It was an early Saturday morning. Nothing exciting was happening besides some routine admissions and new medication orders for common hospice medications.

That all changed at 10:09 AM. Meet Mary. Mary lived in a nursing home and didn’t really have any family close; most were out of state. Mary had been on hospice for about three months with uterine cancer that had metastasized to her bone. Mary slept the majority of the time and had been declining for the last couple of weeks. The nursing home had called the hospice to report that Mary had become nauseated and was vomiting a little bit of blood. The hospice nurse quickly headed to the nursing home to assess Mary. Both Mary and her family had previously made it very clear they did not want any more hospitalizations.

Upon arrival, the hospice nurse (Anne) completed her assessment and reached out to me. She said, “Jason, I’m here and Mary’s nauseated. She’s vomiting a little like the nursing home reported, but frankly it doesn’t look like blood. It looks and smells like stool. Could she be obstructed?”

After a little more back and forth on the physical assessment (bowel sounds etc.), we concluded that it was a very high likelihood she was fully obstructed. Now one of the many skills that hospice clinicians have is we use history, physical assessments, likelihood percentage, etc., to guide next steps, as we often don’t have things like lab values, or in the case of a full bowel obstruction, imaging. The family was clear they didn’t want any more trips to the hospital, so Anne was like, “What do we do?”

We talked through possible plans with the attending physician. I discussed at this stage we were going to need injectable glycopyrrolate (Robinul), haloperidol (Haldol), and dexamethasone (Decadron). We were going to want to place a couple of subcutaneous butterflies to control the symptoms, as changing her intake status to nothing-by-mouth (NPO) was needed and appropriate. We shared with the family that bowel obstructions can often occur when tumors rapidly grow in the abdominal cavity pushing on the intestines and creating widespread inflammation. Since no more hospital visits was her plan, and they did not want any surgical intervention to repair the obstruction, it was about symptom control and comfort. They were on board with the plan, understanding that it would be wise if they headed into town now to see Mary. The plan was to get the gastrointestinal (GI) tract shut down quickly, stopping the pain, spasms, and vomiting of stool with glycopyrrolate; haloperidol to help combat the nausea; and dexamethasone acutely to reduce some of the tumor burden/inflammation. Our goal was to allow morphine concentrate sublingually for pain and, if tolerated, even move back over to oral liquid concentrated haloperidol and dexamethasone, while keeping the glycopyrrolate subcutaneous.

After starting treatment, her symptoms subsided rather quickly. Upon her family’s arrival, she was well-controlled and comfortable; Mary was reaching the end of her journey.

Sometimes calm Saturday mornings flip rather quickly to vomiting stool and mild panic, but with solid training and an interdisciplinary team, even scenarios like this can be effectively managed in the place where the patient calls home, honoring their wishes.