Written by Kay Josephs Clinical Continence Nurse Advisor

Palliative care is defined as “an approach that improves the quality of life of patients and their families facing the problem associated with life threatening illness, through 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.” (World Health Organisation, 2009)

Continence care in end of life situations can be of significant importance for both the patient and their carers. It should be based on the treatment of the problem at hand whilst maintaining dignity and comfort. Many people remain continent until the very last stages of their disease process and they may cope well until then. Continence health professionals and palliative care health professionals must work together to achieve the best outcomes for both the patient and carer.  Good assessment skills are needed to ascertain best management strategies for continence care.

Bowel problems such as constipation and faecal impaction are well known for palliative patients (Thomas et al, 2006) but there could also be problems of urinary incontinence which occur at the end of their life.  A recent study undertaken by Alison Harris, Senior lecturer at Middlesex University , London, noted that continence difficulties could be caused by an underlying condition, medication, mobility, cognitive decline or be present before the onset of the life threatening disease.

Factors which may contribute to palliative patients becoming incontinent include:              

• spinal cord tumours causing compression on the nerves to the bladder
• tumours or cancers to the pelvic region, including both bowel and bladder areas and bladder cancer or neoplasm’s may also lead to bladder dysfunction
• neurological diseases such as stroke, multiple sclerosis, or Parkinson’s disease may cause bladder problems
• decline in cognitive impairment can cause urinary and faecal incontinence
• metastases or a secondary tumour or cancer may also affect the uro-genital region
• risk of falls in the elderly and aged related diseases in palliative patients may play a part in urinary and faecal incontinence
• radiotherapy, chemo-therapy and surgery are also factors that can cause incontinence
• urinary tract infection can cause urge incontinence and/or urgency and frequency
• constipation caused by drugs especially opioid analgesics, sedatives, anticonvulsants and anticholinergics

Before management strategies for incontinence are implemented, a management plan including pain relief for the palliative patient might be considered. A collaborative approach with a multidisciplinary team of health care professionals is essential for the best possible outcome for the person.

Management strategies for incontinence

• Maintain fluid intake with sips of fluid such as fruit juice given at regular intervals.
• Maintain a good high fibre diet. Supplementary high fibre drinks may have to be given if the patient cannot tolerate solids, this will help prevent constipation.
• Regular toilet routine especially for bowel management.
• Commode or urinal (for men) or slipper pan at the bedside.
• Correct toileting position if the person is able to sit on the toilet.
• Appropriate disposable pads. Good assessment to determine the correct product, will allow the person to maintain continence containment with a suitable pad.
• Continence aids such as sheaths or urodomes for men.
• Intermittent catheterisation or indwelling catheters if needed (with a closed drainage system) and catheter care information for carer. Catheters may be needed for urine retention or in late stage of the illness.
• Skin care with the use of barrier creams and protective creams to maintain good skin integrity.
• Medications for urge incontinence and/or urgency if required.
• Medications for constipation. A bowel chart should be kept and laxatives taken accordingly to prevent constipation.

Planning ahead for good continence care for a person who is palliative can be less stressful for all concerned. Continuing evaluation of the situation regarding bladder and bowel care is of utmost importance to allow the person to voice their preferences to maintain dignity and respect in their end of life care.

For further information visit the Department of Health and Ageing website www.health.gov.au/Palliativecare or call you healthcare consultant on 1300 134 260 to find products to help with palliative care.

References:
Harris, A. (2009) Providing urinary continence care to adults at the end of life. Nursing Times; 105; 29
Thomas, S. et al (2006). Choices in Opioid Induced Constipation. Maidenhead: Wyeth Pharmaceuticals.
http://www.who.int/cancer/palliative/definition