The management of constipation in end-stage disease

A rectal examination may be considered an invasive intervention in a frail patient, but it is preferable to a blanket approach to treatment, which may be ineffective or do more harm than good, for example, giving antidiarroeals when the diarrhoea is spurious secondary to impaction, or continuing to soften soft faeces when in fact a stimulant laxative is required. The rectal examination can be modified to a gentle inspection. It should not need to be performed repeatedly if the regular regimen is altered according to the findings. This approach prevents the need for routine suppositories, enemas or manual evacuation. However, on the occasions that the above measures are unsuccessful, an enema may need to be employed. Microlax (containing osmotic agents such as sorbitol) is relatively well tolerated. Intractable cases may require a Clezy enema (a large volume enema that is prepared by a hospital pharmacist and contains the softeners: Paraffin oil 30 mL, Glycerine 30 mL, Enema soap 30 mL, and olive oil 60 mL, made up to 400 mL with water). If manual evacuation is contemplated, a pre-medication with midazolam 5 mg subcutaneously will give short sedation for this procedure.