for class IV heart failure, and cyclosporine (CSA,
Sandimmune, Novartis, Basel, Switzerland), used most often
in organ transplant patients in conjunction with adrenal corticosteroids, also may have variable absorption in patients
with end jejunostomies and ileostomies. Although Depakote
potentially could be replaced with another shorter-acting anticonvulsant or adjuvant, therapeutic drug levels of digoxin
or CSA may have to be monitored more frequently.43 All persons with a stoma must be counseled by the nurse practitioner (NP) or CNS on the potential for drug malabsorption
and the need to check the ostomy pouch for drug fragments
whenever a new medication is prescribed.40
Pancreatic enzymes or lansoprazole and omeprazole,
medications packaged in acid-stable microspheres that disintegrate in the alkaline pH of the small intestine, may be inconsistently absorbed in people with short bowel syndrome
or pancreatic insufficiency with loss of bicarbonate secretion.40 Pancreatic enzymes may be prescribed to aide with
digestion in persons with advanced pancreatic cancer, while
proton-pump inhibitors are routinely ordered as gastrointestinal prophylaxis in patients taking steroids, drugs that enjoy
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Ostomates in Palliative Care
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of their bowel regimen, but this practice is not generally recommended for ileostomy patients. Other causes of diarrhea
include partial intestinal obstruction, fecal impaction, pancreatic insufficiency, Clostridium difficile infection, chemotherapeutics (notably irinotecan and 5-fluorouracil), and radiation enteritis.48 The incidence of chemotherapy-induced
diarrhea with combination irinotecan and fluorouracil can
be as high as 30% to 80%.46
In HIV infection, infectious diarrhea is especially prevalent,
commonlyfromoffendingorganismsincludingCryptosporidia, Giardia lambila, Escherichia histolytica, and cytomegalovirus.47 If caused primarily by a nonpharmacologic source such
as infection or HIV enteropathy, adding lamivudine/zidovudine (Combivir, GlaxoSmithKline Pharmaceuticals, London,
UK), a common component of highly active antiretroviral
therapy (HAART), may exacerbate the diarrhea.
Given their propensity to alter normal bowel flora and
cause diarrhea, the use of broad-spectrum antibiotics can be
a significant problem for patients with ileostomies”.43
ACE inhibitors (ACEI), a mainstay of heart failure treatment,
maycausehyperkalemia,especiallyinpersonswithanileostomy
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Janssen Pharmaceuticals, Inc, Titusville, NJ) and olanzapine
(Zyprexa, Eli Lilly and Company, Indianapolis, IN).43 Chemotherapeutic agents such as thalidomide, cisplatin, and vinka
alkaloids also may cause constipation, as will many of the
anti-emetics used to prevent chemotherapy-induced nausea
and vomiting.46
Diarrhea may be caused solely by medications or, more
commonly, is multifactorial in etiology. A thorough history
may reveal whether the cause of the diarrhea is secretory,
osmotic, mechanical, pharmacological, or a combination of
factors. In assessing the severity of the symptoms in cancer
patients, the National Cancer Institute’s Common Toxicity
Criteria for Diarrhea, version 2.04744 is a widely used tool
that distinguishes between persons with and without a colostomy and may guide the practitioner in assessment and
management. It is important to reiterate the importance of
digitalizing the stoma as part of a physical exam because
stool may leak around an impaction. In palliative care, the
overuse of laxatives, typically seen when the management of
constipation is suddenly stepped up, is a common cause of
diarrhea.47 Persons with a colostomy may use laxatives as part
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Conclusion
The inevitable increase in the number of palliative care
patients with a stoma presents unique challenges for both
the APRN WOCN seeing palliative and hospice patients and
the Palliative Advanced Practice WOCN. Considering current trends, the need for WOCNs with indepth knowledge of
palliative care concerns is clear. APRN WOCNs who are resourceful and able to meet the often multifactorial challenges
of palliative and hospice care can profoundly affect their patients’ quality of life. Epidemiological studies to obtain information about the type and prevalence of stoma complications, as well as research to increase understanding about
the lived experience of patients at end-of-life with a stoma
to help improve clinician ability to provide evidence-based
practice, are needed. n
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because they are already at risk for fluid and electrolyte imbalances; careful monitoring by the APRN is indicated.43
Nursing’s role. The advanced practice palliative nurse’s
role includes preventing, recognizing, and managing medication-induced problems and complications in the ostomy
patient. The wound, ostomy, and continence NP or CNS is in
a unique position to not only directly improve patient quality of life, but also to serve as a valuable resource for other
members of the patient care team.
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