Many people with life-limiting illnesses struggle with food and nutrition. We explore how dietitians and speech therapists can help patients meet their nutritional needs and find joy in food and drink.

Singapore General Hospital (SGH) Principal Dietitian Ms Lee Miaw Sim (LMS) has a special interest in clinical areas of oncology and nutrition support. Besides providing evidence-based medical nutrition therapy to medical and surgical oncology patients who require individualised nutrition interventions, she also actively participates in the multidisciplinary rounds. Among the patients that she manages, there are some who require palliative care, where the focus may shift from curative therapies to improving comfort and quality of life. Miaw Sim also addresses complex nutritional challenges that arise in advanced stages of illnesses, as well as ensures that nutritional care aligns with the overall goals of palliative care.

Bobbie Jen Lee (BJL) has been a speech therapist for eight years since graduating from the National
University of Singapore with a Master of Science (Speech and Language Pathology). Her years of work
have taken her through a range of institutions and patient populations as she received training and job experience at both restructured and community hospitals. She has been practising as a member of the SGH Speech Therapy Department since 2022 and has a keen interest in paediatric feeding, palliative care,
and post-neurosurgery rehabilitation. Of late, she has also been eagerly exploring the potential for quality improvement through digitalisation.

Why did you choose your vocation and what is your favourite aspect of your role?

LMS: I have always been passionate about nutrition and its impact on health and well-being. In my clinical area of practice in oncology, my role allows me to make a real difference in patients’ lives by ensuring they receive the right medical nutrition therapy before, during, and after treatments, which is so important
in the prevention and treatment of malnutrition and its risk factors as well as managing symptoms of disease, in the hope of enhancing quality of life.

The most rewarding part of being a dietitian is being involved with patients at the most vulnerable part of their lives, especially on their cancer-fighting journey. I find it deeply fulfilling to help patients and their families in navigating the complexities of nutrition and food choices, helping them to feel better with optimal nutrition.

BJL: An undergraduate internship at SGH made me realise how much we take simple everyday pleasures like communicating and enjoying meals with loved ones for granted and how easily those abilities can be stripped away by age, disease, and unfortunate accidents. Being able to share the joy of a patient’s first oral meal after weeks of being fed through a tube or hearing them greet their family for the first time after a period of rehabilitation is thus one of the most rewarding parts of my work. A speech therapist can start the day helping a premature baby learn to feed, guide a middle-aged stroke survivor to swallow and communicate before lunch, and end the workday by ensuring that a palliative patient can comfortably and safely enjoy their favourite drinks in their twilight days.

What are some of the most common problems you help patients address?

LMS: One of the most common issues I help hospice cancer patients with is maintaining adequate nutrition when they have reduced appetite or difficulty eating due to illness- or treatment-related side effects. This might include the prevention or treatment of malnutrition, managing symptoms with specialised dietary management, and adapting diet and nutrition to meet specific medical needs while also tailoring requirements to any preexisting chronic conditions. I also work with caregivers to help them understand the nutrition goals at different stages of disease trajectories and to educate them on meal planning and ways to make eating easier and more enjoyable for their loved ones.

BJL: Speech therapists assess and treat communication and swallowing deficits across the lifespan. Communication problems include aphasia (difficulty understanding and expressing oneself in verbal or written form), dysarthria (difficulty producing clear speech due to muscle weakness), apraxia of speech (problem coordinating muscle movement to produce speech), cognitive-communication deficits (difficulty communicating due to underlying cognitive problems like reduced memory), and dysphonia (an abnormal voice). We also help patients with dysphagia (swallowing difficulties where food, fluids, or both fall into the windpipe instead of the pipe leading to the stomach). In addition, we provide caregiver training and information counselling to those involved in the patients’ care to ensure that they are effectively understood and can have their food and drink safely.

How do difficulties in eating affect a patient and their family’s quality of life?

BJL: Food and drink are an inseparable part of our culture and values and are a means through which we connect with others. Major personal, family, cultural, and religious events are celebrated over meals and sometimes with specific food and drink. Exclusion from participating in these activities can impact patients and their families significantly.

Patients with persistent or chronic dysphagia may experience a lower quality of life simply because it is difficult for them to enjoy the food that their loved ones are having. Some feel self-conscious because of persistent coughing, hacking, or throat clearing, while others are not included at the dining table because they need to be fed through feeding tubes. Furthermore, ingested food or fluids falling into a person’s airway could lead to life-threatening chest infections.

LMS: For the family, watching a loved one struggle with eating can be emotionally distressing, often leading to feelings of helplessness and frustration. By offering proper guidance on nutrition, I can help alleviate some of the stress, ensuring that the patient’s nutritional intake is better optimised to improve comfort and quality of life.

How are your roles different from each other and how do the two of you work together as a team to care for a patient?

BJL: Dietitians assess and determine what and how much food our patients should be taking to meet their nutrition and hydration needs. Speech therapists, on the other hand, recommend the texture and consistency of food and drink that patients may take safely and how they should be fed (e.g., via cup or straw). We also request referrals to each other when relevant concerns arise.

LMS: Once the speech therapist has decided which texture of food and fluid is safest for a patient to consume (using the “International Diet Descriptors – International Dysphagia Diet Standardisation Initiative”), a dietitian will then assess the individual’s requirements (based on preexisting comorbidities, laboratory results, weight, etc.) and work with the patient to put these recommendations into practice.
Dietitians help patients plan and curate individualised meal and snack ideas that balance food preferences, nutrition, and demands of other health issues while keeping to texture recommendations, monitoring their weight, and adjusting requirements and plans to ensure they are meeting their needs for energy and nutrients.

Besides medical conditions and health status, what other considerations do you have when developing a care plan?

LMS: Cultural backgrounds and sensitivity are important aspects in the development of an effective
nutrition care plan for each patient. In this process, I will take their favourite food and their daily dietary intake into consideration, working within the medical and dietary constraints due to their specific conditions or treatments and offering alternatives or modifications that maintain the essence of those cultural food. This personalised approach not only improves nutritional intake but also helps patients maintain a sense of connection to their cultural identity.

Involvement of patients’ loved ones is always encouraged and essential, as they often play a crucial role in supporting the patients in both nutritional and emotional aspects. Whether it is helping with meal preparation or creating a supportive environment, involving loved ones, when appropriate, can ensure a more holistic, patient-centred approach that caters to patients’ needs, preferences and comfort.

Which patients are feeding tubes recommended for?

BJL: Speech therapists typically recommend feeding tubes to patients when we have determined that oral feeding is unsafe or significantly uncomfortable after detailed assessment. A feeding tube may be a temporary measure, depending on the reason for the swallowing issue and how curable it is. The decision to insert a feeding tube becomes more complex, especially when the tube is likely to be permanent or the patient is nearing the end of their life. We explore numerous alternatives and quality of life with patients and their families to help them decide how to proceed. We ensure that the necessary considerations are made when weighing the risks of oral feeding against personal desires surrounding food and drink.

What signals should caregivers look for that indicate a dietitian or speech therapist is needed?

LMS: It is important to monitor changes in appetite and food intake closely, as they can affect patients’ overall nutritional status and quality of life. A noticeable and persistent loss of appetite, rapid weight loss,
or inability to meet nutritional needs due to trouble in keeping food down or food refusal are some signs that necessitate a prompt intervention. Caregivers should seek help from the healthcare team and a qualified dietitian, as these issues can lead to malnutrition, dehydration, and weakened immunity, which may complicate overall health and well-being.

BJL: Patients and their caregivers should look out for prolonged coughing, choking, throat clearing, or shortness of breath while eating or drinking. They may also look out for changes in mealtime behaviour, such as holding food in the mouth or taking considerably longer to finish a meal. These often indicate a swallowing difficulty. In such cases, they should obtain a referral for an appointment with a speech therapist through a polyclinic or hospital doctor.

Please share a rewarding experience at work.

LMS: One of the most rewarding experiences I had was working with a patient who had lost a significant amount of weight and was having prolonged poor oral food intake due to various disease-and treatment- induced side effects. Through a carefully planned nutrition strategy and motivational support, I was able to help the patient improve his nutritional intake and regain some weight and strength, enabling him to continue with his treatment without interruptions due to severe malnutrition. Seeing the physical and emotional improvement brought about by personalised nutrition care was incredibly fulfilling.

BJL: I had a patient who was in his final months battling lung cancer. Having just survived a traumatic stay in the ICU (during which he had a feeding tube inserted through his nose), he was terrified that eating and drinking orally could land him back in the ICU or result in a choking incident. Yet, he was desperately missing his favourite chicken rice. Through careful diagnostics, encouragement, and working with the whole multidisciplinary team to manage his breathlessness, we managed to get him off the feeding tube comfortably and safely. We were all elated that he got to enjoy his favourite chicken rice and many other dishes before he passed away, and the memory of his smile as he took that first bite has stayed with me ever since.

What would be your last meal?

LMS: My final meal would be something comforting and close to my heart, perhaps a simple home- cooked dish, such as ABC chicken soup or fried egg with rice. They are nourishing, soothing, and bring back memories of family meals. This choice reflects my appreciation for the power of food to nourish and refuel, as well as creating comfort and connection with my loved ones.

BJL: My grandma’s tau yu bak (pork braised in dark soy sauce) would be my last meal of choice. Apart from the amazing taste, the dish carries many memories of my childhood. Like many Asian grandmothers and mothers, she expressed her love for me by feeding me when she was still physically able to do so, and understanding this has given the foods she prepared so much more significance.