Presentation on theme: "DYSPHAGIA AND ORAL CARE ISSUES AT THE END OF LIFE"— Presentation transcript:
1DYSPHAGIA AND ORAL CARE ISSUES AT THE END OF LIFE Jason Trottier, RN, BNICU EducatorNicole Miller, M.Cl.Sc., SLP(C)Speech-Language Pathologist
2DysphagiaDefinition: 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:StrokeDementiaHead injuryTracheostomyProgressive 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).
3Other Symptoms Associated With Dysphagia Reluctance or refusal to eatReduced appetiteIn palliative patients, these are common physicalsigns associated with approaching deathOn 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).
4Swallowing and Nutrition Goals at End of Life Assess for signs/symptoms of dysphagiaPromote safe intake of food and liquids as desiredSafe chewing and swallowing through:- Increased use of texture modifications- Feeding/swallowing strategiesReduce risk of aspiration/chokingMaximize nutrition and hydration when possibleUnsafe for oral intake- possible NPO recommendation- may not be able to meet nutrition and hydrationneeds orally determine wishes with respect tofeedingUltimate 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
5Educating Families Fears of “starvation” and “dehydration” Ensure they understand the dying processCareful feeding can reduce the risk of aspirationand aspiration pneumoniaArtificial feeding and hydration will not cure theunderlying problem, and will not improve quality oflife in progressive disease processes.No evidence that natural dying (in the absence ofTF) 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
6Comfort Care Offer food and fluid for pleasure and comfort, while minimizing aspiration/choking riskFollow the direction of the patient on how muchfood/liquid is takenProvide favourite itemsMaintain excellent oral hygiene and treatcomplaints 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 hygieneOne of the most common complaints/evident issues is dry mouth
7Secretion Management Xerostomia (dry mouth) Excess Secretions Causes: reduced oral intake, dehydration, medications, mouth breathing, reducedsaliva productionManagement:- medication review (opioids – ie. morphine)- frequent oral hygiene- ice chips, fluids- MoiStir sprayExcess SecretionsCauses: mainly secondary to impaired control of swallow reflex- we swallow reflexively up to 1000x/day- medications (Scopolamine, Glycopyrrolate)- suctioning- oral hygieneOpioids: morphine – used for tx at EOL, therefore pros outweigh cons – need to use mouth care to treat side effectsExcess secretions tend to be very distressing for the family to hear…therefore often rx meds for management
8Oral Care Dehydration causes dry mouth and the sense of thirst We can alleviate this through good mouthcare, offering ice chips and/or fluidsThe condition of the mouth dependson oral care provided, not on the stateof hydration
9Oral 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)
10What Are The Barriers? PERCEIVED MEASURABLE Priority level Gross/unpleasant taskLack of caregiver knowledgeSwallowing problemsMEASURABLELack of suppliesLack of time/staffResistant patientDecreased LOC and/or ability to participatePatients choose to be independentPERCEIVED:Given the multiple needs/demands on nursing, oral care tends to fall as a lower priorityIt is not seen as a pleasant task to have to “dig around” in someone else’s mouthSome staff feel as though they don’t know what’s requiredConcerns with patients being able to manage water/toothpaste/etcMEASURABLESupplies such as toothbrushes are not available on the units; patients/family must bring inBeing understaffed and/or having high patients needsPatients who are resistant/aggressive to oral careSome patients choose to do it themselves, some of these may benefit from assistance, but choose not to accept the help
11Oral Care Why is it important? - maintains comfort - improves communication- easier chewing/swallowing- decreases sensation of dry mouth, dehydration- enhances quality of lifeWhat does it involve?- keep mouth and lips clean, moist- remove debris, dried secretions- clean the tongueFrequency?- minimum every 2 hours- during last days/hours, every minutes[lead into next slide)…Pictures are worth a thousand words…
16Involving the Family Proper training from SLP and/or Nursing staff Get them to bring in supplies recommendedChange the focus- oral care for comfort, not food for comfortSense of being involved and helpingAlways 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)…
17Oral 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 toothpasteNon-alcohol based mouthwash- dip toothette in mouthwash, squeeze excessoff, and clean oral cavityAvoid glycerine-based products more drying
18Oral Care SuppliesSuction toothettes – help apply lubricating/cleaningproducts, and suction out excess material/debrisBite blocksBrush/clean denturesMoistened toothettes to remove dried secretionsfrom the palateTongue depressorFlashlightMouth moisturizer, lip balm
19What’s Happening at Concordia? Oral Care in the ICU… “Back to BASICS”
20ICU began a Patient Centered Improvement Campaign called Back to BASICS
22How 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….”
23How 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.
24Concordia’s ICU Baseline Mean Ventilator Days: 3.2Mean Length Of Stay: 3.9CLI = 0 in 1991 Central line days (2 years) as of February 13th 2013VAP = 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.
25Agreed 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.
26The 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!
27Regional ICU Program Component Regional directive to change to a chlorhexidine oral rinse/toothbrushRegional directive to try to reduce VAP to a goal of 1.8 cases/1000 ventilator days in 2013Concordia’s immediate goal is to reduce VAP rates by 50% to 2.8/1000 vent days
28Other factorsIncreased 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.
29The Plan Complex problem with a simple solution… Place oral care on the Medication Administration Record (MAR).
30The Plan (continued…) Initiated December 3rd, 2012 Oral care written as a physician’s order:Schedule teeth brushing times 0800 andOral care schedule every 6 hours in between teeth brushing and PRN.Compliance- Began tracking weekly ventilator days and product usage.
31Getting Buy-In Transparency ICU staff shown our data and agreed change required.Staff embraced the change.Staff wanted to be accountable for this.
35Questions - 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?
36ReferencesMercadante 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), ppWRHA 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.