Feeding the family at the end-of-life: An ethnographic study on the role of food and eating practices for families facing death in Portugal

Caregiver burden and eating-related guilt during dysphagia rehabilitation: A descriptive cross-sectional time series study

BACKGROUND

Caregivers of patients with chronic dysphasia experience stress and guilt regarding their eating behaviors. Dysphagia rehabilitation, including minimal oral intake with tube feeding, may be vital for caregivers. This study investigated the effects of dysphagia rehabilitation on caregiver well-being and attitudes toward eating assistance.

METHODS

This cross-sectional questionnaire study was conducted at two dental university hospitals on caregivers of homebound patients with dysphagia undergoing rehabilitation. Caregivers' experiences, with an emphasis on guilt and psychological status, were assessed using the Apathy Scale and Patient Health Questionnaire-5 Depression Scale. Patients were evaluated at the time of the survey and rehabilitation commencement using the Barthel Index and Functional Oral Intake Scale (FOIS). Changes in FOIS scores and caregiver guilt were assessed using the Wilcoxon signed rank test and McNemar test, respectively. The impact of oral intake changes on caregiving motivation was assessed using the Fisher exact test.

RESULTS

Between August 2019 and January 2021, 55 of 100 targeted caregivers responded (median age=64.5 years). A significant difference in FOIS scores was found (median rehabilitation duration=9.7 months). Despite 25 pneumonia cases, 65% of the caregivers continued to encourage oral intake. Guilt decreased from 48% during peak dysphagia to 22% at survey time (odds ratio=0.2, 95% CI=0.04-0.70; P < 0.01). No association was found between caregiving motivation and improved oral intake.

CONCLUSION

Severe dysphagia impacted caregiver well-being, indicating preferences for patients' oral intake. To support caregivers, healthcare professionals should explore and integrate new multidisciplinary approaches into dysphagia rehabilitation strategies.

Evaluation of preventive care for swallowing difficulty through policy changes in Japanese long-term care insurance: analysis of a nationwide claims dataset for long-term care insurance

BACKGROUND

Swallowing/feeding difficulty is a serious hidden health problem in the older population. Although oral intake services based on the degree of this difficulty have been provided and revised in Japanese public long-term care (LTC) insurance since 2006, their implementation has not been examined. We evaluated the impact of policy changes on these services.

METHODS

The nationwide database of LTC service uses in Japan was analysed for three oral intake services: Enhanced Oral Function in daycare facilities whose users were slightly disabled, Maintenance of Oral Ingestion and Transition to Oral Ingestion from tube feeding in residential facilities. Data were extracted for each June from 2015 to 2020 when monthly usage of these services was aligned and each June from 2009 to 2020 for the proportion of users according to LTC insurance certification. The major policy changes were the addition of municipal provision in Enhanced Oral Function and a requirement for multidisciplinary collaboration in Maintenance of Oral Ingestion in 2015. The impact of the medical fee reduction for developing percutaneous gastro-tubing to Transition to Oral Ingestion was also examined.

RESULTS

Between 2015 and 2020, the use of Enhanced Oral Function and Maintenance of Oral Ingestion increased and Transition to Oral Ingestion decreased, resulting in a total increase in use of 275,000 times or approximately 5,000 times per 100,000 among all older adults with LTC insurance certification. Concerning the proportion of users' disability status, the major users of Enhanced Oral Function in 2020 were slightly disabled and independent older adults (70%, up from 55% to 2009). Regarding the major users of Maintenance of Oral Ingestion between 2013 and 2020, care-need level 5 (most severe) decreased by 11%, whereas the total of care-need levels 4 and 3 increased by 9%. The use of Transition to Oral Ingestion, which had been declining, showed a further decline after reduction of the medical fee for percutaneous gastro-tubing in 2014.

CONCLUSIONS

Due to policy changes, Enhanced Oral Function and Maintenance of Oral Ingestion have increased in the number of use among slightly disabled persons. However, this increase may be insufficient given the hidden swallowing/feeding difficulty.

Caring for patients with eating deficiencies in palliative care-Registered nurses' experiences: A qualitative study

AIMS AND OBJECTIVES

The aim was to explore RNs' experiences of caring for patients with eating deficiencies in palliative care.

BACKGROUND

Food and mealtimes are fundamental aspects for wellbeing and social interactions. The worldwide trajectory of ageing populations may result in increased need for palliative care. Everyday life with chronic life limiting illness and eating deficiencies is challenging for patients and families. RNs are key care providers at end-of-life.

DESIGN

A qualitative study with an inductive approach was used.

METHODS

Nineteen experienced RNs in palliative care were interviewed through telephone; interviews were audio recorded and transcribed verbatim. Inductive qualitative content analysis was performed, and the COREQ checklist was used to guide proceedings.

RESULTS

The overarching theme, Supporting persons with eating deficiencies in-between palliative care and end-of-life care, is represented by three sub-themes: Easy to stick with doing, Just being, without doing, is hard and Letting go. Near end-of-life, eating symbolized social belonging and quality of life for RNs, whereas for patients and families, eating symbolized life. RNs tried practical solutions, however, not always according to patients' and families' preferences.

CONCLUSIONS

RNs were well prepared to tackle physical inconveniences and provide support, however, less prepared to encounter existential, psychological and social issues in relation to eating deficiencies. Although RNs stated that human beings stop eating when they are about to die, letting nature run its' course and facilitating patients' transition to end-of-life care was challenging.

RELEVANCE TO CLINICAL PRACTICE

Food and mealtimes represent fundamental aspects of human life and denote central parts in RNs clinical practice in palliative care. The findings can inspire development of a comprehensive palliative care approach to support patients and families. Structured reflection in relation to clinical practice may support and encourage RNs, caring for patients with eating deficiencies, in mastering both doing and being.