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Swallowing disorders and aspiration in palliative care: Assessment and strategies for management

Tessa Goldsmith, MA, CCC-SLP
Audrey Kurash Cohen, MS, CCC-SLP
Section Editors
Kenneth E Schmader, MD
Daniel G Deschler, MD, FACS
Deputy Editor
Diane MF Savarese, MD


Difficulty swallowing is a disturbing symptom that occurs in the vast majority of patients with a serious life-limiting illness. In fact, swallowing disorders are part of the natural process at the end of life, irrespective of the etiology. Swallowing disorders occur frequently in patients with malignancies of the upper aerodigestive tract and brain, progressive neurologic disorders such as amyotrophic lateral sclerosis (ALS), Parkinson disease, and multiple sclerosis; dementia; and the general debility that develops in patients with a variety of medical illnesses who are near the end of life. Swallowing disorders are also common after a stroke. Swallowing dysfunction can impact important pleasurable activities (eg, social interaction, communication, intimacy, and food consumption) and impair nutrition. Swallowing disorders are also a major predisposing condition for aspiration, which can compromise quality of life and lead to several pulmonary syndromes, including pneumonia, while contributing to malnutrition and, in some cases, death. Finally, for many patients with a terminal illness, the inability to swallow may represent a pivotal symptom that prompts the decision to consider end of life or hospice care.

Given that dysphagia is a major risk factor for aspiration, care providers, family, and patients themselves would be well served in recognizing the signs of dysphagia, securing airway protection, and determining appropriate routes for providing nutrition and hydration and administering medications in the palliative care setting.

The consequences of aspiration range from no injury at all to pneumonia or asphyxiation from obstruction of the airway. The consequences depend upon the volume of the aspirated material, its chemical composition including bacterial load, and most importantly, on the underlying health status of the patient. The effectiveness of a particular patient’s pulmonary defenses and airway clearance can help determine the implications of aspiration of food or liquid from the airway.

An important point is that even with the assistance of therapeutic interventions, aspiration remains a real risk for patients with swallowing disorders, especially since health status is likely to decline over time. Adherence to recommendations for safe swallowing is challenging for patients and their caregivers. Patients may not wish to change their diet consistency and serious illness may impact their attention and vigilance to performing postural maneuvers. Given these multiple variables, it is challenging for providers to quantify the true aspiration risk even if swallowing is only somewhat impaired.

(See "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology".)

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Literature review current through: Nov 2017. | This topic last updated: Jan 06, 2016.
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