to go back to the landmarks list:
Decreased Eating
    
      *   May feel more comfortable eating small snacks rather than full meals

      *   May not be interested in eating on a regular schedule

      *   May find food genuinely repulsive

      *   Nausea will greatly decrease the interest in food

      *   May not
initiate meal discussions, but may merely accept food when offered

      *   May no longer be interested in foods that require a lot of "work" or foods that previously made him or her choke

      *   May prefer softer foods such as pudding, yogurt, mashed potatoes and gravy, ice cream, or blended drinks (see below for smoothie
           recipes and links)

      *   May lock on to a single favorite or a small repertoire of foods so that there is no longer a healthful variety to the diet

      *   May have a difficult time choosing among presented options; may do better when each option is presented separately with a yes/no
           response.

           Not:     "Do you want scrambled eggs or French toast?"

           Better:  "Do you want scrambled eggs? No? Would you like French toast?"

      *   May express interest in a food but then no longer be interested or take only a few bites of it when it arrives

      *   May feel the sensation of something within the throat (often, mucus) and may find swallowing more difficult

      *   Increased sleeping may unavoidably affect the frequency of meals

      *   May experience increased clumsiness in feeding oneself and may require more assistance (especially if in bed while eating)

      *   May not fully swallow foods or may leave unchewed bits within the mouth

      *   Some patients maintain a hearty appetite right up until the end, when there is a dramatic change; most experience a waning interest
           over several days to a week

      *   In the final week or two of life, may reach a point of adamantly rejecting
all offers of food; this may include clenching the teeth or
           lips, turning the head, clamping down onto the spoon or moisturizing sponge/cloth, accepting a straw but not sucking anything in,
           or spitting out food or drink
What the Patient May Be Feeling

      *   Annoyed at having food pushed at him or her so often

      *   Too tired to eat and too tired to care

      *   Truly disinterested in or disgusted by food

      *   Unappreciative of the fact that not eating will only add to the fatigue and weakness

      *   Frustrated or embarrassed if help is required in order to eat

      *   Determined not to give in to the caregiver/patient power struggle

      *   Desperate to maintain control and independence in this major, vital area

      *   Fearful of feelings of choking or "drowning"

      *   Strongly aware of a sensation of fullness in the throat due to mucus

      *   In the very end stages, willful refusal of food can be an expression of how exhausting eating can be or can signal a plea not to be
           forced to survive
What the Caregiver May Be Feeling

      *   Disappointed by the "rejection" of offered meals because "food is love"

      *   Optimistic that the following day will bring a return of appetite

      *   Helpless and inept at nourishing the patient adequately

      *   Afraid that each skipped meal means another lost opportunity for calories and strength

      *   Frustrated by how hard it is to schedule other family members' meals around the patient's unpredictable schedule

      *   Impatient with the tug-of-war over control or the repetitive battle of encouraging the patient to eat

      *   Insecure about whether to wake the patient in order to maintain nutrition

      *   Afraid that as less food is taken in, it will become harder to administer certain medications within the food

      *   Afraid that death will come sooner---and be partially the fault of the caregiver---if the patient's nourishment decreases

      *   Worried that refusal to eat may be a form of suicide by the patient

      *   Desperate to find creative solutions in more appealing foods

      *   Sad because the adult caregiver/patient roles have become more like those of parent/child

      *   Fearful that hospice nurses might look upon the quality of caregiving judgmentally if mealtimes have not been more successful

      *   Exasperated and defensive when advice is offered by visitors and family members who don't understand and appreciate the measures
           already taken by the caregiver

      *   Frustrated and defensive when outsiders push for the patient to be fed, even by stomach tube or via IVs, once all food intake has stopped
           in the final period of life

      *   Afraid that backing away from pushing food is the equivalent of "letting the tumor have its way," as if in acceptance, when this is not
           actually the case
Tips

    Offer---never push---foods.

    If the patient prefers soft foods, making up a blended drink with a base of canned Boost or Ensure, with added fruits like bananas or straw-
    berries and a bit of ice cream or yogurt, can provide nutrition and calories as well as flavor.

    Don't worry if the patient latches on to a particular favorite food and isn't too interested in variety. A well-balanced diet is less important now
    than it was;
most important, however, is the quality of your relationship with the patient.

    If the patient doesn't want the bowl of broccoli but has a hankering for a Snickers bar, know that the Snickers bar will not kill the patient...
    nor will the broccoli save his or her life. Maintain perspective over the situation; small choices such as this will not alter the outcome. Whenever
    possible, maintain the patient's dignity and independence, and take pride in doing so.

    Don't spend a loved one's final days or weeks struggling over feeding issues. There are other wonderful ways to "feed" the patient at this time---
    read aloud to the patient, brush his or her hair, hold the patient's hand, talk and listen, open up a photo album and discuss old times and
    outrageous hairstyles, etc. There comes a time when that "food is love" statement must be flipped around as the caregiver instead offers "love
    as food."

    If medication is added to foods---check with the doctor, hospice nurse, or pharmacist before doing so---put it into a
small quantity, not a large
    bowl or glass. If the patient decides not to finish the food or drink, you'd have no way of knowing how much medicine was actually taken in,
    and you wouldn't be able to store the rest for later. It is best to offer the medicine in a single teaspoon of something thick and flavorful, say,
    chocolate pudding, and then allow the patient to eat more if able.

    The patient may have more trouble with thin liquids than with semisolid foods, so if choking and spluttering become a problem, you may need
    to avoid broth-based soups and offer beverages through a straw.

    It can be wise to encourage the patient to bend forward or sit up straight and attempt a throat-clearing cough (to dislodge mucus) before
    beginning a meal. If the patient brings up mucus material into the mouth, use a paper towel to clear it away before offering foods. This may
    make the swallowing path clearer and avoid choking during the meal.

    Offer drinks frequently during the meal, to help clear the mouth and throat. After the meal, encourage more drinking, as remnant foods---and
    even medications---sometimes remain within the mouth and can cause problems once the patient has lain down to sleep later.

    Once the patient's body no longer truly needs food, he or she will strongly reject it, even by clenching the teeth or adamantly shaking the head.
    At this point, forcing food or feeding the patient by stomach tube or IV can actually cause harm and pain, a fact that many people are not aware
    of. The "work" of dying takes an incredible toll on the patient's body, and as certain systems become inefficient at processing food and wastes
    because of the natural shutdown process, introducing food can cause tremendous discomfort and gain nothing in terms of time.

    Know that friends, family, and other well-intentioned people on the periphery of caregiving may not understand the dynamics of the dying body.
    As difficult as it can be for the caregiver not to become defensive in "justifying" his or her actions on behalf of the patient, explain that feeding
    past the point of interest could, in fact, do more harm than good. Know also that, for many people who have not played a close, active role in
    the journey, the realization that the fight is drawing to an end can be traumatic, while long-term caregivers may have done some pre-grieving
    and have a firmer, more logical sense of the situation and its needs. Encourage peripheral caregivers who join the scene in its final stages to
    express love for the patient in other ways which will bring greater comfort and be less stressful on everyone.
Fruit Smoothies
 
   Berry Blast


   2 cups frozen mixed berries (straw-
   berries, raspberries, blueberries, black-
   berries)

   1 cup unsweetened apple juice

   1/2 cup frozen cranberry cocktail
   concentrate

   3 ice cubes

   1 large ripe banana

   1/2 cup plain nonfat yogurt

   Combine ingredients in a blender.
   Cover and blend for 1 minute. (The
   bonus of this drink is the fiber.)

   Original


   1 cup vanilla ice cream

   3/4 cup whole milk

   1/4 cup frozen orange juice
   concentrate or 1/2 ripe banana

   Combine ingredients in a blender
   until smooth.


  
Modified

   1 cup nonfat vanilla frozen yogurt

   3/4 cup skim milk

   1/4 cup frozen orange juice con-
   centrate or 1/2 ripe banana

   Combine ingredients in a blender
   until smooth.
Links to Sites on Cancer Nutrition

  
www.cancernutrition.com Good resource on dietary and nutrition concerns
   during cancer treatment. Includes a portion on how to address the problem
   of changing tastes during radiation and chemo, which could be useful here
   as well. Click on Nutrition Handbook.

  
www.cancer.med.umich.edu/learn/nutrnausea.htm Cancer nutrition while
   dealing with nausea

  
www.mayoclinic.com/home?id=HQ01133 Nutrition tips for managing
   nausea and vomiting in cancer patients. From the Mayo Clinic

  
http://cancernet.nci.nih.gov/eating_hints/eatintro.html Nausea management
   in cancer patients

  
http://cancer.med.upenn.edu/support/tips/tip1.html Dealing with nausea in
   the cancer patient