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A deadly case of chronic constipation December 2008- The 17th annual report of the Geriatric/Long Term Care Review Committee to Ontario 's Chief Coroner contained the case of an elderly man who died from constipation while living in a long-term care facility. The gentleman was considered to be at high risk for constipation since he was 83 years old and bed ridden. As well, he had long-term use of two medications that contributed to the constipation. The physician in the long-term care facility was either unaware of or did not appreciate the risk this gentleman was at to develop bowel complications, and when the patient developed abdominal pain, no investigation was done to identify the cause. The physician did not appear to know that the patient had had only two bowel movements during his last surviving month. The cause of death in this case was incorrectly reported as "heart disease," however the Review Committee disagrees, and attributes it to constipation. Based on this case, the Committee made the following recommendations: • Health care professionals should be reminded that constipation and obstipation (severe constipation that prevents passage of both stools and gas) are common, preventable and treatable medical conditions that affect the elderly. Untreated, these conditions can be devastating and may even result in death. Once obstipation is suspected, aggressive investigation and treatment should be considered on a case by case basis. As with many geriatric syndromes, obstipation may present either typically (abdominal pain, fecal incontinence) or atypically (confusion, delirium). Health care professionals should be especially aware of elderly patients who present with constipation/obstipation who have associated systemic symptoms (tachycardia). • Health care professionals should be reminded of the importance of not prescribing medications with anticholinergic properties such as Diphenhydramine Hydrochloride and Ranitidine Hydrochloride to elderly patients. When medications such as these are prescribed, their use should be directed toward managing a specific clinical symptom or symptoms and the duration of their use should be minimized based on the elderly patient's clinical response and/or the development of side effects. • Health care professionals should be reminded that disease presentation in the elderly is frequently atypical and may vary greatly from patient to patient. A subtle change in a patient''s clinical status may well indicate that something serious is going on which may not be readily apparent. The underlying cause(s) of these atypical presentations may be missed if the investigator does not obtain an appropriate history, conduct a thorough examination, and judiciously utilize available laboratory and imaging resources. Documentation of the entire process including why certain therapeutic interventions are or are not done should be mandatory. • Health care professionals should be reminded of the importance of conducting a comprehensive investigation in the elderly looking for the cause of newly developed symptoms such as nausea, vomiting, and a change in bowel function, including increasing constipation. • Health care professionals should be reminded of the importance of keeping complete, comprehensive, and accurate progress notes regarding treatment decisions and assessments. Frequently, the Committee finds these notes to be absent, scanty, incomplete, irrelevant, inaccurate, and/or illegible. These notes should meaningfully reflect issues identified by all members of the health care team (including the family) and include the reason why certain treatments are/are not being done in relation to these issues. Institutions need to develop quality assurance programs in order to determine their level of compliance with these programs and to correct any deficiencies where present. • Medical health care professionals should be reminded of the importance and requirement for legible handwriting on the health care record. The College of Physicians and Surgeons of Ontario (CPSO) has a Policy on Medical Records (2005) which reminds physicians that, under Ontario legislation, physician records must be legible and the record must be interpretable by the average health care professional. |