1. DYSPHAGIA AND ORAL CARE ISSUES AT THE END OF LIFE
Jason Trottier, RN, BN
ICU Educator
Nicole Miller, M.Cl.Sc., SLP(C)
Speech-Language Pathologist

2. Dysphagia
Definition: Difficulty chewing or swallowing which may be the result of reduced muscle strength, sensation, anatomical abnormalities, or the awareness of “how to swallow”.
Associated Causes:
Stroke
Dementia
Head injury
Tracheostomy
Progressive neurological conditions (PD, MS, ALS)
You can’t talk about oral care without discussing dysphagia, as many of our patients at end of life have swallowing difficulties. SLP’s are involved with assessment and management of dysphagia, and our role changes as a patient progresses towards end of life care. Regardless of whether a patient is in the last weeks or last days of life, much of what we do is provide education to the patient/family.
So to start off, an explanation as to what dysphagia is, and how SLP plays a role.
Dysphagia = difficulty eating.
Many causes – listed here – most commonly we see the above conditions in acute care. SLP assesses to determine if texture modifications are needed (solids and/or liquids), and recommends what is safest for patient to eat/drink to minimize risk of aspiration pneumonia (define).

3. Other Symptoms Associated With Dysphagia
Reluctance or refusal to eat
Reduced appetite
In palliative patients, these are common physical
signs associated with approaching death
On top of oral (mouth) or pharyngeal (throat) swallowing issues, we may also see patients refusing to eat and/or having reduced appetites. This is believed to be a strategy/process that allows an individual to die with less suffering (person senses end of life is near).

4. Swallowing and Nutrition Goals at End of Life
Assess for signs/symptoms of dysphagia
Promote safe intake of food and liquids as desired
Safe chewing and swallowing through:
- Increased use of texture modifications
- Feeding/swallowing strategies
Reduce risk of aspiration/choking
Maximize nutrition and hydration when possible
Unsafe for oral intake
- possible NPO recommendation
- may not be able to meet nutrition and hydration
needs orally  determine wishes with respect to
feeding
Ultimate goal is to reduce risk of choking/aspiration, and make the patient as comfortable as possible at the end of life.
Balance between QOL and safety

5. Educating Families Fears of “starvation” and “dehydration”
Ensure they understand the dying process
Careful feeding can reduce the risk of aspiration
and aspiration pneumonia
Artificial feeding and hydration will not cure the
underlying problem, and will not improve quality of
life in progressive disease processes.
No evidence that natural dying (in the absence of
TF) causes discomfort (Post, 2001).
Fears of starving and dehydration can cause family members a lot of stress.
- As Chelsa discussed, dehydration actually offers benefits to the dying patient.
Need to explain how to minimize aspiration risk

6. Comfort Care Offer food and fluid for pleasure and comfort,
while minimizing aspiration/choking risk
Follow the direction of the patient on how much
food/liquid is taken
Provide favourite items
Maintain excellent oral hygiene and treat
complaints of dry mouth (xerostomia)
Essentially, the SLP role in comfort care is two-fold: (1) dysphagia assessment and management and (2) promotion of excellent oral hygiene
One of the most common complaints/evident issues is dry mouth

7. Secretion Management Xerostomia (dry mouth) Excess Secretions
Causes: reduced oral intake, dehydration, medications, mouth breathing, reduced
saliva production
Management:
- medication review (opioids – ie. morphine)
- frequent oral hygiene
- ice chips, fluids
- MoiStir spray
Excess Secretions
Causes: mainly secondary to impaired control of swallow reflex
- we swallow reflexively up to 1000x/day
- medications (Scopolamine, Glycopyrrolate)
- suctioning
- oral hygiene
Opioids: morphine – used for tx at EOL, therefore pros outweigh cons – need to use mouth care to treat side effects
Excess secretions tend to be very distressing for the family to hear…therefore often rx meds for management

8. Oral Care Dehydration causes dry mouth and the sense of thirst
We can alleviate this through good mouth
care, offering ice chips and/or fluids
The condition of the mouth depends
on oral care provided, not on the state
of hydration

9. Oral Care
“Despite being an essential element of caring for palliative care patients, oral care may still be deemed insignificant or of minor importance when considering overall disease load.”
(Rohr et all, 2010)

10. What Are The Barriers? PERCEIVED MEASURABLE Priority level
Gross/unpleasant task
Lack of caregiver knowledge
Swallowing problems
MEASURABLE
Lack of supplies
Lack of time/staff
Resistant patient
Decreased LOC and/or ability to participate
Patients choose to be independent
PERCEIVED:
Given the multiple needs/demands on nursing, oral care tends to fall as a lower priority
It is not seen as a pleasant task to have to “dig around” in someone else’s mouth
Some staff feel as though they don’t know what’s required
Concerns with patients being able to manage water/toothpaste/etc
MEASURABLE
Supplies such as toothbrushes are not available on the units; patients/family must bring in
Being understaffed and/or having high patients needs
Patients who are resistant/aggressive to oral care
Some patients choose to do it themselves, some of these may benefit from assistance, but choose not to accept the help

11. Oral Care Why is it important? - maintains comfort
- improves communication
- easier chewing/swallowing
- decreases sensation of dry mouth, dehydration
- enhances quality of life
What does it involve?
- keep mouth and lips clean, moist
- remove debris, dried secretions
- clean the tongue
Frequency?
- minimum every 2 hours
- during last days/hours, every minutes
[lead into next slide)…
Pictures are worth a thousand words…

12. WRHA Oral Care Initiative Proposal

16. Involving the Family Proper training from SLP and/or Nursing staff
Get them to bring in supplies recommended
Change the focus
- oral care for comfort, not food for comfort
Sense of being involved and helping
Always have to remember to put ourselves in their shoes…if it was your family member - What would you do? What would you want for them? What would you want/need from the team treating that person?
On that note, keep comfort, compassion, and caring in mind…(last slide)…

17. Oral Care Supplies Soft bristled toothbrush Non-foaming toothpaste
- helps remove debris from teeth, tongue, gums,
buccal cavities
- avoid Sodium Lauryl Sulfate – drying effect
- specialized products - Biotene toothpaste
Non-alcohol based mouthwash
- dip toothette in mouthwash, squeeze excess
off, and clean oral cavity
Avoid glycerine-based products  more drying

18. Oral Care Supplies
Suction toothettes – help apply lubricating/cleaning
products, and suction out excess material/debris
Bite blocks
Brush/clean dentures
Moistened toothettes to remove dried secretions
from the palate
Tongue depressor
Flashlight
Mouth moisturizer, lip balm

19. What’s Happening at Concordia? Oral Care in the ICU… “Back to BASICS”

20. ICU began a Patient Centered Improvement Campaign called Back to BASICS

21. Plan

22. How is Oral Care Palliative Care in the ICU?
WHO definition of Palliative Care:
“…an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through prevention and relief of suffering….”

23. How will we improve quality of life for our clients?
ICU specific quality care markers:
- Ventilator days
- Length of stay
- Hospital Acquired Pneumonia (HAP)
- Ventilator Associated Pneumonia (VAP)
- Central Line Infection (CLI)
Oral care is part of a quality bundle shown to decrease Ventilator days, HAP and VAP.

24. Concordia’s ICU Baseline
Mean Ventilator Days: 3.2
Mean Length Of Stay: 3.9
CLI = 0 in 1991 Central line days (2 years) as of February 13th 2013
VAP = 5.6/1000 ventilator days in (double the regional average)
In Canada, a VAP represents $11,000/case in avoidable costs.
$61,600 (estimated) avoidable costs in calendar year.

25. Agreed upon ICU standards
Teeth should be brushed twice daily.
Oral Care should be performed at least every 4 hours and as needed (prn).
Assumption was we were at a 75% compliance rate.

26. The Facts ICU oral care comes in a 24 hour kit.
One (1) kit should be used for every ventilator day.
Concordia ICU had 632 ventilator days in fiscal year.
Concordia ICU used 80 kits in the same time frame.
Teeth brushing was roughly at a 15% compliance rate!

27. Regional ICU Program Component
Regional directive to change to a chlorhexidine oral rinse/toothbrush
Regional directive to try to reduce VAP to a goal of 1.8 cases/1000 ventilator days in 2013
Concordia’s immediate goal is to reduce VAP rates by 50% to 2.8/1000 vent days

28. Other factors
Increased cost = roughly $15,000 per year in oral care supplies.
Reviewed the literature found this was not a unique problem.
Contacted researchers in the USA and Canada.

29. The Plan Complex problem with a simple solution…
Place oral care on the Medication Administration Record (MAR).

30. The Plan (continued…) Initiated December 3rd, 2012
Oral care written as a physician’s order:
Schedule teeth brushing times 0800 and
Oral care schedule every 6 hours in between teeth brushing and PRN.
Compliance
- Began tracking weekly ventilator days and product usage.

31. Getting Buy-In Transparency
ICU staff shown our data and agreed change required.
Staff embraced the change.
Staff wanted to be accountable for this.

32. The Early Results
Baseline

33. As of February - 75% compliance

34. Ongoing Challenges Product changes/Switch to chlorhexidine.
Ongoing education.
Physicians forgetting to write orders.
Solution 1: Standing orders updated.
Solution 2: Preprinted MAR’s developed.
Continued auditing.
Maintaining momentum.

35. Questions - Outside of the ICU
Should oral care be on the MAR be hospital wide?
Are there certain groups (i.e. end of life) where using the MAR would be an option?
Limited equipment - suction toothettes and toothbrushes in ICU only.
Should we provide toothbrushes to all patients?
Finances - cost effective vs. cost neutral vs. cost deficit?

36. References
Mercadante S. Dry mouth and palliative care. European Journal of Palliative Care ; 9(5), pp Rohr Y, Adams J, Young L. Oral discomfort in palliative care: Results of an exploratory study of the experiences of terminally ill patients. International Journal of Palliative Nursing ; 16(9), pp
WRHA PCH Speech-Language Pathology Program. Feeding and Swallowing Issues Related to End of Life: information for Caregivers Adapted from: Communication and Nutrition, CTS SLP Program (2002).
Hallenbeck, J. Palliative Care Perspectives. Chapter 5: Non-Pain Symptom Management. Oxford: Oxford University Press, Print.