Feeding and medicines • Oral feeding • Enteral tubes • Parenteral nutrition • Safe administration in palliative care

Feeding the Patient and Safe Drug Administration in Palliative Care

A practical nursing and emergency-medicine guide to nutrition, swallowing, tube feeding, medication routes and end-of-life decisions

Learning objectives

• Assess nutrition, hydration, swallowing, aspiration risk, comfort, goals and caregiver capacity.
• Describe oral, enteral tube and parenteral feeding, including indications, preparation, procedures and complications.
• Safely administer medicines by oral, tube, subcutaneous, intravenous, buccal, transdermal and rectal routes when appropriate.
• Prevent aspiration, tube blockage, infection, medication errors, refeeding syndrome and fluid/electrolyte complications.
• Plan patient-centred feeding and medication care when disease progresses or swallowing fails.

1. Why feeding and medication care matter

Illness, cancer, pain, weakness, dysphagia, surgery, treatment toxicity, depression and altered consciousness can reduce intake. The supplied reference emphasizes that hospitalized patients may already have lost weight and may need help to eat, maintain hydration and follow therapeutic restrictions.

In advanced dying, appetite and thirst usually decline as part of the dying process. Forced feeding or fluids may cause choking, oedema, secretions, vomiting or distress. Comfort feeding, mouth care and shared decision-making may be more appropriate than artificial nutrition.

2. Initial assessment before feeding

1. Airway and consciousness: can the patient protect the airway, sit upright and respond? Is there delirium, sedation, seizure risk or acute stroke?
2. Swallowing: cough or wet voice after drinks, pocketing, drooling, choking, recurrent chest infection, weight loss and fatigue.
3. Nutrition/hydration: weight trend, intake, vomiting/diarrhoea, mouth condition, urine, oedema, dehydration and food access.
4. Gastrointestinal function: pain, distension, bowel movements/flatus, obstruction, malabsorption, surgery and diarrhoea.
5. Goals and consent: what does the patient want feeding to achieve? Is the decision restorative, rehabilitative, comfort-focused or time-limited?
6. Practical safety: posture, dentures, vision/hearing, caregiver ability, food texture, allergies, cultural/religious diet and medicine interactions.

Refer for speech/swallow assessment when aspiration is suspected. A feeding tube does not eliminate aspiration; refluxed feeds can still enter the airway.

3. Types of nutrition support

Method	Description	Indications and limits
Oral feeding	Normal meals, modified textures, oral nutritional supplements and fluids by mouth.	Preferred when swallowing is safe and the gastrointestinal tract works. Requires assistance, pain control, mouth care and time.
Enteral nutrition	Nutrients delivered through the gastrointestinal tract by mouth or feeding tube.	Useful when oral intake is inadequate but the gut works; may be nasogastric, orogastric, nasoenteric, gastrostomy or jejunostomy.
Parenteral nutrition	Protein, carbohydrate, fat, vitamins, minerals and fluid infused into systemic circulation, bypassing the gut.	Consider when gut feeding is impossible or contraindicated and benefits align with goals; requires central/peripheral-line expertise and intensive monitoring.

4. Assisting with oral feeding

4.1 Preparation

• Verify diet prescription, allergies, fluid/salt/sugar restrictions, texture and cultural preferences.
• Relieve pain, nausea, breathlessness and constipation before the meal where possible.
• Wash hands; ensure a clean covered tray, appropriate utensils, napkin, towel/mackintosh, kidney bowl and fluids at a safe temperature.
• Provide privacy, good lighting, dentures/hearing aids/glasses and an upright supported position.
• Explain the meal and obtain consent. Never feed a patient who is too drowsy to protect the airway.

4.2 During feeding

1. Confirm identity and food before offering it.
2. Sit at eye level; allow the patient to choose pace, order and amount.
3. Offer small spoonfuls and allow time to chew and swallow; do not rush or pour fluids into the mouth.
4. Observe cough, throat clearing, wet/gurgly voice, breathlessness, fatigue, pocketing, colour change or refusal.
5. Wipe the mouth and chin gently; offer fluids only as prescribed and safe.
6. Stop for choking, repeated cough, distress, vomiting, reduced alertness or oxygen desaturation; position safely and escalate.

4.3 After feeding

• Offer mouth rinse/spit or oral care; clean dentures and hands.
• Keep upright for the period recommended by local swallow/feeding policy.
• Remove equipment, manage waste, clean reusable items and ensure comfort.
• Record food/fluid intake, assistance required, swallowing tolerance, symptoms and patient preference.

5. Tube feeding: routes and indications

Tube	Route	Typical use
Nasogastric (NG)	Nose to stomach.	Short-term feeding, decompression or medicines when swallowing is unsafe and stomach function is adequate.
Orogastric (OG)	Mouth to stomach.	Selected ventilated, neonatal or nasal-obstruction situations.
Nasoenteric/nasojejunal	Nose to small intestine.	When gastric feeding is poorly tolerated or aspiration risk requires post-pyloric delivery.
Gastrostomy (PEG or surgical)	Abdominal wall to stomach.	Longer-term enteral feeding with a functioning stomach and appropriate goals.
Jejunostomy	Abdominal wall to jejunum.	Post-gastric feeding when stomach use is unsafe or not possible.

Indications from the supplied reference

• Unconscious or semiconscious patients who cannot swallow safely.
• Stroke, neurological or movement disorders with dysphagia or increased energy needs.
• Surgery of the mouth, throat or oesophagus.
• Premature infants, failure to thrive or paediatric inability to eat.
• Head/neck cancer, critical illness, trauma, severe anorexia or treatment-related fatigue/nausea.
• Selected gastrointestinal disease when enteral absorption is possible; parenteral nutrition may be needed when the gut cannot be used.

6. Tube-feeding preparation and safety

• Confirm the prescription: patient, tube, formula, volume, rate, schedule, water flush, allergies and fluid restrictions.
• Confirm initial tube placement by the approved method—usually radiography for a newly inserted tube, with bedside pH/position checks according to local policy. Do not rely on air auscultation alone.
• Use clean/aseptic technique, hand hygiene, labelled feed, calibrated syringe and appropriate giving set.
• Position the patient upright, usually 30–45 degrees, unless contraindicated; maintain during feeding and the locally recommended post-feed period.
• Check for abdominal pain/distension, vomiting, diarrhoea, aspiration risk, tube displacement and tolerance.
• Do not use a tube that has migrated, is blocked unexpectedly or whose placement is uncertain.

7. Tube-feeding procedure

1. Explain the procedure, confirm identity, check the prescription and perform hand hygiene/glove use as required.
2. Place the patient upright and protect clothing/linen with a towel or mackintosh.
3. Inspect nostrils, mouth, tube fixation and external length; follow local placement verification.
4. Do not routinely aspirate and discard gastric contents unless local policy and clinical assessment require it; never force fluid against resistance.
5. Clamp/pinch the tube before disconnecting to prevent air entry. Use a large enteral syringe or feeding system designed for the tube.
6. Flush with the prescribed water volume; allow feed to flow by gravity or pump at the ordered rate. Never force a bolus that causes pain or coughing.
7. Do not allow the syringe/barrel to run dry if this introduces air; refill safely as directed.
8. Flush after feeding and between medicines according to local policy, considering fluid restriction.
9. Clamp, recap and secure the tube; keep the patient upright, observe for symptoms and document.

The supplied slides describe 150–300 mL per feed at intervals of 2–4 hours; actual volume, rate and frequency depend on age, tube position, formula, fluid status, tolerance and the prescriber/dietitian plan.

8. Tube-feeding complications

Complication	Signs	Nursing response
Aspiration	Cough, choking, wet voice, desaturation, cyanosis, wheeze, fever or respiratory distress.	Stop feed, position safely, assess ABCDE, suction only when indicated, call help and review tube/airway plan.
Tube displacement	Changed external length, coughing, pain, feed from mouth/nose, new respiratory symptoms.	Stop use; verify placement by approved method before restarting.
Blockage	Resistance, inability to flush or pump alarm.	Do not force. Check clamp/kink, use warm water or approved declogging protocol; replace tube if necessary.
Gastrointestinal intolerance	Nausea, vomiting, cramps, distension, diarrhoea or constipation.	Pause/review rate, formula, medicines, infection, obstruction and hydration; escalate severe symptoms.
Metabolic complication	Hyper/hypoglycaemia, electrolyte change, oedema, dehydration or refeeding syndrome.	Monitor ordered glucose/electrolytes, fluid balance and weight; involve dietitian/medical team.
Local infection/skin injury	Redness, swelling, discharge, leakage, pressure or pain.	Clean and protect site, assess infection and tube tension, document and refer.

9. Refeeding syndrome

Severely malnourished patients may develop hypophosphataemia, hypokalaemia, hypomagnesaemia, fluid shifts, arrhythmia, weakness, seizures and heart failure when nutrition is restarted rapidly. Screen for risk, check electrolytes, give prescribed thiamine and start/titrate feed gradually under medical and dietetic supervision. Monitor fluid balance, glucose, phosphate, potassium, magnesium, oedema, respiratory status and cardiac rhythm.

10. Parenteral nutrition nursing care

• Confirm indication, goals, route, formula, rate, line type and compatibility; parenteral nutrition is not a routine substitute for safe oral/enteral comfort feeding.
• Use strict aseptic technique and a dedicated line where required; never add medicines to the nutrition bag unless pharmacy has approved compatibility.
• Check glucose, electrolytes, triglycerides, liver function, fluid balance, weight, fever and catheter site as ordered.
• Watch for catheter infection, thrombosis, hyperglycaemia, hypoglycaemia after abrupt interruption, fluid overload, electrolyte shifts and refeeding syndrome.
• At end of life, review whether parenteral nutrition improves comfort or meaningful goals; burdensome monitoring may be inappropriate.

11. Safe drug administration: general principles

Rights and checks

• Right patient, medicine, indication, dose, route, time, assessment, allergy, preparation, documentation, response and education.
• Compare the prescription with the label at preparation, at the bedside and after administration.
• Use generic name, exact strength, expiry, formulation and concentration; calculate liquid volumes in milligrams and millilitres.
• Check renal/hepatic function, pregnancy, swallowing, interactions, duplicate therapy and current goals.
• Explain the medicine and obtain consent; respect the right to refuse unless emergency law/policy applies.

12. Oral medicines

• Assess alertness, swallowing, nausea, aspiration risk, mouth condition and ability to sit upright.
• Give one medicine at a time with the prescribed fluid; do not hide medicine in food without consent and compatibility review.
• Never crush modified-release, enteric-coated, sublingual, buccal, cytotoxic, hormone or hazardous products unless pharmacy confirms it is safe.
• Remain with the patient until swallowed when appropriate; inspect the mouth if pocketing is likely.
• Document refusal, vomiting or inability to swallow and arrange an alternative route.

13. Medicines through feeding tubes

1. Confirm tube placement and route; stop feed if the product requires a feed-free interval.
2. Ask pharmacy whether the medicine can be given through the tube; select a liquid formulation when possible.
3. Do not crush extended-release, enteric-coated, sublingual/buccal or hazardous medicines; do not mix medicines together or add them to feed.
4. Flush before the first medicine, between each medicine and after the last using the local water volume and fluid restriction plan.
5. Administer each drug separately, diluted appropriately; never force against resistance.
6. Restart feed according to medicine–feed compatibility and document the route, flush and response.

Feeds can alter absorption of medicines such as phenytoin, warfarin and some antibiotics. Pharmacy or the prescriber should specify timing, monitoring and an alternative when necessary.

14. Alternative routes in palliative care

Route	When useful	Safety points
Subcutaneous	When swallowing fails, for morphine, antiemetics, anxiolytics and other compatible medicines.	Use correct dilution/volume and site; monitor sedation, infection and absorption.
Buccal/sublingual	Selected medicines when rapid mucosal absorption is intended.	Do not swallow or crush unless the product is designed for it; protect mucosa and confirm formulation.
Transdermal	Stable analgesic requirement when oral route is unsuitable.	Not for rapid titration; heat/fever and patch errors can cause overdose; document application/removal.
Rectal	Selected medicines when oral and parenteral routes are unsuitable.	Avoid with neutropenia, thrombocytopenia, rectal disease or refusal; maintain dignity.
Intravenous	Urgent, monitored or replacement therapy when appropriate.	Check line patency, compatibility, rate, extravasation, infection and high-alert medicine policy.

15. Medication administration in the last days

• Review every medicine for current benefit, burden, route and goal; stop non-essential preventive drugs when appropriate.
• Continue essential symptom relief—analgesia, antiemetic, anxiolysis, seizure control and secretion management—by a feasible route.
• Do not force oral medicines in a drowsy patient; provide mouth care and explain route changes to family.
• Record the decision, patient/surrogate preference, capacity, review date and escalation plan.

16. Caregiver teaching

• Teach the purpose, dose, route, schedule, storage, missed-dose plan, adverse effects and emergency signs.
• Demonstrate oral syringe use and have the caregiver calculate a liquid dose in milligrams and millilitres.
• Teach upright positioning, aspiration warning signs, tube security, flush procedure and what to do if the tube blocks or moves.
• Explain that food and medicine refusal may be part of dying; comfort and consent remain central.
• Provide a named contact and clear instructions for breathing difficulty, vomiting, bleeding, seizures, severe pain or reduced consciousness.

17. Clinical cases

18. Quick self-test

1. What are the three main feeding methods?
2. Give five checks before oral feeding.
3. Why should tube placement be confirmed before feeding or medicine?
4. Name four tube-feeding complications.
5. Which medicines must not be crushed without pharmacy confirmation?
6. What should happen when a dying patient can no longer swallow?

Answers

1. Oral/enteral by mouth, enteral tube feeding and parenteral nutrition.
2. Alertness/airway, swallowing, upright position, diet/allergy/restriction, pain/nausea control, mouth condition and consent.
3. Misplacement can cause aspiration, pneumonitis, injury or death; air auscultation alone is unreliable.
4. Aspiration, displacement, blockage, nausea/vomiting, diarrhoea/constipation, refeeding/electrolyte problems, infection and skin injury.
5. Modified-release, enteric-coated, sublingual/buccal, cytotoxic/hazardous and other formulation-specific medicines unless pharmacy confirms safe alteration.
6. Assess goals and capacity, stop unsafe oral administration, provide mouth care, convert essential medicines to a suitable route and explain the plan to the patient/family.

Key take-home points

• Feeding is clinical care, not merely a task: assess swallowing, aspiration, nutrition, hydration, comfort and goals.
• Oral feeding is preferred when safe; tubes and parenteral nutrition have indications, burdens and complications.
• Confirm tube placement, never force feed, prevent aspiration and monitor refeeding/metabolic risks.
• Use medication rights, independent checks, pharmacy advice and route/formulation safeguards.
• At the end of life, comfort, consent and mouth care often matter more than forced calories or fluids.

Further study and references

• Feeding the Patient — supplied Slideshare reference
• WHO: Palliative care
• Related lesson: Nursing care for common palliative symptoms
• Related lesson: Oral morphine safety and Uganda’s legal framework
• Related lesson: Palliative-care emergencies

Educational resource for supervised learning. Use current Uganda feeding, medication, controlled-medicine and infection-prevention protocols.