Oropharyngeal Problems (Palliative Care) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Patients with active, progressive and usually advanced disease for which the prognosis is limited
  • Patients with unresolved complex needs that cannot be met by the caring team

This guidance does not cover:

  • Patients under 18 years of age

Assessment

Overview
  • Oropharyngeal problems may affect up to 60% of patients with cancer and can impact greatly on quality of life, both physically and psychologically.
  • Patients suffering from advanced cancer at any primary site frequently present with symptoms and signs of oral disease. Saliva is a major protector of the tissues of the mouth and cancer patients may have risk factors for developing a dry mouth.
  • Patients should be specifically questioned about mouth problems and their mouths examined regularly for signs of treatable oral pathology.
Causes and risk factors
  • Poor oral hygiene
  • Poor oral intake : may relate to debility, dehydration or drowsiness
  • Oral thrush and other infections
  • Local tumour
  • Dry mouth: often aggravated by medications (e.g. opioids, tricyclic antidepressants and anticholinergics), mouth breathing, oxygen therapy
  • Chemotherapy
  • Local radiotherapy can cause decreased saliva and oral ulcers

Management

General mouth care
  • Good mouth care is essential for the well­being of debilitated patients in order to prevent problems before they arise and to control unpleasant symptoms.
  • Ensure that patients are asked about mouth problems and that the mouth is examined
  • Use of a small, soft toothbrush is preferable for mouth care.
  • Foam mouth swabs are an alternative
    • Check the foam head is firmly attached
    • Do not leave swabs soaking; due to a risk of detachment and choking
    • Dispose after a single use
  • Remove dentures at night and clean (using chlorhexidine 0.2% if thrush suspected)
  • If the patient is conscious: support them to brush their teeth and perform mouth care at least twice a day.
  • If the patient is unconscious:
    • Provide mouth care hourly
    • The oral mucosa, teeth and tongue are cleaned using a soft toothbrush or foam sticks moistened with water.
    • If the mouth is particularly dry a thin film of water soluble lubricating jelly may be applied to the oral mucosa with a foam stick.
Dry mouth
  • It is important to continue general mouth care
  • Review reversible causes including medication
  • Encourage frequent sips of cold, unsweetened drinks. Sucking ice may also be an alternative
  • Advice natural salivary stimulants such as sugar-free chewing gum, sugar free fruit pastilles or boliled sweets
  • Artificial saliva substitutes
    • There are many products available and choice may dictated by patient preference and tolerance
    • Biotene Oral-balance ®, AS Saliva Orthana ® (contains pork)
  • Saliva stimulants (such as Pilocarpine) may sometimes be used, if the above measures are not effective. Please seek specialist advice.
Oral candidiasis
  • It is important to continue general mouth care
  • May present as a dry mouth, loss of taste, reddened tongue, soreness, dysphagia, angular cheilitis or asymptomatically.
  • Consider whether there are any reversible causes, such as steroid use (oral/inhaled), dry mouth, dehydration, poor oral hygiene, mucosal damage.
  • Remove and clean dentures using chlorhexidine 0.2% soaks. Dentures must be rinsed thoroughly prior to use.
  • There are a number of options for drug management:
    • Nystatin oral suspension
      • 100,000 units/ml, 5ml QDS for 7 days.
      • Hold in the mouth for 1 minute and then swallow
      • Avoid concomitant use of chlorhexidine.
    • Fluconazole (capsules of suspension)
      • 50mg daily for 7 days.
      • Longer courses or higher doses may be needed for immunosuppressed patients.
      • If eGFR is less than 50, give the usual initial dose then halve the dose
      • Beware of potential interactions due to inhibition of various cytochrome P450 enzymes
    • Alternative options may include Mitoconazole gel and Itraconazole
Sore or ulcerated mouth
  • It is important to continue general mouth care and to treat dry mouth
  • Look for an underlying cause: infection, mucositis post chemotherapy or radiotherapy, tumour, aphthous ulcer, vitamin deficiency
  • Simple 0.9% saline mouth washes can be soothing & help to maintain oral hygiene.
  • Gelclair ® oral gel can also be used as a mouthwash
    • Topical analgesia:oSoluble paracetamol to gargle and swallow
    • Benzydamine 0.15% oral rinse (Difflam ®)
    • Choline salicylate (Bonjela ®)
  • Topical anaesthetic
    • Lidocaine (Xylocaine ®) 10% spray
    • Apply using a cotton bud directly to the affected area
    • Avoid analgesia to the pharynx pre oral intake
  • In severe oral pain systemic preparations may be required. Please seek specialist advice.
  • Topical corticosteroids may be required to treat apthous ulcers
  • Chlorhexidine 0.2% mouthwash can be used to treat and prevent oral infection

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details for further information

Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Supporting Informtation

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL9 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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