Profile of speech therapy in oncology and palliative care residency program at an oncology referral hospital

Introduction: Hospital environments are among the different professional contexts in which speech therapists can work. Patients with cancer or at their final stage of life are eligible for speech therapy intervention. Based on this premise, a program called Residência Multiprofissional em Saúde was created focusing on Oncology-Palliative Care. Objective: This study aimed to analyze the assistance provided by speech therapists in the scope of a multiprofessional residency program at an oncology referral hospital. Methods: The documentary research was based on a retro - spective qualitative-quantitative approach. A sample of 344 medical records were analyzed using a form containing open and closed questions as part of the study. Results: All data were organized in spreadsheets and submit - ted to statistical treatment using the chisquared test and the G-test. Only 67 patients were evaluated by speech therapists, and among these only 16 underwent rehabilitation. Functional evaluation of swallowing was the most frequent evaluation method found in the analyzed medical records (9.30%), tactile-thermal-stimulation was the most used therapeutic method in speech therapy (2.03%), and most patients had no clinical evolution with speech therapy (1.74%). Discussion: It is possible to observe a variation in the types of evaluation performed, which makes the evaluation an even more subjective process, increasing the risks of diagnostic confusion. Health services managed based on quality man - agement advocate standardized care, with the implementation of protocols, forms, indicators and care flows; features that have not yet been implemented or developed in current palliative practice. Conclusion: Results suggest that there is a fragmentation in the structure of the Speech Therapy Service, which is directed especially towards swallowing disorders, thus evidencing the need for a systematization of speech therapy assistance provided to PC patients.


INTRODUCTION
Speech Therapy is among the various professional categories found in a hospital environment.It is a professional area that can contribute to the good evolution of patients´ clinical condition and to their hospital discharge.
As professionals who are part of a hospital environment, speech therapists have to adapt themselves to a new reality, starting to deal with death and life, and having in mind that the intervention they provide can lead to one situation or another 1 .
One of the areas in which speech therapists can intervene, although still little explored, is Palliative Care (PC).
Within the PC philosophy, the term "terminal patient" falls into disuse because it is used in a stereotyped way, supporting an idea that "there is nothing to be done", which may lead to a process of disinvestment in patient care 2 .
With the advancement of scientific technology, the population's life rate has increased, also increasing the morbidity rate, that is, the number of people alive grew, but so did the number of patients who are not cured 3 .Admitting that a treatment is useless in face of a terminal ill condition seems to be inhumane and wrongly hurts human dignity 4 .
Speech therapy in PC consists of a unique segment of very productive performance, however, not widespread and well understood by Speech-Language Pathologists (SLPs).
The practice of Palliative Care can be interpreted as a philosophy of care and protection, where the main objective is to offer a supportive atmosphere to help patients reach death as actively as possible and with quality.
As the PC philosophy has been described so far, it is important to understand cancer: Cancer is a group of diseases characterized by the abnormal growth of cells caused by internal or external agents.The transformation of the normal cell into cancer occurs through changes in its DNA with the participation of viruses, the appearance of the environment or in virtue of food or physical agents, such as some types of radiation 6 .
The difficulty or inability of the patient to eat means, in many cases, the worsening of health 7 .Loss of the ability to feed oneself often accompanies the death process 8 .The speech therapist, in this perspective, helps to minimize the feeling of failure around eating 9 , because through efficient swallowing it is possible to optimize the patient's quality of life (QL) 10 , developing motivation, comfort and the pleasure of eating 11 .
Attempts to restore a patient´s oral feeding function should always be done by the speech therapist, given that eating is something pleasurable for the individual, not only for the ingestion of tasty, fragrant and visually pleasant foods, but for the social act itself and for everything it generates around that moment 10 .
Many of the pathologies that require PC alter swallowing and communication functions throughout their evolution, resulting in a compromised QL of the patient and their families 8 .The objective of the speech therapist in PC is to provide the possibility of communication between the patient and their family, preserving the pleasure of oral feeding in a safe way 12 .
In the residency program, the speech therapist cooperates with other professionals who work at the Clínica de Cuidados Paliativos Oncológicos (CCPO).The multidisciplinary team does not aim to provide care regarding only the mechanical aspects of the swallowing function, but also other aspects that can have a significant impact on dysphagia, such as positioning, cervical mobility, environment, independence, nutritional support, general health and emotional state 13 .
In PC, essential care must be provided to the patient, such as nutrition, hydration and hygiene, so that death can occur in its natural course and with dignity 14 .
The caregiver has a feeling of anguish when the patient is not able to eat orally and, therefore, has many questions about alternative nutrition, in addition to the patient showing resistance to accepting it 12 .It is up to the speech therapist professional to explain the advantages and disadvantages of each alternative feeding method, thus trying to reduce the anguish and suffering of the patient and their family 8 .
Providing comprehensive care to patients and their companions is part of the practice of SLPs residents in PC.
In cases when the patient cannot ingest food orally but desires to do so, their will is prioritized as far as possible, since this patient is on PC.Offering food and liquids to the dying patient is synonymous with humanity and compassion 7 .
The fact that all professionals see the patient at different times does not exclude the effective work of an interdisciplinary team, provided that everyone is available and attentive to the close contact among them.As stated by Mello (2003,   p. 18), "cada serviço tem uma dinâmica própria, mas ao interagirem entre si e devidamente ajustados, produzem um funcionamento equilibrado, cumprindo o principal objetivo do hospital, o da promoção de saúde e recuperação do indivíduo" 15 .
In addition to Speech Therapy, currently there are many different areas in the PC team that contemplates residency in Palliative Care, such as: Nursing, Physiotherapy, Nutrition, Psychology, Occupational Therapy and Social Service.
For the speech therapy work to be done in the best possible way in the hospital environment, it is necessary, first, to understand the dynamics of a hospital 15 .Based on Initially, data from medical records were tabulated and organized in Excel spreadsheets.Then, they were submitted to percentage and statistical analysis according to the research objectives, using the chi-squared test and the G-test.

RESULTS
After having evaluated 344 medical records of patients admitted to the PC clinic at the Ophir Loyola Hospital, we found that 63.37% were female (24/107) and 36.63% were male (18/93), with a mean age between both the genders of 58.02 years and the minimum and maximum ages of 18 and 107 years, respectively.
From the total sample of medical records analyzed, records of speech therapy care were found in only 67 records (19.48%).
Among the medical records in which records of speech therapy consultations were found, there were patients who had not been evaluated.We sought to identify the reason for that lack of evaluation.It can be observed in Table 1  Table 2 shows the type of specific assessment performed.The assisted oral assessment was the most common assessment found in the medical records, being present in 31 cases (9.01%), followed by the Orofacial Motricity Assessment, present in 30 cases (8.72%), and functional evaluation of swallowing, present in 32 cases (9.30%).The types of assessments performed less frequently in the CCPO were Pain assessment, with a frequency of only 1 case (0.29%), and Blue Dye Test, with a frequency of 1 case as well (0.29%).
From the 67 patients evaluated, only 16 received speech therapy.Table 3 shows the techniques used during speech therapy for these 16 patients undergoing rehabilitation.

Tactile-thermal stimulation was the most used therapeutic
technique in therapy, being present in the consultations of 7 patients (2.03%), followed by swallowing maneuvers (1.45%).
The least used therapeutic method corresponded to vocal speech therapy, being used in only 1 case (0.29%).

4
With regard to the evolution achieved following speech therapy, it is possible to observe in   Lat Am J Palliat Care 2023; 1:eLAPC2022045

DISCUSSION
One of the speech therapist´s technical competences in a hospital environment is the management of food consistency for patients with dysphagia.Therefore, it is through the clinical findings observed in the evaluation process that the speech therapist can suggest changes in food consistency, ensuring a safe diet and protection of the airways.Therefore, in order for the speech therapist to prescribe or manage such changes it is first necessary to carry out an evaluation 16 .
Contrary to what is imagined, not every PC patient has some difficulty in eating -to the point of depending on an alternative feeding route (nasogastric or nasoenteral tube, gastrostomy, jejunostomy or parenteral diet).Our data clearly show that 6 patients (13.95%) were not evaluated because they did not present complaints regarding dysphagia, that is, they did not present a speech-language pathology demand from the swallowing point of view.In a research also carried out at the CCPO, in which it was sought to analyze the swallowing of hospitalized patients, this author found that 59.9% of the individuals ate exclusively orally, but with restrictions 17 .
PC patients will inevitably evolve to death, which means that at some point, the swallowing impairment will be present; therefore, speech therapy intervention was necessary.
Critically ill patients correspond to a group with multiple risk factors for food aspiration 18 .In the present study, the Speech-Language Pathology team did not see the majority of patients (80.52%).
Monitoring the patient's vital signs is important to verify the most appropriate time for action, and can contribute in the best possible way, without putting the patient's life at risk, making it necessary to evaluate these parameters before and after speech therapy intervention 19,20 since the patient's clinical status tends to worsen as death approaches 21 .
Among the patients evaluated by the Speech-Language Pathology and Audiology service, it is possible to observe a variation in the types of evaluation performed, that is, there was no standardization of the evaluation method, which makes the evaluation an even more subjective process, Although not all patients have undergone speech therapy, the role of the speech therapist in the process of adapting the swallowing function of PC patients should not be ignored.Among the benefits of speech therapy is the reduction of the negative effects of muscle atrophy and reduction of oropharyngeal structures 22 .
The tactile-thermal stimulation can be considered an important technique for the rehabilitation of the swallowing function in the dysphagic patient.Tactile-thermal stimulation is used to stimulate intraoral sensitivity, to improve the oral preparatory phase and to prevent extraoral leakage 23 .In the present study, this technique was the most used by speech therapists at the CCPO (2,03%).
The swallowing mechanism can be modeled by sensory stimuli, such as gustatory stimuli that increase salivation, therefore facilitating swallowing 24 .These authors also argue that foods of different consistencies, temperature and flavor excite various types of sensory fibers that innervate the oropharyngeal mucous membrane.
Regaining the ability to swallow, even in minimal volumes, can mean the recovery of health and physical and psychosocial well-being for the patient 23 .
The importance of speech therapy work with PC patients is justified by providing quality of life while helping to reintroduce oral diet 16 .In this study, 3 patients were able to resume oral feeding, being 2 exclusively orally (0.58%) and 1 on a mixed diet (0.28%).In addition, 1 patient (0.28%) had the possibility to re-experience foods of different consistencies through the evolution of consistency, which allows us to infer that the comfort/pleasure to which food is related was possible to be guaranteed to these patients with a reserved prognosis, thus implying a better quality of life/death.

CONCLUSION
The

DEDICATION
In memory of Jorge Leão, and in recognition of my fellow speech therapists who are interested in the subject and who allow themselves to venture beyond the realms of palliative care and who, like me, have felt and feel doubts and insecurity when exploring this new area of activity.
the risks of diagnostic confusion.Quality management-based health services recommend standardized care, with the implementation of protocols, forms, indicators and care flows, resources that have not yet been performed or developed in the current palliative practice.There is a fragmentation in the Speech-Language Pathology service at the CCPO, since not all hospitalized patients received care from this medical specialty, although there are residents and preceptors in that clinic.Against this background, relevant questions arise, such as: Why is not every patient evaluated by a speech therapist at the CCPO?What are the criteria for a patient to be considered "eligible" for speech therapy?Why not all patients who present demand for such care were submitted to speech therapy?To what extent can the condition of a PC patient improve from a speech-language pathology point of view?To what extent is it pertinent to recommend therapy to patients whose philosophy of care surrounding proposes not to evolve/treat but to control the symptoms instead?
findings of this study indicate that the speech therapy assistance provided by the professional speech therapist in the Multiprofessional Residency Program on Oncology and Palliative Care is fragmented, not standardized with regard to interventions and procedures, and not yet based on scientific evidence, implying on severe risks for a comprehensive care management and lack of good practices for end of life patients.As the clinic residency is a program within an oncology hospital, it is necessary that the SLPs have knowledge about the peculiarities of cancer, as well as its treatment modalities and implications for communication and vital functions of the human being.Most hospitalized patients are not treated by speech therapists, and those who are evaluated did not receive therapy.In addition to the speech therapy evolution being difficult, the Speech-Language Pathology service at CCPO is especially directed to swallowing disorders.It is important to emphasize that this study did not propose to highlight the negative points of the Speech-Language Pathology service at the CCPO, but rather to briefly discuss the present reality of the service in this clinic.It is believed that this specialty is fundamental for the proper functioning of the CCPO, and could improve the performance of the service.It is evident, then, the need to restructure the fragmented service of Speech-Language Pathology and Audiology currently available and to promote the construction of a systematic service of screening, evaluation, diagnosis and treatment of dysphagia and other disorders that require the competence of the SLPs.It is recommended the creation and use of a Standard Operating Protocol for the Speech-Language Pathology service in palliative care.Perhaps the Speech-Language Pathology service is still far from an ideal model.However, with dedication and good will of professionals who always seek to improve their practice, assistance and service, it will be possible to succeed in our ultimate goal: the well-being of the patient and their family.The Multiprofessional Residency routine involves an exclusive dedication and obligatory 60 hours per week split into theoretical classes and care assistance.In spite of the difficulty of flexible schedules for accessing the medical records this study aimed to provide practical knowledge on the role of speech therapists with patients with no prospects of cure, in addition to enriching the theoretical contributions of the role of speech therapists with PC patients.Thus, this research has gathered some elements for reflection on the service in palliative care, proposing a methodologically structured practice in palliative care for speech therapy, aiming at service excellence and improvement of the assistance provided, therefore contributing to the professional training of residents.

Table 1 .
Profile of the Speech-Language Pathology and Audiology service, referring to the justification of patients who were not evaluated from 2012 to 2015.
This documentary research consisted of a retrospective case study based on a qualitative-quantitative approach.To this end, after approval by the Ethics and Research Committee (CEP) under number 1,223,739, the Medical Archive and Statistics Division (DAME) (Divisão de Arquivo Médico e Estatísticos) during the period from March 2012 to October 2015 in the morning.A script was prepared to assist in the analysis of medical records (Supplementary Material).As an inclusion criterion, we considered the medical records of patients of both sexes admitted to the CCPO from March 2012 to October 2015, regardless of color, age, creed, race or diagnosis.A total of 403 patient medical records were accessed.Among those records, 55 records were excluded because they corresponded to patients admitted to the CCPO, but who were not eligible for PC.From the remaining 348 records of PC patients admitted to the CCPO, four records corresponded to patients hospitalized in 2010, who were also excluded from the survey, because the residency program in oncology-palliative care had begun in 2012.In short, the sample consisted of a total of 344 medical records of PC patients admitted to the CCPO from 2012 to 2015.

Table 4
that from the number of patients submitted to speech therapy 6 (1.74%) did not present any evolution, but others presented different types of evolutions, such as diet release by oral route (n=2), improvement in vocal intensity (n=1), decrease in the pathological reflex (n=2), decrease in the aspiration procedure by the physiotherapy team (n=1), and consistency evolution (n= 1).

Table 3 .
Profile of the Speech-Language Pathology and Audiology service, referring to the therapeutic technique from 2012 to 2015.

Table 2 .
Profile of the Speech-Language Pathology and Audiology service, referring to the evaluation method from 2012 to 2015.

Table 4 .
Profile of the Speech-Language Pathology and Audiology service, referring to the speech-language pathology evolution from 2012 to 2015.