Skip to main content

Food is love, or The fundamentals of Long Term Care



Although I usually think with my stomach, I have been particularly preoccupied with how we feed our most vulnerable elders this week. That’s because my Home Based Primary Care team took up the #ThickenedLiquidChallenge in order to raise our awareness of what we put our patients through. The challenge is admittedly biased to make one hate thickened liquids. Participants have to thicken everything they drink with corn starch until it resembles honey in consistency. Those of us who have fed these products to our patients are well aware that “nectar-thick” liquids are much more palatable (i.e. less disgusting).

It has been fascinating to watch a transformation take place as we accept the challenge. Our dietitians are speaking up in team meeting. They are questioning whether or not thickened liquids are consistent with our patients’ goals and wishes. We care for patients at home, so we are well poised to ask this question. HBPC can even bring a provider and the RD out together on a house call in order to discuss the lack of medical evidence about risks and benefits. More importantly, we can sit in the kitchen and address what we definitely know about the burdens of gagging down thickened liquids and the burdens of attempting to enforce a “chin tuck” when feeding thin liquids to a person who has dementia. This is not just patient centered care, it is family centered care.

I’m also a nursing home doc who has taken care of SNF patients for a decade, so I was delighted to see that this week’s Journal of the American Medical Directors Association (JAMDA) has published a special research agenda to improve food and drink intake in nursing homes. It was even more exciting to see an exhaustive literature review of the research, such as it is, about increasing fluid intake and decreasing dehydration. They found modest evidence that dehydration was reduced when nursing home residents had a greater choice of things to drink, when staff were made aware of the need to encourage fluids and became more involved assisting with drinking and toileting. Not surprisingly, it concludes with a plea for well-designed studies.

Getting back to the thickener question, we need well-designed studies that examine quality of life, incidence of pneumonia, and hydration status before and after we choose to abandon thickened water. Qualitatively, I can tell you that my patients with dementia so severe that they were wheelchair bound appeared much happier when liberated to plain water. So did the ambulatory patients. Shoot, so did everyone. And the only significant aspiration I’ve ever witnessed involved a desperate theft of a big hunk of meat from a neighbor’s plate. To be fair, giving plain water carries burdens for help dysphagic patients to drink. After 15 minutes of saying “tuck your chin” before every swallow, I get twitchy with frustration, yet that is what is needed to reduce coughing and sputtering. If I had to choose between my own impatience and my patients’ happiness, I choose their happiness. No question.

At the end of the day, food is love. Drink is no different. It hurts us in subtle ways when we force people to eat and drink the things they hate. We often demonstrate affection through the food and drink we give to those who we love. When the Speech Pathology report comes back showing high risk of aspiration, we should put that love on the table as we discuss goals of care and the burdens of treatment.

by: Theresa Allison


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:

Comments

Anonymous said…
As a registered dietitian who has worked in long-term care for over a decade I appreciate your post! It is heartbreaking to hear someone beg for simple plain water especially when there isn't clear evidence of harm. Food is love and I think this conversation is important! Thank you!

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …