Friday, January 23, 2015

Working with rather than against speech & swallow therapists #ThickenedLiquidChallenge


Photo by Joan Teno

By Alex Smith @AlexSmithMD and Sarah Stranberg, Speech Pathologist, University of Pittsburgh Medical Center

Consider the following vignettes, common in both geriatrics and palliative care:

1. A 93 year old woman with advanced dementia is admitted to the hospital for the third time in the past 6 months for an aspiration pneumonia. The admitting team orders a speech and swallow consult.

2. A 68 year old man suffers a massive ischemic stroke. After 15 days in the ICU he has recovered minimal function.  The neurology team requests a speech & swallow consult to justify likely need for PEG (a hole into the stomach for artificial feeding through a tube).

In each of these cases, my initial reaction has always been “Noooooooooooooooooo!!!!! Don’t place the speech and swallow consult!” I worry that the consult will place the patient on an inevitable path toward a PEG tube, without assessment of goals, values, and alternative approaches such as hand feeding.

However, at the annual Foley retreat of the National Palliative Care Research Center, Bob Arnold suggested a different approach. He has been working with his speech & swallow colleagues to develop a palliative approach to patients with difficulty swallowing. Here are some of the changes:

Old speech and swallow recommendations

• Unsafe for feeding
• NPO. Needs feeding tube

New speech and swallow recommendations

• High risk for aspiration
• Assess goals and values related to feeding and nutrition

This is a great idea, and something we should try more broadly around the country. For more detail, attend the workshop at the HPNA/AAHPM Annual Assembly on “palliative dysphagia” Saturday at 1:15.

This post appeared first on Pallimed as part of a wager on the World Series.   

Note: This post is part of the series on the #ThickenedLiquidChallenge.  To watch the videos of this challenge go to our original post here, or check out the videos on YouTube:

1 comment:

Val said...

Thank you for the article. I'm a palliative care physician in Singapore and many of us have the same sentiments, that we are often working against my specch therapist colleagues.

Last year, we managed to put together a programme in Dover Park Hospice involving the speech therapist in an quality improvement and education project ti improve the assessment, goals of care and management of palliative care patients with dysphagia and the response was great. Physicians, nurses and speech therapist felt they could communicate and patients were all screened and had their diet modification and fluids thickened after clear discussion with patients, family and the medical team.
The best part of it all, was that there was no funding used for this project. A team of passionate doctors, nurses and a volunteer speech therapist.

Thank you for posting the #ThickenedLiquidChallenge and I hope our story will inspire physicians to work even more closely with our speechies colleague.