Empowering Patients Navigating Malignant Bowel Obstruction
– Dr Devina Juneja, Delhi
In the intricate landscape of cancer care, especially among those patients confronting advanced gastrointestinal and ovarian cancers with multiple peritoneal metastases, patients are often made to navigate symptoms and treatment decisions which pose formidable challenges for them as well as for healthcare providers.
Malignant bowel obstruction occurs when tumours block the normal transit of contents through the intestines, resulting in a build-up of fluids, gas, and waste material. This blockage precipitates a debilitating array of symptoms, further compounding the physical and emotional burdens already borne by the cancer patient. Consequently, the onset of bowel obstruction represents a significant setback in the patient’s journey, diminishing their ability to sustain oral intake and engage in daily activities.
We recently admitted a 42-year-old female diagnosed with advanced ovarian cancer. Her condition had led to extensive peritoneal metastases, culminating in a malignant bowel obstruction. She experienced severe nausea, persistent vomiting, abdominal distension, and significant discomfort associated with obstipation. These symptoms had drastically reduced her ability to eat and participate in daily activities, which in turn significantly impacted her overall quality of life. Such situations not only undermine a patient’s quality of life, but also presents complex management challenges for palliative medicine physicians, such as:
- Decisions to intervene with measures such as nasogastric (NG) tube placement for decompression is pivotal yet complex. A patient’s overall prognosis, treatment goals, and individual preferences must be meticulously weighed before embarking on invasive interventions. The potential benefits of NG tube placement must be carefully weighed against the risks of complications and the potential impact (both positive and negative) on the patient’s quality of life. While some practitioners advocate for their use due to the symptomatic relief, they can provide by decompressing the stomach and intestines, others are wary of the discomfort and potential complications associated with the procedure. The debate centres on whether the benefits outweigh the risks and how the use of an NG tube aligns with a patient’s overall goals of care and quality of life considerations.
- Importance of the language we use while communicating with patients and their caregivers. The conventional term “Nil Per Oral” (NPO), signifying complete abstention from oral intake, can inadvertently evoke feelings of deprivation and helplessness in patients who are already grappling with the burdens of cancer. When we acknowledge this, we transition towards embracing the concept of ‘bowel rest’ as a more nuanced and empathetic alternative. By reframing dietary restrictions as a period of ‘bowel rest’, coupled with permission for oral sips as tolerated, we help patients to actively participate in their care while preserving their sense of autonomy and dignity.
- Need for ongoing evaluation and adaptation of interventions. Palliative care is dynamic, and the needs of a patient can change rapidly. Regular assessments and adjustments to the care plan is essential to ensure that we meet the evolving needs of our patients. Continuous monitoring of symptoms along with regular communication with the patient and the family, allows us to adjust the care plan as needed.

- Importance of interdisciplinary collaboration in managing malignant bowel obstruction. Working closely with the medical oncologist, surgeon, nutritionist, and other members of the team enhances our ability to provide comprehensive care. This collaborative approach (Figure 1) ensures the adoption of holistic and effective management strategies to address all aspects of a patient’s condition.
We often find ourselves balancing the fine line between medical intervention and patient comfort. In the case of our 42-year-old patient with malignant bowel obstruction, we faced the challenge of deciding whether to insert an NG tube. While the tube provides relief by decompressing the stomach, it may also cause discomfort and distress, along with risks of complications such as irritation and aspiration. Since we emphasize on providing patient-centred care with clear communication to address a patient’s physical and emotional needs, we discussed the potential benefits and risks with the patient and their family to ensure that their values guided their decision-making process. This fostered trust and collaboration between the patient, their family, and the healthcare team. Additionally, we shifted management from traditional NPO orders to a more compassionate ‘bowel rest’ approach which significantly improved the patient’s experience by offering relief and a sense of normalcy. Allowing small sips of water as tolerated, allowed for the patient to maintain their dignity and be comfortable. As palliative medicine practitioners, our paramount objective is to therefore alleviate suffering and enhance the holistic well-being of our patients by focusing on the patient’s physical, emotional, and psychological well-being.
Managing malignant bowel obstruction in patients with advanced cancer, is a complex and multifaceted challenge. Education and training in palliative care is also crucial to keep ourselves abreast of the latest research, guidelines, and best practices to provide the best possible care for our patients. In this case, understanding the nuances of NG tube placement and management, as well as being aware of the latest evidence on bowel rest, played a crucial role in our clinical decision-making process which ultimately resulted in improved patient outcomes.
An ongoing commitment to deliver high quality palliative care, by practicing patient-centred care along with compassionate communication must be the corner stone for each of us to support patients who are navigating a challenging and complicated journey caused due to a serious illness. Palliative care practitioners must prioritize the emotional well-being and preferences of a patient along with one’s medical needs, so that a patient’s overall quality of care improves and we foster a sense of dignity and empowerment for those traversing the challenging terrain of serious illness.