Often nutrition is part of restoring health. However, as a person approaches the end of their life, the focus on food and nutrition changes from sustaining life to the person’s quality of life. [1] With this, there is a shift in emphasis to the symbolic and pleasurable aspects of eating and drinking rather than their nourishing purpose. [2] This change in approach can be challenging for families and care providers to accept and put into practice. [2]
Nutrition in palliative care includes adjustments for the person to maintain oral intake as their condition changes or when they have difficulty swallowing (dysphagia). [1-4] As older people near the end of life, their eating and drinking often decrease, but this change can be different for each person and hard to predict. Some may still enjoy eating, while others might feel discomfort, tiredness, or pain when eating. [2]
Why nutrition matters in aged care
Careful attention to nutrition is important as it influences the wellbeing, social engagement, and comfort of the older person and their family. [2,5,6]
Nutrition in aged care is increasingly recognised as an area closely linked to autonomy, consumer agency, and human rights. [6,7] For many people nearing the end of life, the act of eating becomes more about preserving a sense of agency and personal dignity. Standard 6 of the strengthened Aged Care Standards highlights the importance of residential aged care services aligning nutritional care with the specific nutritional needs and preferences of the older person and any issues that impact the older person’s ability to eat and drink. [6]
Decisions about nutrition can represent what is known as the ‘dignity of risk’, that is, acknowledging a person’s rights to make choices about their own care, even when these involve some level of risk. [6] In aged care, this can include a person’s decisions relating to texture of foods when they have difficulty swallowing. [6]
At the end of life, food safety becomes an important consideration. Dysphagia affects approximately half or more of people in residential aged care facilities and those living with dementia. [3,4] This requires careful decisions about food modifications to reduce the risks of aspiration pneumonia, malnutrition, dehydration, and hospitalisation. [3,4]
What the evidence tells us
Taking a person-centred approach, nutritional care includes allowing the person to prioritise certain food and decline others, making their meals for taste and enjoyment rather than nutrition. [5,8,9] Advance care planning and case conferences are key opportunities to discuss changes in an older person’s health and how this may affect eating and drinking. [2,10]
Dietitians and speech pathologists can help with nutritional support and decisions around food and eating. [1,3,9]
Dysphagia
Dysphagia occurs in one half or more of people in residential aged care facilities and those living with dementia. [3,4] When a person has difficulty swallowing, attention can be paid to positioning the person’s body, head and neck; prompting and cueing them to swallow; care with food temperature and volume of each mouthful; and hand feeding. [2,3,8] Texture-modified food and fluids usually involve the use of thickening agents to change the consistency of food or fluids for swallowing safety. [3,4,11]
Care of people with dementia
For people with advanced dementia, maintaining familiar routines around meals and creating a more home-like dining environment can create a sense of comfort with eating. [3,9] Serving familiar foods in small portions on plain plates and cutlery using colour to helps contrast the food from the plate can help. [12] Setting up the room for it to be quiet and well-lit can also help, as well as keeping the table simple and removing distractions. [12]
Texture modification is widely applied to manage swallowing issues, though it may impact daily calorie intake. [4,13] A dietitian can help fortify these diets to add nutritional value.
Texture-modified diets are commonly used to reduce the risk of aspiration. [2-4,9,13] and assistance with eating is often required (e.g. prompting, cueing to swallow, hand feeding). [2]
Cultural considerations
The experience of sharing food and drink can be important for many older people. [7] In many cultures, sharing food fosters feelings of familiarity, connection and belonging, especially for older people. [6,7] Residents value familiar foods that respect their cultural preferences and dietary needs. [5]
Food can be seen as essential for comfort across many cultures. [14] This may lead to believe that people nearing the end of life might be starving or dehydrated. [9,14,15] It is important to address these concerns with care and reassure families that people at the end of life may no longer be hungry or thirsty. [14,15] In this case, they can help with regular mouth care or other aspects of care of their family member (e.g. conversation and therapeutic touch). [8,14,15]
Nutrition in last days
A person’s desire and ability to eat and drink diminishes over a period of weeks to months as their health deteriorates. [15,16] The person's tastes might change and they will not always need to eat at the same times every day. [17] Some may no longer feel hungry or thirsty and as they enter the last days of life, and they are often not able to communicate thirst or hunger. [8,15] They may have difficulty swallowing, a sore or dry mouth, or feel sick. [2,15,17] Some may maintain pleasure from eating or drinking and others may experience discomfort, fatigue, or pain with this. [2] Palliative nutrition involves a flexible approach that accounts for changing appetites, dysphagia, and comfort. [2,3]
Many people at the end of life do not actually feel thirsty or hungry, but they might experience a dry mouth, which can be uncomfortable. The family can help by providing mouth care, especially if the patient has a dry mouth. The family may need to be reassured that the person is not dying because they aren’t eating or drinking; instead, they are not eating or drinking because they are in the dying process. [8,15]
Implications for families
Families play a role in supporting nutrition, and decisions about eating and drinking are common and challenging for families and aged care staff. [2] Clear communication and support from aged care staff can help them make informed choices aligned with the person’s quality of life. [2]
The person's family and carers may fear that the person will die of starvation or dehydration, and they may ask for artificial nutrition or hydration to be started or continued. [15] It can be helpful to explain that these are unlikely to be beneficial when the person is dying and may cause problems that can make the person uncomfortable and prolong their suffering. [15] It can be appropriate to explain that the person is not eating and drinking because they are dying, rather than dying because they are not eating and drinking. [15] The family can be encouraged to participate in feeding routines to promote social connection. [15,16] The family may also be able to assist with mouth care, especially if the person has a dry mouth. [2,15]
Considerations for home care
Families and carers can be encouraged by home care staff to offer foods the person enjoys, in small amounts if appetite is low. Attention to mouth care is important. [2,8]
Discussions with healthcare providers about feeding small, manageable amounts help families understand that eating less is normal in this stage and can ease worry about nutrition. [8]
Page updated 02 January 2025