Dietary Management of Palliative Symptoms

Symptoms

Common Causes

Suggested Interventions

Taste or smell change¹

1. Medical conditions or aging²:

• Neurodegenerative disease (i.e., Parkinson's disease or Alzheimer's Disease (AD).
• Cancer.
• Age-related changes.

2. Iatrogenic³:

• Chemotherapy
• Medications (i.e., morphine, nonsteroidal anti-inflammatory agents, corticosteroids, etc)⁴.

• Flavour dishes with different condiments (pepper, soy sauce, tomato, or chili sauces), tart flavoured dressings (lemon or lime juices), herbs or spices (chopped spring onions, fried onions, garlic, sambal or pickles)¹.
• Some patients may find food tastes better at cold or room temperature as the smell of food is reduced¹.
• Sugar-ree gums or mints may help to improve bad taste in the mouth⁵.
• Advise patient to omit food or drink that does not taste nice until taste returns. Retry or reintroduce food after a couple of weeks¹.
• If food tastes metallic, use plastic or porcelain utensils⁶.

Nausea and vomiting¹

1. Medical conditions⁷:

• Neurological (i.e., space-occupying lesions or cerebrovascular lesions).
• Gastrointestinal (i.e., obstruction or constipation).
• Metabolic (i.e., renal failure or hypercalcaemia).

2. Iatrogenic⁷:

• Medications (i.e., opioids or antibiotics).
• Chemotherapy.
• Radiotherapy.

3. Psychosomatic (i.e., anxiety or fear)⁷.

• Intermittent nausea associated with early satiety and postprandial fullness or bloating, indicating impaired gastric emptying⁸:
  • Suggest small, frequent meals and snacks over the day.
  • Advise patient to sip warm or cold fluids throughout the day, examples include milk shakes, fruit juices, barley water, chrysanthemum tea or oral nutrition supplements suggested by dieticians (i.e., Ensure, Fresubin or Resource Fruit).
• Persistent nausea, aggravated by the sight and smell of food, unrelieved by vomiting, suggesting chemical causes, activating the chemoreceptor trigger zone⁸:
  • Consider replacing food with strong smells (i.e., fried food or highly spiced and greasy food such as curry and laksa) with dry or plain food (i.e., plain crackers, plain porridge, or clear soup). Serving food cold will help to mask the overwhelming smell.
• Use antiemetic as prescribed.
• Some patients find ginger (ginger powder, ginger tea, or pickled ginger), coconut water⁹ or carbonated drinks¹⁰ helpful to reduce nausea.

Dry mouth (xerostomia)¹

1. Medical conditions¹⁰:

• Infection (oral candidiasis).
• Autoimmune disease (Sjogren's).

2. Iatrogenic^10,11,12,13:

• Oxygen therapy (non-humidified)
• Surgery, chemotherapy or radiotherapy to the head and neck region.
• Medications (i.e., opioids, diuretics or antidepressants).

3. Dehydration, restricted diet/fluid intake¹¹.

• Maintain good oral hygiene (tooth brushing, frequent mouth rinsing and/or water spray.)¹².
• Encourage patient to suck on ice chips or frozen lemon slices.
• Encourage patient to sip warm or cold water throughout the day, ensure a drink is by the bedside of patients which can help minimise disturbance and may result in better quality sleep¹².
• Moisten food with soups, sauces, and gravies.
• Use sugar-free gums and sweets.
• Use mouth gel.

Mouth / throat pain¹

1. Medical conditions¹¹:

• Infection (oral candidiasis).
• Ulceration (Herpes Simplex Virus).
• Iron deficiency (angular stomatitis and glossitis)
• Vitamin C deficiency (gingivitis and bleeding)
• Dry mouth.
• Tumour infiltration.

2. Iatrogenic¹¹:

• Mucositis post chemotherapy or radiotherapy.

3. Dental problem¹¹.

• Consider providing soft, bland, moist food.
• Avoid rough, acidic, spicy, or extremely salty food or fizzy beverages.
• Consider providing food and beverages which are served at room temperature instead of food and beverages with extreme temperature.
• Maintain good oral hygiene.
• Use antimicrobial mouth wash if needed.
• Use medications for fungal infections.
• Avoid mouth rinses that contain alcohol.

Swallowing difficulty¹

1. Medical conditions¹¹:

• Neurological (i.e., amyotrophic lateral sclerosis (ALS), Parkinson disease (PD), or multiple sclerosis (MS)).
• Cancer (i.e. head, neck, brain, oesophageal or stomach cancer).
• Reduced level of responsiveness.
• Dry Mouth.

• Assessment and intervention by a speech therapist is recommended for a texture modified diet and thickened fluids¹⁵.
• Dietician can work with speech therapist to increase nutrients for these diets.

Diarrhoea¹

1. Medical conditions¹¹:

• Colonic or rectal tumours.
• Pancreatic cancer.
• Rare endocrine tumour (carcinoid tumour).
• Gastrointestinal infection (Clostridium Difficile).

2. Iatrogenic¹¹:

• Imbalance of laxative therapy (when laxatives have been increased to clear severe constipation).
• Medications (i.e., antibiotics, antacids, non-steroidal anti-inflammatory drugs (NSAIDs) or iron preparation).
• Chemotherapy.
• Radiotherapy involving the abdomen or pelvis.
• Malabsorption associated with carcinoma of the head of pancreas with insufficient pancreatic secretions, gastrectomy, ileal resection, or colectomy.

3. Formula osmolality and rate of delivery for enteral feeding.

• Withhold stool softeners, laxatives, and monitor.
• Check and treat bacterial-induced diarrhoea.
• Antidiarrheal medication, if appropriate
• Rehydration (orally or by parenteral infusion).
• If diarrhoea is due to short-term lactose (milk) intolerance caused by antibiotics/treatments, try replacing lactose-rich food such as milk, ice cream, and custard with bean products (i.e., soya bean milk, almond milk, or bean curd)⁷.
• Refer to dietician for the recommendation of oral nutrition supplements. Pump-assisted feeding or oral nutrition supplements of lower osmolality (Isocal or Jevity) or partially hydrolysed (Peptamen) may be considered⁷.

Constipation¹

1. Medical conditions^7,11:

• Neurological (Parkinson’s disease, brain tumours, spinal cord compression, autonomic dysfunction, or sacral nerve infiltration).
• Structural (i.e., gastrointestinal, or pelvic tumours, peritoneal metastasis, or adhesions).
• Metabolic (i.e., dehydration, hypercalcemia, hypokalaemia, hypothyroidism, diabetes mellitus or uraemia)
• Pain (i.e., anal fissures or haemorrhoids).
• Psychosomatic (i.e., lack of privacy or comfort because of assistance with toileting, reduced mobility, depression, or sedation).

2. Iatrogenic ⁷:

• Medications (i.e., opioids, tricyclic antidepressants, ondansetron, calcium supplements or iron supplements.

3. Low amounts of food intake, low-fibre diet or dehydration¹⁶.

4. Lack of activity due to prolonged hospitalisation¹⁶.

• Promote hydration, sip liquids throughout the day including water, soup, juice, milk, oral nutritional supplements.
• If medical conditions allow, suggest increasing fibre intake by incorporating 2 servings of fruits and vegetables, add wholegrains or beans to soups. Apples and prunes (dried or juice-form) are high in sorbitol and can help to soften stools¹⁷.
• Encourage some light exercise if possible after meals.
• Use laxatives as prescribed.

Breathlessness¹

1. Medical conditions^11,18:

• Lung tumour.
• Bronchospasm.
• Infection.
• Pleural effusion.
• Pulmonary embolism.
• Heart failure.
• Anaemia.
• Lymphangitis carcinomatosa.
• Large airway obstruction.
• Superior vena cava (SVC) obstruction.

• Try to provide energy and protein rich food or beverages (tuna sandwiches, egg tart, waffle, cake, milk shakes, cheese, yoghurt, oral nutrition supplements, etc).
• Encourage patient to have small and frequent meals.

Loss of appetite¹

1. Multifactorial and can be related to all the symptoms mentioned above.

• Offer patient’s usual favourite food.
• Encourage patient to have small and frequent meals by having energy and protein rich food and beverages.
• Advise patient to sip nourishing fluids throughout the day.
• Avoid drinking with and before meals to prevent early satiety.
• Make mealtimes relaxing and enjoyable (e.g. listen to music, eat with family and friends)