| A Patient-Centered Approach to Chronic Constipation
6/17/2010 |
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A number of major trends are emerging in long-term care settings, including an emphasis on community building and a commitment to patient-centered care. The MDS 3.0 (Minimum Data Set, version 3.0), launching in October 2010, reflects these emerging trends, emphasizing that, whenever possible, clinical decisions should be made with residents/surrogates, rather than for residents. Field testing of the MDS 3.0 has demonstrated that even residents with dementia can give valid responses when asked how they feel and what they want. The patient-centered approach in long-term care is leading to improved management of a variety of conditions, including diabetes mellitus, pain, and constipation.
The sliding scale in diabetes mellitus management--a one-size-fits-all set of instructions for administering insulin dosages based on specific blood glucose readings--has generally fallen out of favor. When supplemental insulin must be added, it indicates that an opportunity to work with the resident to maximally manage their glucose may have been missed. The same holds true in pain management. When residents must request PRN pain medications, it indicates that they are no longer in control of their symptoms. Surveyors in long-term care settings are, appropriately, citing facilities under F-Tag 309 for not proactively managing pain. A patient-centered approach requires that pain management be continuous and sufficient.
Constipation management fits perfectly within the patient-centered philosophy. Residents frequently complain of constipation, but we cannot always rely on them to ask for relief. To help residents enjoy a more spontaneous, less somatic quality of life, the clinician's goal should be to anticipate and alleviate symptoms whenever possible. Facilities must be proactive in the management of these symptoms and stay ahead of any problems.
Some facilities are moving away from awkward standing orders, for example, to titrate docusate from "once a day to twice a day" or from "two pills a day to three or four pills a day" either on a regular or intermittent basis. Standard practice might also entail adding sennosides to docusate on the occasions when constipation is judged to have worsened. Such policies/orders often result in complex schedules that leave caregivers chasing down symptoms after the fact. A patient-centered approach entails a new proactive standard--one that assesses each resident's individual risk factors, history, and current condition, and attempts to prevent complaints with an appropriate regimen from the start. In this scenario, nursing tasks are simplified and resident discomfort is minimized.
This is a robust, straightforward approach that is relatively simple to execute if consistently implemented throughout a facility. This approach also allows for better recognition when a resident deviates from expectations. If a daily regimen does not achieve a satisfactory baseline, then the members of the care team have a better opportunity to identify any additional problems and suggest alternative therapies to restore quality of life and functional well-being.
When the staff makes the effort to listen to residents and/or their surrogates, they are in a better position to understand what "quality of life" means to them. For instance, iron and calcium are elementally challenging to the well-being of the bowel. When constipation plays against anemia or osteoporosis, residents should be given the opportunity to discuss the benefits and burdens of treating each illness, and empowered to express their preferences for care. Some residents may opt to stop the iron or calcium to avoid the constipating effects.
Policies and procedures can be implemented in a facility, but individual actions also drive change. A patient-centered approach requires both the facility and the practitioner to work in concert to empower and protect the resident.
Editorial by:
Eric G. Tangalos, MD, FACP, AGSF, CMD
Professor of Medicine and Chair (Emeritus)
Primary Care Internal Medicine
Mayo Clinic College of Medicine
Medical Director
Samaritan Bethany Heights Skilled Nursing Center
Rochester, MN
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