Ep 2 - Small and Tasty - Tempting Someone To Eat

Meals can become difficult at end of life – learn about the signs of when to encourage someone to eat, knowing when to let them be, and meeting the food desires of your patient.
An interview with Dr. Sue MacDonell, a dietitian with a wealth of experience in palliative nutrition.

Written resources to support this podcast can be found here

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Transcript

EP 2: Small and Tasty - Tempting Someone to Eat
 
 Kia Ora and welcome to The Ending Life Well Podcast. This podcast series for carers focuses on advice and practical solutions for carers who have been thrown into the deep end looking after a loved family member or friend in their last days, weeks or months of life. 

 Our episode today is Small and Tasty - Tempting Someone to Eat

 Denise
Hi, I'm Denise van Aalst, a senior palliative care nurse and educator at Otago Community Hospice. And today I'll be talking with Dr. Sue MacDonell, a dietitian with a wealth of experience in palliative nutrition. Hi Sue.

Sue
Kia Ora Denise

Denise
Sue, it's really important, nutrition, can be quite almost a touchy subject really, at the end of life isn't it? Around people wanting to feed, whether people are eating, are they eating the right things? What should they be eating? So, we've got a whole lot that we can really talk about today.

Sue
Yeah, I think it's a subject that everybody has questions about. And also, there's a whole sort of raft of knowledge out there. Some of its really good, and others perhaps not quite so credible. 

Denise
I thought maybe the first thing Sue, is often families worry, that, you know, Dad's just not eating anything anymore, and I'm trying to feed him, and I don't know what to cook.

Sue
yeah, I think this is a common problem that people face. Food is one of those things that everybody has their own history with, their own habits with. And it's also a way that we demonstrate caring and nurturing and being there to support people. If you're cooking for someone who's not well or is nearing the end of life, your responsibility is to cook the food presented in a way that will be attractive and appealing to eat. But you can't make somebody eat. That, that really is the responsibility of the person who you're serving. And that can be quite a hard thing to get your head around, because you know, we all know that if we don't eat, then the body doesn't get nourished, and we don't work so well. But it's actually quite a natural progress. You know, as we near end of life, the body doesn't need as much food, it's not storing food away, it's not using food in the same way that you might when you're really well. So it's taking the cues from that person, by all means ask about food that they might feel like eating. But if you've spent all that time preparing that thing they've asked for and then they don't want it, don't take it personally, because tastes change really quickly, and from almost minute to minute sometimes.

 Denise
Sure. And I think sometimes too, don't they, the person says oh, oh look, I might fancy an omelette. And they’re really actually saying that to please you, rather than the fact that they really want the omelette. But it can be almost heart-breaking when you go away and you cook this wonderful omelette, and then they don't want to eat it.

Sue
And you've put all the effort in, and I guess at that stage, it really is about having that conversation with someone as well, about saying that, if they can't think of anything to eat, that's actually okay. Give them that permission almost to say, I really don't feel like eating or if they say ‘whatever’, take them at their word, and offer some small bits and pieces. But then, it's up to them as to whether they want to actually have that or not.

Denise
I think you made a good point before that actually, as part of this winding down, towards the end of life, we simply don't need to eat as much. So it isn't, the fact that not eating means we are going to die. It means the fact that we're dying means we don't need to eat so much.

Sue
Absolutely, I think that's a really good way of putting it. And I think what that does do, is allow us to shift food from being that necessary thing for nutrition, to perhaps something that provides some enjoyment, might tweak some memories and some conversations, you know. In our family, food is one of those things that we remember, and we associate with the things that we've done or places that we've been to. And maybe that's the way that food should be looked at as we near end of life, that it's more as a comfort, a quality, almost a facilitator in some ways, to actually share time with the person that you're caring with. 

Denise
That’s a great idea Sue. I can just suddenly see, the idea of a family or a group sitting together and sharing something, a food that has meaning or even just the gathering together and actually, if the person who's unwell doesn't eat, they can still enjoy that social experience of sitting there smelling the foods, of that connection with that meal.

Sue
And it also then gives memories for the people who will survive that person, you know, that that's an important time where the family has gathered and has shared. And the other sort of bonus if you like is sometimes when we're not actually presenting food as a way of you have to eat this to stay well and be nourished, the mere fact that food is there, others are picking and eating, you may actually find that the person who's not well, eats a little bit more than they might otherwise, because the focus isn't on having to eat. It's another reason for gathering more than anything else.

Denise
I do remember a lovely lady that I nursed had two daughters, and they had a habit of sitting and watching Coronation Street together. And they ate a certain thing when they did that. Mum, at this point, was pretty much unconscious. But the daughters decided to come in and watch Coronation Street with her and they bought that food and they ate it. And one of the things that they always had, was they drank ginger ale. And so we used ginger ale on mouth swabs to clean mum's mouth and mum seemed really happy with it, didn't have a huge reaction. But it meant so much to the girls that they were just doing this again. So even though mum wasn't eating, she was still a part of that memory for them.

 Sue
I think that's a fantastic example, Denise, and nutrition had no role to play there, food was the vehicle. But, you know, providing nutrients wasn't the aim, and it shouldn't be our focus, I think at times like that.

Denise
And the other thing, Sue, you've talked about enjoying food, sometimes when we get near end of life, the rules go out the window, don't they?

Sue
So those foods we traditionally think of for breakfast, anytime of the day, you know, I'm a great fan of porridge for supper, I've been known to dip my hand in the cereal box and just have that as a snack through the day. And so, I think sometimes rather than asking what people feel like eating, so they have to think of a particular dish or type of food, ask them perhaps if they have a particular texture that they want, do they want something crunchy? Or are they looking for something more soft and easy to swallow. When I feel really unwell, the only thing I want is something salty. And so that's the immediate thing that springs to mind, potato crisps are usually my go to, but they satisfy that crunchy, salty taste that I want when I don't feel well. And people sometimes find it easier to articulate those sorts of things than it is to actually think of a particular food.

Denise
That's a great way of putting it. Because any mother will tell you the chore’s not cooking the evening meal, it's deciding what to have.

Sue
Absolutely.

Denise
So giving people some little options or saying things like, ‘do you fancy, salty, or crisp?’, that's a great way of putting it. 

Sue
It also gives you a little bit more freedom when you're in the kitchen. You might not have the ingredients for something that somebody actually says that they want, but you can find other things that will fit that sort of tactile or taste requirement that they've got. So it's just a different way of refocusing, I guess what we're doing for someone

Denise
Yeah, somebody who's had a quite a rigid diet, perhaps they've had low salt diet or a no sugar diet or something, those things can be relaxed a bit now too, can't they?

Sue
Absolutely. So, you have to think about the reason that somebody might be on one of those, what we call special diets or restrictive diets. And usually that's because of long term health outcomes. So if I think about saturated fat as a good example, often people might have had, you know, 5-10-15 years ago, they may have had some sort of cardiac event, heart event, and so have been recommended a low fat diet. As a terminal illness progresses, or as we near end of life, then the long term benefits of those restrictive diets, they just don't count anymore. And actually some of those nutrients that you might have been restricting, and fat’s a good example, are a really good source of calories and energy or other nutrients. And they also may be the types of foods that people feel like eating so they they're actually more appealing. And really at that stage anything that provides some comfort is better than nothing at all. So within reason, and if you're not sure, then by all means check with either a dietitian or your GP, somebody like that, but you can start to relax some of those restrictions.

 Denise
And that's great. So if somebody's avoided potato chips for years, I know that you often say potato chips are an ideal food at this point, because they're light, they're easy. They often satisfy those mouth needs of taste and salt and fats.

Sue
And they're really energy dense, they give you a lot of calories, as we all know, but they're also finger foods. So you can think of other things along those lines as well, having little bits of chocolate about the place or little snacks like that. Having readymade milk-based puddings, yogurt, custard, those sorts of things in the fridge that people can just dip in and out of, without it having to be a formal meal or a formal snack. And again, they go any time of the day. So, thinking a little bit outside the square is probably the key to supporting someone at this stage.

Denise
And Sue that's a good idea as well, having some things ready made in the fridge, the good old instant pudding, custard, that you can buy these days.

Sue
There's any number of delicious dessert-type things that come in single serves, if you have a look in the chiller section at the supermarket. But even things like some of the dips and the snacks. So perhaps a savoury taste is more liked, you can get cream-cheese based dips or the hummus based dips with the chickpeas. And these are things that can be served in tiny little amounts, they're finger foods, but they can still be really tasty and really enjoyed by people as well.

Denise
Sue, when people have are still wanting to eat, but they're just sort of struggling, you know, it's hard to get enough in - What are some of your tips for trying to pack that nutrition in or make it easier for them to eat?

Sue
One of the first things I'd suggest is actually considering the size of the meals, perhaps that you're serving. A big plate of food can be really quite off putting. And actually maybe serving things on a side plate, just one or two tablespoons of each of the things that you're offering at a meal. Or even putting the meal in the middle of the table, almost like a platter of some sort, and people can then pick and choose the amounts that they want. And not just sticking to the three meals a day. So actually grazing your way through the day, dietitians have the saying of ‘little and often’. And we mean by that as just sort of having snacks or small meals every couple of hours almost. And if you don't have an appetite, sometimes setting an alarm or having a trigger where you think, if there are things happening through the day, then you tie food into those. So that's the first thing, is just thinking about the amounts of foods you're eating, and then making sure that you're getting them regularly through the day.

Denise
And I do like your point there Sue about the meals, because often it's easy to put out a normal meal and say just eat what you feel like but actually the sight of that can simply overwhelm you and remove all appetite, as can the smells of that, so a tiny portion on a bread and butter plate, It looks so inviting.

Sue
It's about having those conversations, actually talking to the person in a gentle sort of way and teasing out what is it that perhaps might be putting them off having meals. As you say, smells, can be one of those things that, especially if someone feels nauseated or doesn't feel on top of the game, then smells can be one of those things that actually trigger them, make it worse. So coming up with some strategies around minimising the smell of food or the odours associated with food is a good idea.

Denise
And then, Sue if we're trying to pack nutrition in, how do we get the most into what we're offering?

Sue
Yeah, in some ways, you almost tip all the Healthy Eating guidelines in reverse. So we hear all of the guidelines around minimising fat, eating less sugar, doing all those sorts of things. But actually, those are the foods that really give us lots of extra calories. And when you're not eating a lot, you want to pack as much into every mouthful as possible. So adding high fat foods in particular, can be a really good way of making the calorie density or the amount of energy that you're getting from food, increased without having to eat too much more. So I guess I'm talking about things like adding extra butter or cream, and that can be just on any food that you find palatable with those sorts of toppings on top. You could add extra things like grated cheese, chopped nuts are a good way of adding in some extra protein and some extra calories as well. Oil, we go to trendy restaurants these days, they have a swirl of oil on top of the soup, but even that sort of thing at home can work quite well because you get the same amount of calories from a tablespoon of oil as you do from a tablespoon of butter. So again, it's just what fits the sort of food that you're eating and your own particular taste preferences. 

Denise
It's a good way of doing that, isn't it? It’s often something I've found, people crave mashed potato and gravy.  You can certainly pack some extra cream and butter into that.

Sue
Or even grated cheese mixed into it is another good way of increasing the energy and the protein. And for every mouthful of mashed potato, you're just getting more nutrients for what you're eating.

Denise
What about products like Ensure or Complan, Sue are they useful?

Sue
They can be useful. I think the first point to make, is you have to like the taste of them. Some people do enjoy the taste and others are perhaps not quite so keen. So the products that you're talking about Denise, are top-ups to meals, they don't take the place of a meal, but they are, Ensure or Fortisip, those sorts of products are nutritionally complete. So they've got all of the nutrients and all of the protein and energy that we need really. My tips I guess, for those products is that they're best taken after a meal so if you take them immediately before they're really filling, they're going to knock your appetite anyway and then less food gets eaten. And they're probably best taken cold for most people because they’re milk based, it brings back connotations of school milk, those sorts of things if they're at room temperature, so best served cold and sometimes I find that you're almost better to take them as a shot or a medicine rather than thinking of them as a food so serving them in much smaller amounts, sort of 80 to 100 mls, five to six times a day. So after each meal or snack, and knocking them back quite quickly, you'll actually find that people can take a little bit more that way. I guess they're also products that can be mixed into other things so you can flavour them in different ways you can make a smoothie using Ensure as a base. You can put Ensure powder into things like porridge or pikelet mixes. You can use the liquid Ensure Plus or Fortisip to actually make the basis of a custard, those sorts of things. So there are different ways of having them.

I guess the other important thing is that you also have to look after yourself. Actually taking care of the carer is quite important. I find that so much focus is put on the food for the person that's not well, that often people neglect to perhaps look after their own nutrition or they'll grab something that's not ideal, perhaps just on the run. And I think putting some of the focus on you and making sure that as a carer, you're actually looking after yourself, it's really important. I always talk about, you know, a car can't run if the tanks empty. And it's exactly the same with people, that if you're not making sure that you're also sitting down to eat, and then that has the added bonus of actually creating a social atmosphere for eating, then you start to sort of not be as well, or not be working at your peak performance.

 Denise
yeah. And if the person you're caring for is not eating, then it can be hard to bother cooking a meal for one can't it? So this is the time for those pre-prepared meals, the stuff in the freezer. 

Sue
you do make a good point that cooking for one person can be really difficult. But it can also be a bit of a time-saver in itself. So if you're cooking, and you're the only person eating, there's inevitably leftovers, and if they're the types of foods that can be frozen or kept for another meal, then that will actually come in handy, on a day perhaps where you have been out and about or you've had lots of people visiting and you haven't had time to do any meal prep, actually having food that you've cooked earlier, frozen, and you can just pull out and reheat and make into a meal, is actually really important as well. So just thinking about serving and single-serve sizes into muffin tins or food pottles that you have emptied, margarine, yogurt, those sorts of things can actually be a really good way of making sure that you also have a meal on hand when you need one quickly.

Denise
And that's a really good point because we've talked in other sessions about the need for caring for the carer, and nutrition’s a really important one, isn't it?

Sue
I've come across carers, who just feel that they're not quite as important when it comes to food. I've even gone so far as to say that, you know, sometimes, a sneaky Ensure for the carer is not a bad thing. So if you've got Complan or some of those other products in the house, then actually it's better to have something like that than not have anything. It's not something I would rely on every day. But they can be really useful for a time when you're absolutely exhausted. Or you just don't want to even think about cooking, having something available that you can just sort of top yourself up with is actually a good idea as well.

Denise
And some of that planning ahead too. So there's two things come to my mind, so one is when people offer to help, ‘what can I do to help?’ Provide a meal. Something that can go in the freezer or a meal that I know is coming on Wednesday night, I don't have to cook, wonderful. But the other thing is that pre planning of things. What are some of the easy things in the cupboard? Like what are your go-to meals, you know, a toasted sandwich, having some bread in the freezer so you've always got some of that. Cheese, eggs. Those easy go-to meals that you can whip something up.

Sue
And having a think about what you would normally cook quickly is actually a really good idea and that means that you'll have the supplies on hand. I think we think about meals as being that traditional meat and three veg but it absolutely doesn't have to be like that. And I guess as our food tastes have evolved over the years we are moving slightly, a little bit away from that pattern. And so we can use things like couscous for instance, that springs to mind, where you just literally have to pour boiling water over it. But you've got a potato replacement, you can make salads out of it, you can add things to it for flavour. But it's instant, it's really just, doesn't take any effort to prepare at all. I think your point around bread and other bread products so you know, English muffins, or buns or flat breads, those sorts of things, they form the basis of a really good meal. 
And then you think about the other elements that you might have on a traditional plate, so salad, or vegetables, and you can have things that are quick and easy that you can put into or on top of bread like that. So frozen vegetables, for instance, absolutely perfect for those sorts of situations, highly nutritious, and quick and easy to prepare. Some of the pre prepared salads now, that you can literally take a handful out of a bag and you've got a salad really made, it's those sorts of things that you don't have to put any effort into, that can be really useful. But your eggs, I mean, eggs for me are the go-to nutrition bullet really. Apart from an egg-free diet, there's no real reason that people need to avoid eggs at all, and they're quick and easy. 
They can be cooked in a multiple of ways. And they're a really good source of protein, soft, easy to swallow, all those sorts of tick boxes really. I mean, they're a huge number of other things, beans, baked beans, canned fish, all those sorts of products are really useful to have as well.

Denise
It's worth, actually, if you've got just a tiny bit of time, and especially for somebody who's maybe looking ahead, knowing that this time is coming but it's not here yet. As you talked before about browsing the supermarket aisles, there's so much there, we tend to go down and we grab what we're used to grabbing what we need. But actually, when you stop and look, there's lots of pre-prepared easy stuff in supermarket aisles isn’t it, so perhaps now's the time to look and think ahead about that, or maybe even start to stock up on a few things.

Sue
Yeah, absolutely and think about things that you're struggling to cook. So it might be the meat dishes. So spend some time at the freezer and have a look at some of the readymade meals that are available that are to your sort of taste preferences. Or you might think, you know, I quite enjoy fish, so have a look at some of the frozen prepared fish, you know, the crumbed items that you can get, that you keep in the freezer, and they literally take 15 to 20 minutes, you know, in the oven, or you can, you can even cook some of them in the microwave these days. So they're good, sort of, just to have there so that you don't even have to think, you just know there's something in the freezer and you can literally grab and go.

Denise
I have to admit, you say eggs, that's always been my go-to if I get home late, eggs, poached eggs on toast, avocado if I've got it, add it in, maybe even tomato if I'm really splashing out and it's satisfying, it's filling. And I know that actually, it's pretty healthy.

Sue
Yeah, absolutely. So I wouldn't thank you for a poached egg but make me an omelette, and then I can put any number of fillings in there that I fancy at the time, or I've got on hand, and it almost becomes the base of the meal. And actually, baked potatoes are my other go-to. So I usually always have some potatoes in the cupboard that we can bake, either in the microwave or if the oven’s on, I'll throw some extras in, that we can then put any number of toppings on.

Denise
Sue, thank you, it's just good to look at some of those things that are important. And I think, you’re acknowledging, just perhaps reinforcing now that when somebody no longer wants to eat, that's okay. But offering them all the things that we can, so we've had some suggestions here today of what people might be offered, and keeping in mind that importance of people eating for themselves as well.

Sue
And taking the emphasis off food as necessary nutrition, and more for comfort and quality of life, I think is really important to remember.

Denise
It is. Sue, thank you very much for joining us today, and thank you listeners. 

This podcast was brought to you by Otago Community Hospice, with support from Hospice New Zealand. If you found this discussion helpful, check out our other episodes of Ending Life Well, a podcast series for carers. You can also find more resources for caring for a person who's dying at otagohospice.co.nz/education