Oral Complications at the End of Life

CE HOURS Continuing Education1.5

Oral Complications at the End of Life Although dysphagia and stomatitis can have devastating effects on the quality of a patient’s life, there are many ways to manage them.

By Constance Dahlin, MSN, APRN, BC, PCM

en Eldredge, a 76-year-old retired truck driver, has end-stage heart disease and dementia. In the last year, his health has worsened considerably. He is bedbound, extremely weak, and occasionally short of breath. He has a poor appetite and is losing weight. After an evaluation including a complete blood count and computed tomographic scans of the chest and abdomen revealed colon cancer, he received chemotherapy, which ended Ktwo months ago. Mr. Eldredge is being cared for at home by his 75-year- old wife, Jean, and two of their adult children. He complains of dry mouth and says that foods “don’t taste right.” During meals he often coughs and sputters and says his mouth hurts when he eats and that food gets caught in his throat. His wife reports that he often must be coaxed to eat more. Swallowing difficulties (dysphagia) and oral mucosal inflammation (stomatitis) are common in patients who have progressive terminal illness. Perhaps because these conditions are common within the context of a patient’s deconditioning near the end of life, many providers consider them relatively trivial and they’re therefore underreported, underesti- mated, and frequently overlooked for more prominent symptoms such as pain or shortness of breath.1-4 But swallowing difficulties and oral mucosal inflammation can have tremendous adverse consequences for patients and families and should not be dismissed. An impaired ability to eat threatens the patient’s nutritional health. Furthermore, a patient’s nutritional status and a lack of interest in

Constance Dahlin is a nurse practitioner, Palliative Care Service, Massachusetts General Hospital, Boston, and is on the faculty of the Harvard Medical School Center for Palliative Care and the End- of-Life Nursing Education Consortium (ELNEC) project. Contact author: [email protected]. This article is the 14th in a series on palliative nursing that is supported in part by a grant from the Robert Wood Johnson Foundation. Betty R. Ferrell, PhD, RN, FAAN ([email protected]), and Nessa Coyle, PhD, NP, FAAN ([email protected]), are the series editors. The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

40 AJN ▼ July 2004 ▼ Vol. 104, No. 7 http://www.nursingcenter.com Sideways, by Deidre Scherer, fabric and thread, 14.5 13, 1990; photo by Jeff Baird. Part of the series “The Last Year,” which docu- ments the final months of an 89-year-old woman’s life.

To view the entire series, or for more on the artist and her work, go to www.dscherer.com.

food can be deeply troubling to family members. The muscles and requires intact oropharyngeal anatomy lament “If only he could eat more. . .” is often heard and unimpaired nerve conduction, permitting coor- by palliative care staff. If speech is also impaired, it dination between the respiratory and the digestive will be more difficult for the patient to communicate systems. From start to finish, a single swallow takes and to interact. By anticipating and recognizing about 20 seconds and involves four distinct stages. symptoms, nurses can prevent or ease much of this • During oral preparation, the teeth and tongue suffering, either through direct intervention or by break food into small pieces, which are mixed coaching caregivers. with saliva and formed into one or more small boluses. DYSPHAGIA • During oral transit, the lips close to seal the food Dysphagia is defined as difficulty in swallowing boluses inside the mouth, and the tongue propels solid foods or liquids. Whether acute or chronic, the them toward the pharynx. condition affects oral intake and is usually indica- • The pharyngeal stage begins with the involun- tive of some other disease process.4 tary, posterior movement of the tongue. The pas- The act of swallowing involves approximately 50 sage of the bolus stimulates sensory nerves that [email protected] AJN ▼ July 2004 ▼ Vol. 104, No. 7 41 TABLE 1.

Indicators of Dysphagia or Stomatitis Assessment. The goals of care near the end of life must include identifying dysphagia and its underly- Changes in patient behavior at mealtimes ing pathophysiology, as well as determining short- •Avoids eating, or refuses to eat in the presence of others term interventions and helping the patient and •Avoids particular foods or fluids family decide how to safely and effectively deliver •Takes more time to finish meals, leaves more food on plate, nutrition and hydration. requires more fluids to wash down solids Signs and symptoms of dysphagia include diffi- • Chews painstakingly, swallows numerous times for even culty in chewing or in forming a food bolus, drool- small bites ing, coughing during meals, choking on medications • Alters posture while eating or foods, excessive throat clearing, the sensation that food gets stuck in the pharynx or esophagus, Changes in oropharyngeal function shortness of breath during or after eating, regurgita- • Dysarthria or slurred, imprecise speech tion, weight loss, and pain during any stage of swal- •Dry mouth with thick oral secretions lowing. Other indicators of dysphagia may include •Wet-sounding, “gurgly” voice altered cognition resulting from disorders such as •Inability to manage oral secretions; drooling dementia or stroke, behaviors marking a change in • Food residue remains in mouth after attempted swallow attitude toward eating (such as refusing to eat in the •Frequent throat clearing presence of others or avoiding certain foods), and • Coughing or choking during meals vocal changes (such as slurred or gurgled speech). • Nasal regurgitation The following questions may elicit vital information: Changes in swallowing process • When did the patient begin to have difficulty • Reports sensation that food is caught in throat swallowing? • Coughing and choking while eating or drinking • Has the patient recently started a new medication •Oral or nasal regurgitation of solids or fluids or both regimen? • Esophageal pain on swallowing after eating • Does the patient choke on all foods and fluids • Food or fluid in tracheotomy tube regardless of consistency? If not, which consisten- •Inability to manage oral secretions; drooling cies of foods and fluids cause the most difficulty? • Shortness of breath during meals or shortly afterward or both • Does the patient feed himself? • Unexplained weight loss • How has the patient’s experience of eating Source: Dahlin C, Goldsmith T. Dysphagia, dry mouth, and hiccups. In: Ferrell B, Coyle N, changed since becoming ill? editors. Textbook of palliative nursing. New York: Oxford University Press; 2001. Table adapted with permission of Oxford University Press. Physical examination should include inspection of oral mucosa for dryness, lesions, signs of infection, and general hygiene, as well as observation of the carry the signal to the swallowing center in the patient’s swallow. Note changes affecting the voice, medulla oblongata. A peristaltic wave pushes the such as gurgling or hoarseness, and evaluate mouth bolus into the esophagus. closure during speech and at rest. Observe tongue • The esophageal stage involves the peristaltic movement, checking for flaccidity, fasciculation, or movement of food through the upper and lower spasticity. Inspect the mouth and pharynx, looking esophageal areas and into the stomach. for white patches on the tongue or sides of mouth Pathophysiology. During any stage, a disruption and reddened areas on the mouth or gums. Assess can interfere with swallowing. These can consist of the moisture of lips, mouth, and tongue and the con- internal obstruction by cancerous lesions or dition of the teeth. Evaluate cranial nerves V, VII, IX, growths; external compression caused by tumors; X, XI, and XII; this involves assessing the strength diseases that affect the neurologic system (such as and symmetry of facial expressions, lip movement, amyotrophic lateral sclerosis, Parkinson disease, and cheek muscles and observing tongue, soft palate, and dementia); brain damage from strokes; adverse and pharynx movement as the patient says “Ah.”2, 3, 7 effects of treatments such as chemotherapy, surgery, Having the patient first swallow a sip of water and radiotherapy, or medications; conditions causing then a teaspoon of yogurt can help determine the reflux; and general deconditioning associated with effectiveness of his swallow. Note whether he the end stage of any chronic or terminal illness. takes the sip or spoonful on his own or needs a Dysphagia has been found to occur in about 30% cue, and whether he coughs, sputters, or drools of patients with stroke, in 40% to 60% of patients while swallowing.8 with neurodegenerative disease, and in about 20% Difficulty swallowing liquids may indicate poor of patients with cancer.5, 6 Moreover, dysphagia can muscular control, whereas difficulty swallowing cause or exacerbate other problems such as weight solids may indicate a physiologic abnormality such loss, debility, and aspiration pneumonia, and in as a tumor. Gradual onset of dysphagia may indi- some cases it can perhaps hasten death. cate a neoplastic or neuromuscular etiology. Sudden

42 AJN ▼ July 2004 ▼ Vol. 104, No. 7 http://www.nursingcenter.com TABLE 2. Swallowing Difficulties and Possible Etiologies

Patient’s complaint Possible causes Choking on fluids Impairment at any stage of swallow Long, drawn-out meal times Weak chew Fatigue and diminished endurance resulting from deconditioning Esophagitis Nasal regurgitation Impaired closure of posterior palate Difficulty starting to swallow Reduced oral and esophageal sensation Solid foods catch in throat Weak swallow resulting from deconditioning Esophagitis Nasal or oral regurgitation (emesis) Poor esophageal motility after swallow Esophageal obstruction Postprandial taste changes Gastroesophageal reflux Metallic or cardboard taste in mouth Dysgeusia Little or no sensation of any or all of the four Ageusia, dysgeusia basic taste types (bitter, salty, sweet, sour) Pain with swallow Stomatitis Esophageal obstruction Presence of cottage cheese–like patches Candida on oral mucosa Presence of vesicles Herpes simplex Oral ulcerations Stomatitis

Source: Dahlin C, Goldsmith T. Dysphagia, dry mouth, and hiccups. In: Ferrell B, Coyle N, editors. Textbook of palliative nursing. New York: Oxford University Press; 2001. Table adapted with permission of Oxford University Press.

onset may be indicative of psychogenic etiology.1-3, 8 may cause swallowing to require greater effort. In some situations, a referral to a speech–language Finally, depression, which is associated with immo- pathologist may help in evaluation. bilizing fatigue, may be a factor. The case. Mr. Eldredge’s initial evaluation reveals Management. Because eating is often a social hoarseness and vocal slurring. He can’t remember activity, it’s important to consider not only the effi- when his difficulties began; his wife says they began ciency of oral intake and whether dysphagia threat- about two months before he was diagnosed with ens the patient’s safety, but also how eating (or not cancer. An oral examination shows a dry mouth eating) affects the patient’s psychosocial health. and tongue, and there are red patches under his den- Most people prefer to continue eating normally for tures and on the back of his throat. Given a sip of as long as possible. Other routes of food administra- water, Mr. Eldredge takes a long time to swallow, tion such as intravenous nutrition or gastrostomic and when he does, he coughs and sputters. When tube feedings may be pursued when they can no he’s given a teaspoon of applesauce, his favorite soft longer eat. food, some of it spills from his mouth and he again If the cause of the dysphagia is treatable, when takes a long time to swallow. caused by infection, reflux, or obstruction, a trial of A speech–language pathology evaluation reveals appropriate pharmacologic therapy may be recom- poor lip closure, poor tongue control, and reduced mended, particularly if the patient is not imminently swallowing reflex. His difficulty in forming a food dying. Treatment for deconditioning may involve bolus and controlling it when swallowing indicates muscle strengthening. In some cases, assistance with sensory losses. His inability to make the sounds pa eating may help to maximize intake and ensure the and ka is a sign of facial muscle weakness. The patient’s safety. speech–language pathologist’s impression is that There is a growing body of evidence showing many factors cause Mr. Eldredge’s dysphagia. that the use of gastrostomy tubes for feeding Dementia may have affected the neural aspects of patients with dementia neither improves the quality swallowing. Deconditioning (especially of cheek of their lives nor prolongs them.9 Gastrostomy tubes and tongue muscles) and concurrent lung disease aren’t without complications. It’s a common mis- [email protected] AJN ▼ July 2004 ▼ Vol. 104, No. 7 43 TABLE 3. Eating Positions for Specific Swallowing Dysfunctions

Dysfunction Position during swallowing* Reduced posterior propulsion by tongue Head back Unilateral vocal fold paralysis or absence Head rotated to damaged side Reduced pharyngeal contraction Lying down on either side Unilateral pharyngeal pareses Head rotated to damaged side Unilateral oral and pharyngeal weakness Head tilted to stronger side Cricopharyngeal dysfunction Head rotated to either side *Unless otherwise specified, the patient should be in an upright, sitting position.

Source: Galvan TJ. Dysphagia: going down and staying down. Am J Nurs 2001;101(1):37-42.

conception that tube feedings prevent aspiration of mended dietary modifications vary according to the oral and regurgitated gastric secretions, prevent level and severity of dysphagia.12 The “dysphagia malnutrition, reduce infection, improve functional puréed” diet consists of “homogenous, cohesive, status, and prolong survival. Patients who receive puddinglike” foods such as applesauce, mashed tube feedings can and do develop aspiration pneu- potatoes, yogurt, and puddings. The “dysphagia monia and upper respiratory infections, may con- mechanically altered” diet incorporates “moist, tinue to lose weight, and often fail to experience semisolid foods” such as pasta, scrambled eggs, and improved function. Often such patients can’t toler- cottage cheese; the patient must have some chewing ate feedings in amounts large enough to promote ability. The “dysphagia advanced” diet includes soft daily function. Instead they may develop cramping solid foods such as canned fruit, baked fish or and diarrhea, build up gastric residue from the tube chicken, and tofu, and requires greater chewing abil- feeding fluid, and ultimately experience aspiration. ity. For all levels of dysphagia, hard or crunchy If the patient’s prognosis is relatively poor (indi- foods, such as most raw fruits and vegetables, and cating only days or months to live), the benefits and dry foods, such as most bread products and crack- burdens of oral intake should be considered care- ers, should be excluded from the diet. Medication fully. In patients with multiple comorbidities, dys- modifications, such as pill crushing and administra- phagia may indicate that death is near. tion in puréed foods, may also help. Life-prolonging interventions in such cases may be Postural changes can help patients swallow.1-3, 8 inappropriate. The focus should be on providing Sitting upright can help a patient focus on eating for comfort through meticulous oral care, which can be two reasons: it’s the usual position for eating, and it performed by family members and other caregivers. allows gravity to assist in swallowing. Tucking the This involves gentle cleansing of the mouth with a chin immediately after taking a bit of food into very soft toothbrush or oral swab, frequent misting the mouth usually enhances bolus formation since it or swabbing to relieve oral dryness, and frequent increases pressure on the bolus and reduces the application of a water-based lip balm. laryngeal opening. Similarly, raising the chin and Strategies for maintaining safe, adequate oral tilting the head backward as the bolus begins to nutrition may include pharmacologic treatments, move down the esophagus usually improves transit dietary modifications, postural changes, and man- time and facilitates passage into the stomach. If the agement of the environment.1-3, 10, 11 patient’s swallow is stronger (more intact) on one Pharmacologic treatment. Steroids may tem- side—for example, in a patient with unilateral pha- porarily reduce swelling of tissues adjacent to ryngeal paralysis—turning the head toward the obstructive tumors, making swallowing easier. A weaker side may help food move down the intact side trial of steroids, in pill or elixir form, might include of the esophagus, thus decreasing the risk of aspira- dexamethasone (Decadron, Hexadrol, and others) 8 tion. In some cases it may help to have the patient mg PO QID to 8 to 12 mg BID. To help reduce excess turn his head toward the stronger side. For more on production of salivary and bronchial secretions, a positioning the head, see Table 3, above. 1.5-mg scopolamine transdermal patch (Transderm Environmental modifications such as minimizing Scop) may be reapplied every three days. audio and visual stimuli, by turning off the televi- Dietary modifications should be considered in sion for example, can help the patient to relax and terms of the five aspects of food consistency: texture, focus on eating. This is particularly effective with cohesiveness, viscosity, temperature, and density.11 In patients who have dementia or Parkinson disease. 2003 the National Dysphagia Diet: Standardization For some patients, there may be no best solution for Optimal Care was published by the American to the problem of chronic aspiration. A patient and Dietetic Association, based on standards developed his family may weigh the heightened risk of pneu- by the National Dysphagia Diet Task Force. Recom- monia that comes with dysphagia against the pleas-

44 AJN ▼ July 2004 ▼ Vol. 104, No. 7 http://www.nursingcenter.com ure of eating and decide that he wants to continue eating anyway. These preferences will need to be communicated to the nurse and others on the treatment team. Such decisions are difficult for all involved; for more, see “Ethical Concerns in End- of-Life Care,” AJN, January 2003. The case. Mr. Eldredge’s family tries to create a calm, quiet atmosphere during meals by turning off the television or radio and minimizing loud chatter. They take turns helping him sit upright and remind- ing him to chew by touching his cheek gently after he’s taken a bite of food. His diet is modified to include puréed, semisolid, and soft solid meats and Medical Dictionary Photograph: Stedman’s vegetables that he can make into a bolus. Because Contact stomatitis. thin liquids such as water are more likely to be aspi- rated, they’re excluded; liquids that can be thick- reaction to medications, food flavorings, or preser- ened with an agent such as cornstarch are vatives, or as a response to irritants such as heat or permitted. Family members are taught to mist his frictional trauma.13 A burdened immune system mouth frequently with water and to help him tuck may cause such reactions even in a patient who has- his chin after he takes a bite, measures that will help n’t previously shown sensitivity. Those at greatest in bolus formation and transit. risk for stomatitis include the seriously ill, as well as A family meeting is held. Mr. Eldredge and his frail, older adults with poor oral hygiene.14 family talk about nutrition and hydration issues Although it may seem to be a mere inconvenience, that can be expected to arise as his illness pro- stomatitis can be painful and may lead to malnutri- gresses. He says that he loves food and wants to con- tion, volume depletion, electrolyte imbalance, infec- tinue eating “no matter what.” He doesn’t want to tion, and bleeding.15 be moved to a nursing home and he doesn’t want a Pathophysiology. Squamous epithelial cells line feeding tube to be inserted or other life-prolonging the entire GI tract, serving as the first line of defense measures to be taken. The family agrees to respect against infections. Stomatitis is a process whereby his wishes. Everyone understands that if he does persistent damage to these cells occurs; possible develop aspiration pneumonia, it won’t be treated causes are chemotherapy, radiotherapy, and immuno- with antibiotics; rather, the focus of treatment will suppression (a low white blood cell count can lead be on comfort, with acetaminophen (Tylenol) sup- to bacterial or fungal oral infection). Viruses, dehy- positories given to reduce fever and opioids to dration, poor oral hygiene, tobacco, alcohol, and relieve respiratory distress. It’s also agreed that certain medications may predispose the mucosa to when oral nutrition becomes unsafe or ineffective infection and cell damage.16, 17 Symptoms include for Mr. Eldredge, further interventions, specifically initial burning, followed by pain and difficulty swal- tube feeding, will not be initiated. lowing.16 Risk factors for the development of stomatitis include ages younger than 18 or older than 65, STOMATITIS high-dose and intensive chemotherapy and radia- The terms stomatitis and mucositis are often used as tion (especially to the head and neck), impaired synonyms, although they’re not exactly the same. renal function, concomitant conditions such as dia- Stomatitis refers to inflammation of the oropharyn- betes or HIV infection, poor oral hygiene, concur- geal mucosa and can stem from a variety of causes. rent oral trauma such as that caused by ill-fitting Mucositis refers to mucosal inflammation at any dentures, and mucosal irritants such as alcohol and point in the gastrointestinal (GI) tract that’s caused smoking or chewing tobacco.16, 18 However, a corre- by chemotherapy or by radiotherapy to the GI tract. lation between risk factors and incidence has not The term stomatitis is used here for the purpose of been clearly demonstrated.18, 19 addressing a wider population than patients with Sonis has described five stages of mucositis devel- cancer and because this article concerns only oral opment,16 and this analysis can be applied to stom- complications. atitis as well. In stage 1, damage occurs to mucosal Stomatitis, which can be an underlying factor in epithelial cells, resulting in the production of reactive dysphagia, frequently occurs in immunocompro- oxygen species (also known as oxygen free radicals). mised patients, such as those undergoing chemo- During stages 2 and 3, further injury to the epithe- therapy or radiotherapy for head and neck cancers lium and mucosa occur. Ulceration occurs in stage 4. or those with HIV. Oral ulcerations can accompany In stage 5, healing begins. Red ulcerations can any type of cancer, as well as a variety of other con- appear seven to 10 days after an insult. In cancer, ditions. Contact stomatitis can occur as an allergic without infection, stomatitis can heal in two to four [email protected] AJN ▼ July 2004 ▼ Vol. 104, No. 7 45 weeks by itself.20 In patients with HIV, there may be rinses can be costly, and studies have not demon- a recurrence of aphthous ulcers.21 strated healing with their use.19, 22 Assessment for stomatitis includes history taking • diet modifications. Sharp, hard, coarse, spicy, and an inspection of the voice, swallow, lips, salty, and acidic foods that can irritate or damage tongue, saliva, mucous membranes, gingiva, and fragile mucosa and existing ulcers should be teeth. Patients may complain of voice changes or avoided. A bland, low-acid, high-protein diet is painful swallowing. Listening for voice strength or recommended, including milk shakes, bananas, hoarseness may give clues. Examining for cracked applesauce, mashed potatoes, cooked cereals, lips, erythema of the mouth, pain, bleeding, dry soft-boiled or scrambled eggs, cottage cheese, mouth, thick or absent saliva, and abnormal tongue macaroni and cheese, pudding, custard, and gel- surfaces is essential.17 atin. Popsicles and frozen yogurt or ice cream Management. There are no preventive or cura- may be especially soothing. tive therapies for stomatitis; treatment focuses on •preprandial protectants. Single-agent anesthetics palliation of ulcers to promote healing.16 Most such as lidocaine or sucralfate are safest and may research on stomatitis and mucositis has focused on be comforting. “Triple” mouthwash mixes, such populations with cancer, with the following results. as those containing viscous lidocaine, diphenhy- The use of antimicrobial agents has been studied dramine (Benadryl), and loperamide (Imodium), and has been found to reduce infection. Chlorhex- are not recommended because they may cause idine (Peridex and others) is used to control plaque- further ulceration.19, 22 dependent oral disease and is effective against • analgesics. Cryotherapy (sucking on ice chips) Gram-positive and Gram-negative bacteria. Coating may help, as can nonsteroidal antiinflammatory agents such as sucralfate (Carafate) and viscous drugs. Oral or parental opioids may be pre- lidocaine (Xylocaine and others) are thought to scribed if pain is severe. facilitate healing and cell regeneration, although • minimizing oral trauma by, for example, serving studies haven’t consistently demonstrated changes food in “bite-size” pieces or puréed; pills can be in the severity of stomatitis. Antiinflammatory crushed into powder, if it’s appropriate. rinses have not been shown to reduce stomatitis. • oral hydration and lubrication by using a water Most effective is oral rinsing with bland mouth- spray or a saliva substitute and by applying a wash, although further study is needed.19 nonpetroleum lip balm.23 Good oral care for patients at risk for stomatitis The case. When examined, Mr. Eldredge’s mouth should include the following: appears reddened, with ulcers on his tongue and • daily oral assessment particularly under his dentures. His lips are dry and • meticulous oral hygiene and the use of cleansing cracked, and saliva is absent. It’s clear that he has rinses, especially before chemotherapy or radio- not been able to maintain adequate dental hygiene. therapy begins His treatment for stomatitis overlaps with the man- • oral care after each meal and at bedtime, includ- agement of his dysphagia. He has already been ing the use of fluoride toothpaste and the softest placed on a soft diet, which will protect his fragile toothbrush available mucosa. He and his family have been instructed in If stomatitis develops, treatment can include mouth care, and he’ll be assisted with oral hygiene • antibiotics. Fungal infections may appear as cot- after meals and at bedtime. In this case, the use of tage cheese–like lesions and respond to nystatin rinses is contraindicated because thin fluids are dif- (Mycostatin and others) or clotrimazole (Myce- ficult for patients with dysphagia to manage and Mr. lex and others). Viral infections such as herpes Eldredge’s dementia may cause him to forget to spit respond to acyclovir (Zovirax and others); re- a rinse. Instead, oral swabbing with sucralfate slurry current aphthous ulcers can be treated with top- several times a day as a protectant and viscous lido- ical steroids such as fluocinonide (Lidex) 0.05% caine before meals to reduce pain and discomfort is six times daily or clobetasol (Temovate and oth- recommended. Monitoring for new oral vesicles or ers) 0.05% TID.21 Dexamethasone (Hexadrol and lesions will be ongoing. ▼ others) 0.5 mg can be used as a swish-and-spit rinse TID.21 Complete the CE test for this article by • oral rinses of normal saline or sodium bicarbon- using the mail-in form available in this ate solutions; the latter is the safest and gentlest issue or visit NursingCenter.com’s rinse. Studies have found both to be equally “CE Connection” to take the test and find other CE activities and “My CE Planner.” effective in removing oral debris and cleansing the mouth.22 Other rinses include those containing chlorhexidine or sucralfate, available by pre- REFERENCES 1. Dahlin C, Goldsmith T. Dysphagia, xerostomia, and hiccups. scription, and glutamine, an over-the-counter In: Ferrell B, Coyle N, editors. Textbook of palliative nurs- amino acid typically sold in powder form. These ing. New York: Oxford University Press; 2001. p. 122-38.

46 AJN ▼ July 2004 ▼ Vol. 104, No. 7 http://www.nursingcenter.com 2. Bass N. The neurology of swallowing. In: Groher M, editor. Dysphagia. Diagnosis and management. Boston: Butterworth- Heinemann; 1997. p. 7-35.

3. Miller R. Clinical examination of dysphagia. In: Groher M, HOURS editor. Dysphagia. Diagnosis and management. Boston: CE Butterworth-Heinemann; 1997. p. 169-89. Continuing Education1.5 4. Borbasi S, et al. More than a sore mouth: patients’ experience of oral mucositis. Oncol Nurs Forum 2002;29(7):1051-7. GENERAL PURPOSE: To present registered professional 5. Sykes NP, et al. Clinical and pathological study of dysphagia nurses with guidelines on the provision of optimal, conservatively managed in patients with advanced malignant disease. Lancet 1988;2(8613):726-8. appropriate, and supportive management of dys- 6. Schechter GL. Systemic causes of dysphagia in adults. phagia and stomatitis in patients receiving end-of- Otolaryngol Clin North Am 1998;31(3):525-35. life care. 7. Regnaud C. Dysphagia, dyspepsia, and hiccup. In: Doyle D, LEARNING OBJECTIVES: After reading this article and et al., editors. Oxford textbook of palliative medicine. New York: Oxford University Press; 2004. p. 468-83. taking the test on the next page, you will be able to 8. Logemann JA. Role of the modified barium swallow in man- • describe the swallowing process as well as several agement of patients with dysphagia. Otolaryngol Head Neck factors that impede it. Surg 1997;116(3):335-8. • outline an assessment approach for patients who 9. Finucane TE, et al. Tube feeding in patients with advanced have dysphagia, stomatitis, or both. dementia: a review of the evidence. JAMA 1999;282(14): •plan the management of these conditions. 1365-70. 10. Waller A, Caroline N. Dysphagia. In: Groher M, editor. To earn continuing education (CE) credit, follow these Palliative care. Boston: Butterworth-Heinemann; 1997. instructions: p. 155-60. 1. After reading this article, darken the appropriate boxes 11. Bloch A. Nutritional management of patients with dyspha- (numbers 1–15) on the answer card between pages 64 gia. Oncology 1993;7(11 Suppl):127-37. and 65 (or a photocopy). Each question has only one 12. McCullogh G, et al. National dysphagia diet: what to swal- correct answer. low. The ASHA Leader 2003. http://www.asha.org/about/ publications/leader-online/archives/2003/q4/f031104c.htm. 2. Complete the registration information (Box A) and help us evaluate this offering (Box C).* 13. LeSueur BW, Yiannias JA. Contact stomatitis. Dermatol Clin 2003;21(1):105-14, vii. 3. Send the card with your registration fee to: Continuing 14. Mojon P, Bourbeau J. Respiratory infection: how important Education Department, Lippincott Williams & Wilkins, 333 is oral health? Curr Opin Pulm Med 2003;9(3):166-70. Seventh Avenue, 19th Floor, New York, NY 10001. 15. Wojtaszek C. Management of chemotherapy-induced 4. Your registration fee for this offering is $11.95. If you take stomatitis. Clin J Oncol Nurs 2000;4(6):263-70. two or more tests in any nursing journal published by 16. Sonis S. A biological approach to mucositis. Journal of Lippincott Williams & Wilkins and send in your answers to Supportive Oncology 2004;2(1):21-36. all tests together, you may deduct $0.75 from the price of 17. Van Gerpen R. Clinical focus. Stomatitis. Clin J Oncol Nurs each test. 2003;7(4):471-4. Within six weeks after Lippincott Williams & Wilkins 18. Dodd MJ, et al. Risk factors for chemotherapy-induced oral receives your answer card, you’ll be notified of your test mucositis: dental appliances, oral hygiene, previous oral results. A passing score for this test is 11 correct answers lesions, and history of smoking. Cancer Invest 1999;17(4): (73%). If you pass, Lippincott Williams & Wilkins will 278-84. send you a CE certificate indicating the number of 19. Shih A, et al. A research review of the current treatments for contact hours you’ve earned. If you fail, Lippincott radiation-induced oral mucositis in patients with head and Williams & Wilkins gives you the option of taking the neck cancer. Oncol Nurs Forum 2002;29(7):1063-80. test again at no additional cost. All answer cards for this 20. National Cancer Institute. Oral complications of chemother- test on Oral Complications at the End of Life must be apy and head/neck radiation (PDQ). 2004. http://www. received by July 31, 2006. cancer.gov/cancerinfo/pdq/supportivecare/ oralcomplications/healthprofessional. This continuing education activity for 1.5 contact hours is provided by Lippincott Williams & Wilkins, 21. O’Neill J, et al. A clinical guide to supportive and palliative care for HIV/AIDS. 2003. http://hab.hrsa.gov/tools/ which is accredited as a provider of continuing nursing palliative. education (CNE) by the American Nurses Creden- 22. Clarkson JE, et al. Interventions for preventing oral mucosi- tialing Center’s Commission on Accreditation and by tis for patients with cancer receiving treatment. Cochrane the American Association of Critical-Care Nurses Database Syst Rev 2003(3):CD000978. (AACN 11696, category A). This activity is also pro- 23. Stricker CT, Sullivan J. Evidence-based oncology oral care vider approved by the California Board of Registered clinical practice guidelines: development, implementation, Nursing, provider number CEP11749 for 1.5 contact and evaluation. Clin J Oncol Nurs 2003;7(2):222-7. hours. Lippincott Williams & Wilkins is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type 1. *In accordance with Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of this CNE offering may be submitted to the Iowa Board of Nursing.

[email protected] AJN ▼ July 2004 ▼ Vol. 104, No. 7 47