Skip to main content

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:

Comments

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.

Popular posts from this blog

Geroscience and it's Impact on the Human Healthspan: A podcast with John Newman

Ok, I'll admit it. When I hear the phrase "the biology of aging" I'm mentally preparing myself to only understand about 5% of what the presenter is going to talk about (that's on a good day).  While I have words like telomeres, sirtuins, or senolytics memorized for the boards, I've never been able to see how this applies to my clinical practice as it always feels so theoretical.  Well, today that changed for me thanks to our podcast interview with John Newman, a "geroscientist" and geriatrician here at UCSF and at the Buck Institute for Research on Aging.

In this podcast, John breaks down what geroscience is and how it impacts how we think about many age-related conditions and diseases. For example, rather than thinking about multimorbidity as the random collection of multiple different clinical problems, we can see it as an expression of the fundamental mechanisms of aging. This means, that rather than treating individuals diseases, targeting …

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 …

Becoming an Advocate for Older Adults: A Podcast with Joanne Lynn

Geriatricians in the 2030s may be able to prescribe very costly medications for older Medicare beneficiaries who cannot get supper. Most older Americans who live with disabilities will not be able to pay for adequate housing, food, medicine, and personal care. All who serve older adults must shoulder the responsibility to help avert this oncoming suffering and social disruption. The window of opportunity for effective change is already narrow; procrastinating for a decade will be too late.
These are the words of Joanne Lynn, a geriatrician and palliative care physician, who leads Altarum’s work on eldercare. She wrote a recent JAGS editorial titled The “Fierce Urgency of Now”: Geriatrics Professionals Speaking up for Older Adult Care in the United States” which is very much a call to action for those who care for older adults.  We talk with Joanne about this article and some meaningful things clinicians in both geriatrics and palliative care can do to be advocates for a growing popu…