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Dysphagia is commonly reported in the palliative care setting* (Sykes, 2003; Stringer, 1999) and can cause dehydration, malnutrition and aspiration pneumonia (Groher, 1997). Of the speech pathologists surveyed*, all reported that the majority of referrals they received in the palliative care setting related to swallowing problems. It is important to remember in the palliative care setting "the primary goal is improvement of the quality of life, rather than prolonging life" (Borasio, Voltz & Miller, 2001, p. 835). Therefore the course of assessment and intervention may alter as time progresses. Assessment"Assessment of swallowing and feeding disorders forms the basis for developing management strategies" (American Speech-Language-Hearing Association (ASHA), 2001, p. 182). In the palliative care setting such assessments may assist with the move from the treatment of dysphagia to the prevention of complications and dysphagia risk management (Eckman & Roe, 2005).Dysphagia diagnosis can take numerous forms. The commonly reported tools used by speech pathologists in the palliative setting* were bedside evaluation and videofluroscopic swallowing study (VFSS). Other methods include self report, clinical observation and fibre-optic endoscopic evaluation of swallowing (FEES) (Reilly, 2004). Videofluroscopic swallowing studies (VFSS) are commonly used in the diagnosis of dysphagia (Reilly, 2004; ASHA, 2001). However, it is reportedly used less frequently than bedside evaluation when working in the palliative care setting (Pollens, 2004). The VFSS allows for "direct visualisation of (the) oral, pharyngeal and oesophageal cavities" (Reilly, 2004, p. 148) and evidence of pooling of food or fluid in the valleculae and/or aspiration can be observed. Logemann (1983, as cited in Reilly, 2004) believes VFSS are beneficial as they show aspiration which cannot reliably be detected by bedside evaluation alone. However in the palliative care setting the invasive nature of the procedure may be thought of as inappropriate (Pollens, 2004). InterventionIntervention for dysphagia is usually prescribed individually and is dependent upon the aetiology, progression of condition and precise nature of the client's problem (Reilly, 2004). Numerous options are available but those preferred by speech pathologists in the palliative care setting* are diet modification and postural changes.Diet modification consists of changes to the viscosity, texture, volume, taste and temperature of a client's food and fluid (Hyland, 2003; Groher, 1997). Hyland (2003) reports that diet modification has been widely used as a treatment for dysphagia. Langmore (1999, as cited in Reilly, 2004) also suggests that diet modification is one of the most significant contributions a speech pathologist can make to impact upon a client with dysphagia. "Modification of bolus volume and viscosity can compensate for inadequate swallowing function" (ASHA, 2001, p. 184). In palliative care the focus remains on client comfort and quality of life (Borasio, Voltz & Miller, 2001). Therefore any modification to food and fluid is undertaken in consultation with the client. As speech pathologists have suggested*, clients should be actively involved in their diet choices and intervention should remain focused on improving the quality of life, not prolongation of life (Borasio, Voltz & Miller, 2001). The available evidence for diet modification is centred around tradition and clinical opinion. There remains little compelling research evidence to support its use (Hyland, 2003). It is suggested that diet modification is rarely used alone (Hyland, 2003), but rather used in conjunction with postural changes and swallowing manoeuvres (Hyland, 2003). There are a number of suggested manoeuvres which aim to improve the client's swallowing safety by reducing the risk of aspiration (Paik & Han, 2002). A list of some of these manoeuvres and the techniques can be found at: http://www.voiceandswallowing.com/swalltreatment_1.htm It is recognised that clients in a palliative care setting may use "oral intake for pleasure as opposed to survival" (Eckman & Roe, 2005, p. 180). Meal times should be an enjoyable experience and it has been reported that symptoms of dysphagia result in clients avoiding eating with others (Ekberg, Hamdy, Woisard, Wuttge-Hannig & Ortega, 2002). With the primary focus of palliative care being the improvement of quality of life (Borasio, Voltz & Miller, 2001), clients should be encouraged to participate in the social aspects of meal times and "promote positive feeding interactions for family members" (Pollens, 2004, p. 694). Intervention by a speech pathologist to suggest modifications to food and fluid and to offer strategies for postural changes and swallowing manoeuvres can assist in the minimisation of risks and symptoms of aspiration and maximise the client's comfort and satisfaction when eating and drinking (Eckman & Roe, 2005; Pollens, 2004). Another possible feeding option for a client with dysphagia is that of alternative feeding methods such as a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) (Paik & Han, 2002). These methods are a valid alternative as they allow the food and fluid to "bypass the oral cavity and pharynx" (Paik & Han, 2002, p. 262). All clients should be informed regarding these options however, speech pathologists report* that this is not commonly implemented for their clients' with palliative needs as it may be deemed inappropriate (Eckman & Roe, 2005). It is often a difficult and ethically complex decision as to whether to continue oral feeding and/or initiate a non-oral feeding method (see ETHICS section). ReferencesAmerican Speech-Language-Hearing Association (ASHA) (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report. ASHA 2002 Desk Reference, 3, 181-199. Borasio, G., Voltz, R., & Miller, R. (2001). Palliative care in amyothophic lateral sclerosis. Neurologic Clinics, 19(4), 829-847. Eckman, S., & Roe, J. (2005). Speech and language therapists in palliative care: What do we have to offer? International Journal of Palliative Nursing, 11, 179-181. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., & Ortega. P. (2002). Social and psychological burden of dysphagia: Its impact on diagnosis and treatment. Dysphagia, 17, 139-146. Enderby, P., & Petheram, B. (2002). Has aphasia therapy been swallowed up? Clinical Rehabilitation, 16, 604-608. Groher, M. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston: Butterworth-Heinemann. Hyland, P. (2003). Easy to chew means easy to swallow- or does it? The place of diet modification in the management of dysphagia. Asia Pacific Journal of Speech Language and Hearing, 8, 131-145. Owen, W. (2001). ABC of the upper gastrointestinal tract. Dysphagia. British Medical Journal, 32, 850-853. Paik, N., & Han, T. (2002). Critical review on the management of adult oropharyngeal dysphagia. Critical reviews in Physical and Rehabilitation Medicine, 14, 247-272. Pollens, R. (2004). Role of the Speech-Langauge Pathologist in Palliative Hospice Care. Journal of Palliative Medicine, 7, 694-701. Reilly, S. (2004). The evidence base for the management of dysphagia. In S. Reilly, J. Douglas & J. Oates (Eds.), Evidence Based Practice in Speech Pathology (pp. 140-184). London: Whurr Publishers. Seikel. J., King. D., & Drumwright. D. (2000). Anatomy and Physiology for Speech, Language, and Hearing. (2nd ed.). San Diego: Singular Publishing Group. Stringer, S. (1999). Managing dysphagia in palliative care. Professional Nurse, 14, 489-49. Sykes, N. (2003). Gastrointestinal symptoms. In R. Morrison & D. Meier (Eds.), Geriatric Palliative Care (pp. 256-270). New York: Oxford University Press. | ||||||||||||||||||||||||||||||||||
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