In the UK, about 1 in every 20 people will develop colorectal cancer (Office for National Statistics (ONS), 2019). Although the bowel cancer screening programme has reduced colorectal cancer from the third to the fourth most common cancer diagnosis in the UK, it is most commonly diagnosed in a late stage (ONS, 2019). This means that the cancer is less curable and, thus, people are more likely to need palliative care in the first few years after the cancer diagnosis. The reason for late presentation is uncertain, but, with the pandemic, it is known that many people are now presenting with late symptoms of cancer, such as bowel obstruction or bowel perforation. Therefore, it likely there will be an increase in patients who have a stoma and who require palliative care as a result of the pandemic.
The number of people in the UK with a stoma is likely to rise as a result of the pandemic. This is for two reasons: first, surgery to reverse temporary stomas is being delayed, and second, the type of surgery commonly being undertaken has changed. More so than ever before, for people who have emergency surgery, it might be safer to form a stoma rather than risk an anastomotic leak in an already severely compromised patient. The risk factors of colorectal cancer include increased age, smoking, high alcohol consumption, obesity and physical inactivity (Pande and Frazier, 2014). It is recognised that the UK population, in general, is getting older, and obesity is on the increase; thus, it is likely that colorectal cancer numbers will continue to rise.
Stoma care
A stoma is formed to divert either urine or faeces out of the body. A common reason for stoma formation is colorectal cancer and inflammatory bowel disease (Burch and Black, 2017). The most common stoma in the UK is a colostomy, which is formed from the colon and will usually pass soft, formed faeces and flatus. The usual appliance for a person with a colostomy is a closed appliance that is changed between three times a day and three times a week, depending upon faecal output. The other faecal output stoma is formed from the small bowel and is called an ileostomy, which should pass loose faeces and flatus (Burch and Collins, 2021). An ileostomy appliance is emptied of faeces between four and six times each day and changed every day or two. There are fewer people in the UK with a urine output stoma, and this is an ileal conduit or urostomy. A urostomy appliance is drained of urine about four to six times each day and changed every day or on alternate days. All stomas require slightly different stoma appliances or pouches and slight variations in care. It is ideal that patients are taught to look after their own stoma while in hospital after stoma formation, although this may not always be possible. Patients having emergency surgery with an advanced cancer might have many confounding issues that make self-care difficult or impossible, including cachexia and fatigue. Further, towards the end of life, it is possible that people who were previously independent with their stoma care will no longer be able to manage this.
Palliative care
Palliative care is end-of-life care when there is an illness that cannot be cured and support is necessary in the final months or years of life. Palliative care should include active holistic care, although opinions on the exact description of palliative care vary. An international consensus-based definition includes 17 points that relate to palliative care (Radbruch et al, 2020), and it is recognised that palliative care needs to consider other issues such as cultural, spiritual and religious aspects of care (Ferrell et al, 2018). Thus, for community nurses, this might mean being innovative with determining ways to support patients in the management of their stoma and any related complications that may occur towards the end of life. For the purpose of this article, palliative care relates to appropriate action for managing physical issues and supporting patients at the end of life.
Palliative stoma formation
Stomas formed in the palliative setting are more likely to have complications than elective stomas. Complications include mucocutaneous separation, where the skin around the stoma detaches from the stoma instead of healing. This can result in a shallow to deep wound that needs to be carefully managed to ensure healing. The cause of mucocutaneous separation is related to poor nutrition and chemotherapy, for example. Additionally, once wound healing has occurred, there may be a problematic stoma, such as one that is retracted below the surface of the abdominal wall. Retracted stomas may need to be managed by using a convex appliance to ensure that there is a good seal between the skin and the stoma appliance to prevent leakage and skin damage. It is not expected that community nurses will be an expert in stoma care, but it is useful to be aware of what options are available. For additional stoma support, stoma specialist nurses at local hospitals should be contacted.
End-of-life stoma-related issues
There are a number of issues that can occur for community-dwelling people with a stoma in the palliative setting. These include self-care issues, complications occurring as a result of changes in the patient's weight, changes in faecal output, side-effects of chemotherapy, changes in liver function, increased intra-abdominal pressure, as well as anxiety.
Self-care needs
Inability to maintain self-care of the stoma appliance may occur as a result of declining health (Barr, 2015). This might necessitate the inclusion of carers from the family or external agencies to assist. It is likely that carers will require additional teaching from the community or stoma specialist nurse on how to undertake stoma care.
Weight changes
As disease advances, there may be new complications that occur. There may be changes in the abdominal surface due to changes in weight. This might require re-measuring of the aperture in the stoma appliance. The size of the stoma may increase or decrease in size. The community nurse may need to help reassess the aperture size in the adhesive flange. The aperture should be 2–3 mm larger and the same shape as the stoma to prevent skin damage, such as contact irritant dermatitis resulting from a leaking appliance. It is likely that weight will be lost due to reduced appetite, meaning that the stoma and the flange aperture might need to be made smaller. Alternatively, if there is abdominal distension or ascites, there may be an increase in the size of the stoma and, thus, the aperture size may need to be increased.
Changes in faecal output
The faecal output might alter, becoming looser as a result of cancer treatment, such as chemotherapy and/or radiotherapy. If infection is ruled out as a cause for diarrhoea, then medication, such as loperamide, can be prescribed. Loperamide is useful to slow the gut down and, thus, enable increased amounts of fluid to be reabsorbed as fluid passes through the gut. For people with an output of more than about 1200 ml of faeces per day, it might be necessary to commence rehydration solutions; this is particularly useful if levels of electrolytes, such as sodium, are low. If a person with a colostomy is experiencing diarrhoea, as a result of chemotherapy, for example, it is also important to consider changing the stoma appliance. If the faecal output is loose, it is easier to manage with a drainable appliance, to protect the skin from skin stripping as a result of frequent appliance changes. It is important to consider a differential diagnosis for a person with a colostomy and diarrhoea. Liquid, malodourous stool may be due to bowel obstruction resulting in liquid stool that appears like diarrhoea but is, in fact, faecal overflow. In this situation, the blockage needs to be investigated, and laxatives with a drainable appliance may be necessary.
Alternatively, there may be constipation as a result of opioid analgesia. Constipation will appear as hard, dried faecal pellets in the colostomy appliance. Management of constipation can include dietary manipulation to increase oral fluids and fibre or, alternatively, bulking agents or oral laxatives if these can be tolerated by the patient. It needs to be noted that people with an ileostomy do not become constipated; if the output stops from an ileostomy, it is likely to be related to a blockage-this might be a food blockage or there might be a cancer-related bowel obstruction.
Chemotherapy-related complications
Chemotherapy or immunosuppressant therapy can also result in more infections, such as Candida infection (Barr, 2015). Fungal infections can present as painful itching and burning under the stoma appliance flange. This may be treated with topical antifungal powder or sparingly applied topical cream.
There is also a risk of Clostridioides difficile infection for people receiving chemotherapy. If C. difficile or any other infection is suspected, a stool test is needed for microscopy, culture and sensitivity analyses. The stool test will guide the antibiotic treatment needed to resolve the infection.
Another potential side-effect of chemotherapy is peripheral neuropathy. This can be temporary or permanent, but while present, it can result in difficulty in managing the appliance change as dexterity is affected.
Additionally, there may be soreness of the hands and feet associated with chemotherapy, termed palmer-plantar erythrodyaesthesia (Henbrey, 2021). This is painful peeling of the hands and/or feet. To help the skin to heal, it might be necessary to reduce or stop chemotherapy (Wallace and Taylor, 2011).
Liver issues
It is possible that other complications may occur towards the end of life. If the liver becomes compromised with fibrosis or cirrhosis, there is an increased risk of caput medusa (Barr, 2015). Caput medusa is where new blood vessels form to try and compensate for the fibrotic liver. These new blood vessels can appear as skin discolouration, specifically, a bluish colour, around the stoma. The new blood vessels are often weak and can rupture easily, resulting in a bleed through the stoma into the stoma appliance. A large bleed might necessitate a hospital admission for treatment, such as suture ligation. For smaller bleeds, the community nurse can provide advice on stopping bleeding with gentle pressure with a cold compress (Barr, 2015).
For a person with bleeding issues, cleaning at appliance change needs to be undertaken with care so as not to worsen the bleeding. In addition, careful appliance removal is necessary, and this include the use of an adhesive remover (Tilley et al, 2021).
Increased intra-abdominal pressure
For patients with a new or recurrent cancer, there may be an increase in the tumour size, which increases the intra-abdominal pressure. The increased abdominal pressures can result in changes in the abdominal shape or can potentially push on the abdominal content and result in a prolapse of the stoma. A prolapsed stoma is when the bowel telescopes out of the body, becoming longer. It can potentially fill much of the internal capacity of the stoma appliance. In this situation, a larger capacity appliance is useful. Sometimes, the prolapse will return into the body by itself or with gentle manipulation, but, often, it needs to be managed by changing the stoma appliance capacity. However, there is a risk that the prolapsed stoma can become inadvertently damaged and bruised, or bleed. Another way of managing the stoma prolapse is to wear an abdominal support (Barr, 2015), which will reduce the discomfort of a large prolapse when the patient moves.
Anxiety
Anxiety during cancer treatment is common and is likely to be more so in the palliative setting (Henbrey, 2021). However, it is not uncommon for patients to consider that some degree of complication is to be expected with cancer and its treatment. Thus, it can be important for the community nurse to ask pertinent questions about how well the patient is coping and watch for non-verbal signs of pain, for example. Referrals to the palliative care team may be needed if intervention is assessed to be necessary.
Conclusion
A stoma can be formed in a palliative situation, or patients with stoma may beome palliative. There are many interventions that the community nurse can use to improve the care of the palliative patient with a stoma at the end of their life. This might include practical interventions, such as medication advice when faecal output changes or recognising the signs of distress and making appropriate referrals.
KEY POINTS
- There are an estimated 200 000 people in the UK with a stoma
- End-of-life care needs can alter care for people with a stoma
- There are many ways that community nurses can provide advice to patients with a problematic stoma in the palliative care setting
- Patients' anxiety can be reduced by simple measures, such as information provision about why changes have occurred
CPD REFLECTIVE QUESTIONS
- Consider your practice, for patients at the end of their life: what changes in their self-care abilities might occur, and how might you mitigate them?
- Palliative chemotherapy can lead to a number of potential issues; think about what issues you have seen in your stoma patients and ways that you can address them
- What support might you be able to give to carers of a palliative care patient?
- Identify the possible changes in stool consistency that may occur for a palliative patient with a stoma. How can you help to resolve these changes?