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How to tailor your intervention to the individual and why this may make an important difference to them and their loved ones
People often experience mouth care problems at the end of life, yet it is an area that can sometimes be neglected. Some nursing staff may be anxious about causing additional pain or distress to a patient, for example, while a 2021 paper in the Journal of Research highlighted lack of relevant nurse training.
Nursing Standard. 38, 10, 71-72. doi: 10.7748/ns.38.10.71.s21
Published: 04 October 2023
The RCN wants to help improve the situation with a series of guides giving advice on best practice for mouth care. In 2021, it published a guide for nursing professionals, and it has now created a new downloadable resource, designed to help patients at the end of life and their support network to understand mouth care issues.
Here, University of Leeds lecturer in adult nursing Suzanne Monks, a steering member of the RCN pain and palliative care forum, and Marie Curie head of clinical education and practice development Melanie Nugent – both co-authors of the new RCN guide – highlight key points in the guidance for nurses.
Why do mouth problems occur in end of life care?
‘Mouth problems can occur for reasons including disease process, medication, and reduction in oral intake, plus fatigue, which can make people less inclined to undertake oral hygiene,’ says Ms Nugent.
Ms Monks adds: ‘People in the last days of life may also be unconscious, and may be breathing more with their mouth open, which causes drying.’
She also highlights the impact of specific medications. ‘Opioids – and also anticholinergics – can increase dry mouth, while anticoagulants increase the risk of gum bleeding. Steroids and antibiotics increase the risk of oral thrush.’
Why is it important to address mouth care problems?
‘Our mouths are essential for communication, eating and swallowing, and without good mouth care this can impact the way we engage with others, and a person’s quality of life,’ says Ms Nugent.
Ms Monks adds: ‘If your mouth is dry it can stop a person being able to communicate or smile, or swallow food and their own saliva.
‘There may be a smell that comes from the patient’s mouth, too, which can be detrimental to family who want to get close to them.’
What are the most common mouth issues?
The most common mouth care issues are dry mouth, painful mouth, bad breath, changes in taste, and infections such as oral thrush, says Ms Nugent.
‘Drooling is also common in people who have a neurodegenerative condition, such as motor neurone disease, Parkinson’s or multiple sclerosis.’
What are the signs that a patient is experiencing a mouth problem?
‘Signs include dryness, redness, bleeding, coating of the mouth and tongue, ulceration or other sores, infection including abscesses, tooth decay, and difficulty swallowing,’ explains Ms Nugent.
Ms Monks also highlights the need to be aware of whether a patient may be experiencing pain when they are eating, when they stop eating, or they only eat soft food because their mouth is sore.
University of Leeds lecturer in adult nursing Suzanne Monks, a steering member of the RCN pain and palliative care forum and coauthor of the latest RCN mouth care guide, recalls how colleague Michelle Pearson, an admiral nurse with the Derbyshire Dementia Palliative Care Team, used taste for pleasure to help one patient with dementia at the end of life.
‘It was a man who had never tolerated mouth care, for different reasons,’ says Ms Monks. ‘But after a conversation about his life, Michelle was told this gentleman loved champagne – so her care team gave him champagne as part of mouth care. She called it the poshest mouth care in Derby.
‘That taste was so important to the patient – it was individualised care for that person.’
How can nurses help prevent and treat mouth problems in patients at the end of life?
Regular mouth assessments are crucial, says Ms Nugent, to identify changes and support early intervention. ‘Mouth care should be part of daily routine,’ she says.
Ms Monks says dentures should be removed and cleaned thoroughly twice a day. ‘And the mouth should be clean, moist and comfortable, with water-based lip balm used as often as needed.
‘Mild, non-flavoured or non-foaming toothpaste may also be better suited,’ she says. ‘If a standard toothbrush isn’t effective, use alternatives, such as a 360-degree or three-headed toothbrush.
‘And there are water-based gels, sprays and mouth cleansers that can help, along with mouth hydrators.’
Ms Monks also suggests using taste for pleasure – giving patients something pleasant as a way to moisten their mouth, using something like a pipette, alongside other mouth care.
‘The pipette sucks up some of the fluid, which might be strong coffee or milky tea with sugar, red wine or whisky – whatever the preferred taste.’
What information can nurses offer families?
‘The RCN-developed resource for patients, family and carers is endorsed by Marie Curie and provides a lot of information on the importance of mouth care,’ says Ms Nugent. ‘This includes how to support someone with their mouth care, and some advice on frequently asked questions.’
Further information
RCN (2023) Mouth care during end of life care: keeping the mouth clean, moist and comfortable tinyurl.com/RCN-mouth-care-guide
Read about two hospital nurses’ inspirational mouth care improvement initiative rcni.com/oral-hygiene
