The IAHPC Manual of Palliative Care
2nd Edition

IV. Symptom Control

Table of Contents

CONTENTS

• respiratory
• breathlessness
• cough
• terminal respiratory congestion
• gastrointestinal
• nausea and vomiting
• antiemetics

• bowel obstruction
• constipation
• laxatives

• constitutional
  • anorexia
  • weight loss
  • weakness and fatigue
  • neurological
    • acute confusion and delirium
    • terminal restlessness

BREATHLESSNESS OR DYSPNOEA

Breathlessness or dyspnoea is the unpleasant awareness of difficulty in breathing

• dyspnoea, like pain, is subjective and involves both the perception of breathlessness and the reaction of the patient to it
• dyspnoea is always associated with some degree of anxiety, which in turn will make the breathlessness worse

Causes

• airway obstruction
• tracheal
• tumour
• tracheo-oesophageal fistula

• bronchial
• tumour
• chronic bronchitis
• acute infection, bronchitis
• bronchospasm: bronchitis, asthma
• reduction in functional lung tissue
• surgical resection
• tumour
• fibrosis: pre-existing, radiation
• pleural effusion
• infection
• haemorrhage
• pulmonary embolism
• chronic obstructive pulmonary disease

• impaired ventilatory movement
• chest wall weakness, motor impairment, general debility
• chest wall pain
• elevated diaphragm: ascites, hepatomegaly, phrenic nerve lesion
• cardiovascular
• congestive cardiac failure, cardiomyopathy
• pericardial effusion, constrictive pericarditis
• shock, haemorrhage, septicaemia
• anaemia

• anxiety

Assessment

• clinical history and examination, together with knowledge about pre-existing lung disease, are usually sufficient to determine the cause of dyspnoea
• whether investigations should be performed, looking for a reversible cause, depends on
• what stage the patient is at on the terminal illness trajectory
• their identified goals of care

Treatment

• treatment directed at the specific cause, where possible and appropriate
• general measures
• calm, reassuring attitude
• nurse patient in position of least discomfort
• physiotherapy
• improve air circulation
• distraction therapy
• relaxation exercises
• breathing control techniques
• counselling

• oxygen

• if hypoxic
• if it improves symptoms (terminal care situation)
• bronchodilators if there is a reversible element to the bronchial obstruction
• corticosteroids
• effective bronchodilators
• for dyspnoea due to multiple metastases, lymphangitis carcinomatosis and pneumonitis
• opioids—the most useful agents in the treatment of dyspnoea
• nebulised morphine
• effective for some patients, although controlled studies do not support its use
• risk of bronchospasm

• aid expectoration

• steam, nebulised saline
• mucolytic agents
• expectorants
• physiotherapy

• reduce excess secretions

• anticholinergics

• antitussives if dyspnoea exacerbated by coughing
• anxiolytics

Examples of drug therapy

bronchodilators

• salbutamol by metered aerosol or 2.5-5 mg by nebuliser, q4-6h
• ipratropium by metered aerosol or 250-500 µg by nebuliser, q6h
• aminophylline, theophylline PO

corticosteroids

• prednisolone 40-60 mg/d PO or dexamethasone 8-12 mg/d PO
• wean to the minimum effective dose after a few days

opioids

• morphine 5-10 mg PO, q4h or 4-hourly PRN and titrate
• 50% increase in dose for patients on morphine for pain
• nebulised morphine not recommended

anxiolytics

• diazepam 2 mg PO q8h ± 5-10 mg nocte
• alprazolam 0.25-0.5 mg SL, q1-2h
• lorazepam 0.5-1 mg SL, q4-6h

mucolytics (for sputum retention)

• humidified air (steam, nebulised saline)
• acetylcysteine 10%, 6-10 ml by nebuliser, q6-8h

anticholinergics (for excessive secretions)

• glycopyrrolate 0.2-0.4mg SC q2-4h or 0.6-1.2mg/24h CSCI
• hyoscine hydrobromide 0.2-0.4mg SC q2-4h or 0.6-1.2mg/24h CSCI

Terminal Care

• treatment should be purely symptomatic in the last week or days of life
• investigations should be avoided
• antibiotic therapy is usually not warranted
• if of benefit, bronchodilator therapy can be continued by mask.
• unconscious patients who still appear dyspnoeic should be treated with morphine SC

COUGH

Cough is the physiological reflex employed to clear irritant, foreign or particulate material from the respiratory tract

Cause

• airway irritation
• atmosphere: smoke, fumes, dry atmosphere
• tumour: endobronchial tumour, extrinsic bronchial compression
• aspiration
• vocal cord paralysis
• reduced gag reflex
• tracheo-oesophageal fistula

• gastro-oesophageal reflux
• infection: post-nasal drip, laryngitis, tracheitis, bronchitis
• increased bronchial reactivity: ACE inhibitors, asthma
• sputum retention
• excess sputum (bronchorrhoea)

• lung pathology

• infection
• infiltration: primary or secondary cancer, lymphangitis carcinomatosis
• pneumonitis: radiation, chemotherapy
• pulmonary fibrosis
• chronic obstructive pulmonary disease
• pulmonary oedema: congestive heart failure, pericardial effusion

• irritation of other structures associated with the cough reflex: pleura, pericardium, diaphragm

Assessment

• the clinical history, physical examination and chest x-ray will usually define the cause

• whether investigations should be performed, looking for a reversible cause, depends on
• at what stage the patient is on the terminal illness trajectory
• their identified goals of care

Treatment

• treat the specific causes where possible and appropriate
• general symptomatic measures

• avoid smoke, fumes
• atmospheric humidification
• nurse patient in position of least discomfort

• aid expectoration if cough productive
• may be contraindicated for patients who are weak or debilitated
• steam or nebulised saline are as effective as
• inhalations containing menthol or eucalyptus
• the chemical mucolytic agent acetylcysteine
• atmospheric humidification
• physiotherapy
• bronchodilators if bronchospasm present
• antibiotics if infection present
• cough suppressants for persistent dry cough
• opioids
• opioid analogues
• nebulised local anaesthetics
• corticosteroids for lymphangitis carcinomatosis

• sedation may be useful, especially at night

Examples of medications used

Terminal Care

• treatment should be purely symptomatic in the last week or days of life
• treatment of persistent cough is with an opioid drug, which will also reduce respiratory secretions
• investigations should be avoided
• antibiotics and vigorous physical therapy are inappropriate
• sedatives may be of benefit, especially at night

• haloperidol or levomepromazine, which will dry respiratory secretions by their anticholinergic effect, are preferable to a benzodiazepine

• if of benefit, bronchodilator therapy can be continued by mask.
• unconscious patients who are still coughing should be treated with morphine SC

TERMINAL RESPIRATORY CONGESTION

('DEATH RATTLE')

Terminal respiratory congestion is the rattling, noisy or gurgling respiration of some patients who are dying

Cause

• accumulation of pharyngeal and pulmonary secretions in patients who are unconscious or semi-conscious and too weak to expectorate

Treatment

therapy is often more for the comfort of the relatives and other patients, as most of the patients are no longer aware of their surroundings

• position the patient on their side
• oropharyngeal suction should be reserved for unconscious patients
• anticholinergic drugs to suppress the production of secretions
• hyoscine hydrobromide
• 0.4mg SC, ± repeat at 30min, then q2-4h or 0.6-1.2mg/24h CSCI
• antiemetic; sedative; occasional agitated delirium

• glycopyrollate

• 0.2-0.4mg SC, ± repeat at 30min, then q4-6h or 0.6-1.2mg/24h CSCI
• less central and cardiac effects
• atropine
• 0.4-0.8mg SC q2-4h
• may cause tachycardia after repeated injections
• transdermal scopolamine patches
• hyoscine hydrobromide 1.5mg patch q72h
• onset of action is delayed for several hours during which other anticholinergic treatment needs to be given

• reassure relatives that the noisy breathing is not causing any added suffering for the patient

NAUSEA AND VOMITING

Cause - frequently due to multiple causes

• irritation, obstruction of the gastrointestinal tract
• cancer
• chronic cough
• oesophagitis
• gastritis
• peptic ulceration
• gastric distension
• gastric compression
• delayed gastric emptying
• bowel obstruction
• constipation
• hepatitis
• biliary obstruction
• chemotherapy
• radiotherapy
• via chemoreceptor trigger zone
• biochemical abnormality

• hypercalcaemia
• liver failure
• renal failure

• sepsis
• drugs e.g. opioids, antibiotics

• via vestibular system

• drugs e.g. aspirin
• via cortical centres
• psychological factors, anxiety
• sites, smells, tastes
• conditioned vomiting
• raised intracranial pressure

Treatment

• assess for and treat underlying cause(s)
• dietary measures
• liquid and soft foods, selected by the patient
• small meals, eaten slowly
• general measures
• avoidance of noxious or suggestive smells and odours
• relaxation techniques
• use of antiemetics (see below)
• drug selected on basis of presumed causative mechanism
• commence before vomiting starts if possible
• in adequate doses
• in combination if necessary by parenteral route if necessary
• if unresponsive
• assess for psychological factors
• reassess for missed physical causes
• try different antiemetics and/or combinations
• nasogastric intubation and intravenous hydration should be avoided
• in patients whose symptoms can be controlled by other means
• in the terminally ill

ANTIEMETICS

*Abbreviations: CTZ - chemoreceptor trigger zone, EP - extrapyramidal side effects, GI - gastrointestinal, VC - vomiting centre.

Use of antiemetics

Which antiemetic(s) is prescribed depends on

• whether the cause can be determined
• what drugs are available
• the effects of antiemetics already given

Metoclopramide

• is a good first-line antiemetic
• has central antidopaminergic activity and is effective for many of the chemical causes of nausea
• has a gastrokinetic effect useful in delayed gastric emptying and functional bowel obstruction
• is contraindicated in high small bowel obstruction

If there is no improvement after 12-24 hours

• other drugs can be substituted, e.g.
• levomepromazine has a broad spectrum of antiemetic activity
• haloperidol has strong antidopaminergic effects
• cyclizine is both antihistaminic and anticholinergic and is useful in mechanical bowel obstruction
• other drugs can be added, e.g.
• dexamethasone if there is raised intracranial pressure
• benzodiazepine if there is excessive anxiety
• a 5HT3 receptor antagonist if vomiting is related to surgery, chemotherapy or radiotherapy

BOWEL OBSTRUCTION

Cause

• mechanical obstruction
• luminal obstruction: cancer, constipation, faecal impaction
• wall infiltration, stricture formation: cancer, radiation, surgery, benign (peptic ulcer)
• extrinsic compression: cancer, adhesions (surgical, malignant)
• paralytic (functional) obstruction
• autonomic neuropathy

• retroperitoneal infiltration
• spinal cord disease

• drugs: opioids, anticholinergics
• postoperative
• peritonitis
• metabolic: hypokalaemia, hypercalcaemia, hyperglycaemia
• radiation fibrosis

Treatment

The management of bowel obstruction is traditionally based on surgical intervention but for patients in palliative care, particularly those with advanced cancer, conservative therapy for subacute and incomplete bowel obstruction will produce equivalent results.

The treatment options include

• nasogastric intubation and intravenous fluids as a temporary measure only
• preoperative
• pending a decision regarding surgery
• whilst systemic therapy is initiated
• acute phase of recurrent obstruction

• surgery
• resection or bypass of obstruction
• creation of colostomy, ileostomy
• percutaneous gastrostomy as venting procedure
• endoscopic laser resection (colorectal)

• symptomatic
• medications (see below)
• relieve and prevent constipation
• small meals with reduced roughage, served when the patient requests

Examples of medications used for symptomatic management of bowel obstruction

• antiemetics

• metoclopramide 10mg PO q4-6h or 30-60mg/24h CSCI
• cyclizine 50mg PO, PR q8h or 150mg/24h CSCI
• haloperidol 0.5-1mg PO q6h or 3-5mg/24h CSCI
• levomepromazine 6.25-12.5mg SC or 12.5-50mg/24h CSCI

• analgesics

• morphine PO, PR or SC infusion

• anticholinergics

• hyoscine butylbromide 20mg PO q6h or 60-120mg/24h CSCI
• hyoscine hydrobromide 0.4mg SC q6h or 0.6-1.2mg/24h CSCI

• prokinetic agent

• cisapride 10mg PO q6-8h

• somatostatin analogue

• octreotide 0.1mg SC q8h or 0.2-0.3mg/24h CSCI

• corticosteroid

• dexamethasone 8-16mg/d PO or 8-16mg/24h CSCI

CONSTIPATION

Constipation means infrequent or difficult defecation and implies a significant variation from the normal bowel habit of an individual patient

Cause - frequently due to multiple causes

• general
• immobility, inactivity
• muscular weakness, debility
• confusion, sedation
• inability to access or use toilet facility

• nutritional
• decreased intake
• low residue diet
• poor fluid intake

• metabolic
• dehydration
• hypercalcaemia
• hypokalaemia

• neurological
• cerebral tumour
• spinal cord disease
• sacral nerve route infiltration
• psychological
• depression
• fear of diarrhoea, incontinence

• colorectal
• obstruction
• pelvic tumour mass
• radiation fibrosis, stricture
• painful anorectal condition
• drugs
• opioid analgesic
• antidiarrhoeals
• non-opioid analgesics
• anticholinergic drugs or anticholinergic adverse effects
• anticholinergics
• antispasmodics
• antidepressants
• phenothiazines
• haloperidol

• antiemetics e.g. 5HT3 antagonists

Treatment

Established constipation requires the use of suppositories and enemas to clear the lower bowel before a normal bowel pattern can be established with oral medication

• absent rectal tone, reflex or sensation: neurogenic bowel (see below)
• no neurological abnormality
• faeces in rectum
• hard faeces: glycerine PR, microenema, enema, disimpaction
• soft faeces: bisacodyl or docusate PR, microenema, enema, disimpaction
• empty rectum: do plain x-ray
• no bowel obstruction: bisacodyl or docusate PR, oral medications
• bowel obstruction: appropriate therapy

Prevention of constipation

• factors and situations that predispose to constipation are well known
• preventive treatment should be introduced before clinical problems develop
• general measures (where feasible)

• increased food intake
• increased dietary fibre or bulk forming laxative
• increased fluid intake
• encourage activity

• laxatives

• docusate 240-480mg nocte or bisacodyl 10-20mg nocte
• ± senna 15mg nocte
• ± lactulose 30ml nocte
• and titrate the dose against the clinic effect

• explanation to patient, family
• treatment of painful rectal conditions
• ensure access and ability to use toilet facilities
• avoid constipating drugs if possible
• keep a record of bowel actions

Management of neurogenic bowel

• Spinal cord lesion - spastic bowel, hypertonic anal sphincter, sacral reflexes intact
• adequate fluid and fibre intake
• oral laxatives (avoid laxatives that cause excessive softening)
• rectal suppositories or stimulation leads to increased peristalsis and sphincter relaxation

• Sacral nerve root lesion - reduced peristalsis, flaccid sphincter, sacral reflexes absent
• adequate fluid and fibre intake
• oral laxatives
• rectal suppositories or stimulation may lead to evacuation
• straining and abdominal massage

• Patients with a short life expectancy, for whom bowel training is not feasible
• dietary fibre is reduced and bulk laxatives avoided
• constipation is induced with codeine or loperamide
• regular bowel evacuations are planned once or twice weekly using suppositories or enemas

Terminal care

• significant symptoms due to constipation are rare during the last days or week of life
• oral intake is frequently limited and laxatives can usually be discontinued
• a suppository or microenema can be used

• if the patient has pain, feels the urge to defaecate but is unable to do so
• if there is faecal incontinence due to impaction

LAXATIVES

ANOREXIA

Anorexia is a reduced desire to eat

Cause - often due to multiple causes

• cancer
• pain
• disordered taste, smell
• cancer
• stomatitis
• malodorous ulcer or fungating tumour

• gastrointestinal
• stomatitis, xerostomia mucositis, infection
• oesophagitis, dysphagia
• small stomach: gastrectomy, linitis plastica
• gastric compression: hepatomegaly, ascites
• gastric distension: delayed gastric emptying
• bowel obstruction, constipation
• hepatic metastases, liver disease
• chemotherapy, abdominal radiotherapy

• intracranial disease
• metastases, radiotherapy, infection
• metabolic
• abnormalities of sodium, calcium, glucose
• organ failure: liver, kidney, adrenal
• infections
• medications
• psychological

• anxiety, depression, confusion, dementia

• organisational

• poor food preparation or presentation

• religious or cultural customs

Treatment

Treatment of anorexia is important as it

• will improve patient morale
• reduce family anxiety
• the preservation of optimal nutrition may delay the onset of cachexia
• assistance of a dietician may be invaluable

Treatments

• treat or palliate the underlying cause
• activity, exercise
• dietary
• dietary advice (dietician)
• visually appealing food
• tasty small frequent meals
• what they want, when they want it
• sitting up, at a table, in a room free of odours

• appetite stimulants
• alcohol
• corticosteroids, e.g. prednisolone 15-30mg/d, dexamethasone 2-4mg/d
• progestogens, e.g. megestrol 160mg/d

• explanation, counselling.

Counselling

• anorexia and poor food intake frequently cause much distress for patients and families, requiring careful discussion and explanation
• when advanced and progressing cancer is the prime cause, it needs to be explained that enteral or parenteral nutrition will not be of benefit

WEIGHT LOSS & CACHEXIA

Cause

• in patients with advanced cancer, this is primarily due to alterations in protein, carbohydrate and lipid metabolism caused by inflammatory cytokines released by the tumour
• in patients with AIDS, it usually relates to systemic infections and chronic gastrointestinal dysfunction

The causes of weight loss include

• malnutrition
• poor intake due to anorexia
• functional blockage: mouth, oesophagus, stomach
• malabsorption
• vomiting, diarrhoea, fistulas
• protein loss: ulceration, haemorrhage, repeated paracenteses

• metabolic abnormalities secondary to cancer (cancer cachexia)
• increased energy expenditure
• systemic infections
• chronic fevers
• tumour metabolism

Treatment

The treatment options for weight loss include

• correct or palliate cause of malnutrition, anorexia
• treat tumour where feasible
• drug treatment
• there is no satisfactory drug therapy for cachexia
• corticosteroids and alcohol may reduce anorexia but have no effect on the metabolic abnormalities of cancer cachexia
• progestogens may exert an anabolic effect and reduce or prevent weight loss
• dronabinol is effective in maintaining weight for some patients with AIDS
• dietary measures
• small frequent meals
• what the patient wants and when they want it
• dietary supplements
• enteral nutrition
• will not reverse or prevent cancer cachexia
• may be appropriate for patients with upper gastrointestinal obstruction who may otherwise suffer starvation
• may cause fluid overload, abdominal cramps and diarrhoea
• parenteral nutrition
• will not reverse or prevent cancer cachexia
• is appropriate for patients who are temporarily unable to eat for two weeks or more because of anticancer treatment
• is associated with significant complications and cost
• management of the psychosocial consequences

Counselling

• for both the patient and the family, progressive weight loss and cachexia represents progression of the disease
• counselling and discussions may facilitate acceptance and understanding
• the family needs to be dissuaded from trying to force the patient to eat, as this will only cause physical distress and guilt
• the family needs to be helped to show love to the patient by means other than feeding them or pressuring them to eat

WEAKNESS AND FATIGUE

Asthenia is generalised weakness associated with fatigue and lassitude

Cause

In palliative care, asthenia is most frequently associated with progression of the cancer or other underlying disease, but other causes need to be considered, as some are amenable to treatment or palliation. Most relatives attribute weakness to poor eating or to medications.

• neuromuscular
• cachexia-related loss of muscle mass
• cachexia-related muscular dysfunction
• polymyositis
• overactivity, prolonged immobility
• polyneuropathy
• intracranial tumour, paraneoplastic encephalopathies
• acute confusion or delirium

• metabolic
• electrolyte imbalance, dehydration
• renal, hepatic failure

• endocrine
• adrenal insufficiency
• ectopic ACTH secretion
• diabetes

• malnutrition
• inanition, malabsorption

• anaemia
• infection
• psychological
• anxiety, depression, dependency, boredom, insomnia

• anticancer therapy
• radiotherapy, chemotherapy, interferon

• drugs
• opioids, tranquillisers, sedatives, antidepressants diuretics, antihypertensives, hypoglycaemics and others

Treatment

• treatment of underlying cause, where possible
• drug therapy
• corticosteroids

• symptomatic improvement, improved feeling of well-being
• proximal myopathy with continued therapy

• amphetamines and methylphenidate

• physical therapy
• encourage exertion and activity, physiotherapy

• within the patient's physical limitations
• may help maintain dwindling muscle strength

• encourage activities providing diversion from a patient's feeling of weakness
• assistance with the activities of daily living
• physical aids
• reorganisation of the immediate environment to accommodate reduced mobility

• counselling
• supportive therapy: physical and psychological
• redefinition of goals and expectations

ACUTE CONFUSION OR DELIRIUM

Acute confusion or delirium is an organic brain syndrome characterised by the acute onset of disturbance of the conscious state associated with disordered

attention, cognition, perception and psychomotor behaviour

Clinical features of delirium

Cause - in many cases due to more than one cause

• intracranial pathology
• tumour
• haemorrhage
• encephalopathy - radiation, chemotherapy
• infection - abscess, meningitis, encephalitis
• post seizure
• cerebrovascular disease, stroke

• metabolic
• respiratory failure - hypoxia, hypercapnia
• liver failure, hepatic encephalopathy
• renal failure
• acidosis, alkalosis
• electrolyte disturbance - sodium, calcium
• hyperglycaemia, hypoglycaemia
• adrenal, thyroid and pituitary dysfunction

• infection, fever
• circulatory
• dehydration
• hypovolaemia
• heart failure
• shock

• anaemia
• nutritional
• general malnutrition
• vitamin B1, B6, B12 deficiency

• drug withdrawal
• alcohol, benzodiazepine, barbiturate, opioids, nicotine
• drugs
• alcohol, anticholinergics, anticonvulsants, antidepressants, antiemetics (phenothiazines, metoclopramide, nabilone), antihistamines, antiparkinsonian, antipsychotics, anxiolytics and hypnotics (benzodiazepines, barbiturates), corticosteroids, NSAIDs, opioid analgesics, stimulants (amphetamine, methylphenidate, cocaine) and, less frequently, many other drugs

Other potentially reversible contributing factors that may precipitate or aggravate delirium

• anxiety, depression
• pre-existing cerebral disease, dementia general debility
• pain, discomfort
• sleep deprivation
• altered environment

Treatment

• treatment of the cause
• identify and treat the underlying cause
• withhold all non-essential medications
• consider alternatives for essential drugs
• alcohol or drug withdrawal
• consider allowing continued use
• nicotine skin patches
• general measures
• appropriate physical environment
• quiet and well lit room, night light
• minimise number of different staff having contact
• avoid disturbances
• presence of a family member or trusted friend

• develop a regular daily routine
• repeated calm reassurance and explanation
• do not move from familiar surroundings
• avoid physical restraints
• restless patients can be allowed to ambulate if accompanied
• habitual smokers should be allowed to smoke with supervision
• reassure family and patient that the confusional state is due to organic disease

• drug therapy

• haloperidol
• is the most frequently used drug for delirium in medically ill patients
• improves cognitive function and provides sedation
• mild delirium: 1-5 mg/d PO, in divided doses
• severe delirium: 2-5 mg IV or SC, q30-60 min, if required
• alternatives
• chlorpromazine
• levomepromazine
• benzodiazepine
• can be given in addition to haloperidol
• given alone cause sedation without any effect on cognitive function and may aggravate confusion

TERMINAL RESTLESSNESS

Terminal restlessness is an agitated delirium that occurs in some patients during the last few days of life

Clinical features

• agitation, restlessness
• impaired conscious state
• muscle twitching
• multifocal myoclonus
• seizures
• distressed vocalizing

Treatment

• exclude restlessness due to
• anxiety, fear
• unrelieved pain
• urinary retention, faecal impaction
• drug, alcohol or nicotine withdrawal

• review opioid use
• benzodiazepines
• clonazepam 0.5 mg SL or SC q12h or 1-2 mg/24h CSCI and titrate
• midazolam 2.5-10 mg SC, q2h or 20-60 mg/24h CSCI and titrate
• diazepam 5-10 mg IV or 10-20 mg PR, q6-8h and titrate
• lorazepam 1-2.5 mg SL, q2-4h and titrate
• for benzodiazepine failure
• haloperidol 5mg SC, followed by 20-3-mg/24h CSCI and titrate
• levomepromazine 12.5-50mg SC q4-8h and titrate; continue as CSCI
• phenobarbitone 100-200mg SC q4-8h and titrate; continue as CSCI

Treatment

Established constipation requires the use of suppositories and enemas to clear the lower bowel before a normal bowel pattern can be established with oral medication

• absent rectal tone, reflex or sensation: neurogenic bowel (see below)
• no neurological abnormality
• faeces in rectum
• hard faeces: glycerine PR, microenema, enema, disimpaction
• soft faeces: bisacodyl or docusate PR, microenema, enema, disimpaction
• empty rectum: do plain x-ray
• no bowel obstruction: bisacodyl or docusate PR, oral medications
• bowel obstruction: appropriate therapy

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