Are Others Questioning Your Dysphagia Recommendations? When complex dysphagia patients, their caregivers or their physicians disagree with SLPs’ recommendations, treatment can get tricky. In a recent live chat from an ASHA dysphagia conference, swallowing disorders expert Paula Leslie shared how you can navigate resistance in such situations. The Leader listened in. Overheard
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Overheard  |   June 01, 2015
Are Others Questioning Your Dysphagia Recommendations?
Author Notes
  • Paula Leslie, PhD, CCC-SLP, is a professor and director of the clinical doctorate program in medical speech-language pathology at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Groups 15, Gerontology; and 13, Swallowing and Swallowing Disorders. pleslie@pitt.edu
    Paula Leslie, PhD, CCC-SLP, is a professor and director of the clinical doctorate program in medical speech-language pathology at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Groups 15, Gerontology; and 13, Swallowing and Swallowing Disorders. pleslie@pitt.edu×
Article Information
Swallowing, Dysphagia & Feeding Disorders / ASHA News & Member Stories / Overheard
Overheard   |   June 01, 2015
Are Others Questioning Your Dysphagia Recommendations?
The ASHA Leader, June 2015, Vol. 20, 26-27. doi:10.1044/leader.OV.20062015.26
The ASHA Leader, June 2015, Vol. 20, 26-27. doi:10.1044/leader.OV.20062015.26
Jaime Faitlowicz: I am curious about how you would address a situation I commonly find in the skilled nursing facility setting. Upon evaluation (bedside, MBS [modified barium swallow], FEES [fiberoptic endoscopic evaluation of swallowing]), if a patient requires a modified dysphagia diet (thickened liquids, puree, chopped) and the family and/or patient wants to refuse the diet, the following problem often comes up: I have to, as an SLP, recommend what I feel is the safest diet. The patient/family can refuse that; however, I am told that legally the nursing home must provide the safest diet consistency, and even if the patient/HCP signs something saying they understand the risks of chosen diet consistency (i.e., aspiration, aspiration pneumonia, choking), they chose the higher diet without restrictions. This will not hold under a court of law because it is the nursing home’s responsibility to maintain the safety of the patient despite their wants/needs.
Paula Leslie: The issue of what is “legally required” is often touted as a reason for action, but sometimes this has not been checked. Altered diet/drinks is a medical intervention—as such the law states, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.” CMS [Centers for Medicare and Medicaid Services] regulations also support patient choice and self-determination. I would refer people to work by Jennifer Brush and the Rothschild Foundation.
Elizabeth Mathew: Do you have any tips on how to start the dialogue with primary team physicians regarding “listening to the whole patient”? Oftentimes they are preoccupied with medical management and see no benefit to this line of discussion.
Leslie: Even physicians (if we read their blogs!) are to focus on patient outcomes, not just medical expertise. Again, the Patient Self Determination Act of 1990 is a resource for us. Dialogue with the patient on their goals and our hopes, and some compromise usually ends up in improved medical care (maybe even “adherence,” which is equally distasteful to me as “compliance”).
Katie Krings: The idea that we should discharge if the patient “won’t do what we say” is pervasive. How can we help in changing this?
Leslie: If we discharge a patient because “they didn’t follow our instructions,” I think we would be liable for inappropriate discharge. Our job is to bring our expertise to the patient/family first and then (but a close second!) to the clinical team to enable the patient to make an informed decision. If each of us pushes a little and explains why we are doing this thing (challenging the status quo), then others may be more accepting. The more of us that do this, the more often, the more it becomes the standard of practice. You can retire knowing that you changed the world! Karen Stadjuhar-Watson: Is this true for any patient, even those who have cognitive deficits, no swallow disorder, but refuse to follow instructions or suggestions?
Leslie: Yes. We have to be very careful to show that we did all we could to enable the patient to understand consequences and to enable participation as much as possible—so talking at a certain time of day when a patient is most lucid, after meds/before meds, etcetera. We do the best we can, with the patient, the family and the clinical team, and then it is up to the physician if a patient is deemed to be without capacity—remembering that capacity for a decision is for that specific decision at that point in time.
Rich DeWitt: If you are not improving with your established goal, how can you justify continuing therapy? Insurance companies tend to not pay at this time.
Leslie: Whose goal? We need to show that we have crafted a goal with the patient as far as we can. The goal may be to optimize safe oral intake, to enable real-world participation with tasters with a family—the goal thing is a good question. We need to be more creative (and, dare I say it, patient-appropriate) with how we write goals, and at some point it is OK to say no if there really is nothing else that I can offer to this person—which is OK, but just not “because they didn’t do what I thought best.”

If each of us pushes a little and explains why we are challenging the status quo, then others may be more accepting.

Moderator: We have two similar questions, so I’ll post them together.
Deb Ross: I thought I once heard you say that unless and until a legal proceeding has removed a person’s competency (no matter if they have dementia or not), the legal definition of “sound mind” is met. In other words, the patient is to be treated as if she/he has decision-making capacity until the courts deem otherwise. Is this a correct interpretation? If not, please clarify.
Karyn Wagner: Who deems the patient to be without capacity to make decisions? Does this have to officially be done by a court or with cognitive testing if there is a medical POA [power of attorney] appointed?
Leslie: Competence is the legally defined state of a person to make any decisions and that involves judges, physicians, etcetera. Capacity is for a specific decision at a point in time. And yes, you have to presume capacity unless you can document otherwise, so any of us can make the capacity judgment for a decision. We have to document the dialogue of discussion, i.e., the words used, and show that the person trying to make the decision really did not understand the consequences, which is not the same as they disagree with us. And if a person chooses to remain silent and not give reasons, they can do this. This is much more tricky legally and ethically and I’m not going there today. Last thing: A health care POA [HCPOA] needs to be not just a POA. The patient with capacity can appoint a HCPOA and defer decisions to them at any point.
Karyn Wagner: Have you ever used or found motivational interviewing [MI] to help patients/family members be more engaged in treatment?
Leslie: Funny! I say this because I’ve looked into MI and it is how I was trained 20 years ago before it became a word. My first love in in speech-language pathology was stammering (like stuttering, but with a British accent). And the way we tend to work in the U.K. is very much along the lines of patient involvement, goal design and accountability. I think (though I haven’t been on a course yet) that MI could be a useful resource and a shift of perspective for many SLPs.
Michelle Dawson: I do a fair amount of training with new nursing students and CNAs [certified nursing assistants] on aspiration precautions. Is there a visual or chart that you use when discussing bedside manner with students? I hate to say checklist, but something of that nature till they are comfortable.
Leslie: Michael Kahn’s piece on etiquette-based medicine is really spot on.
Patricia Wells: When you have educated both your patient and their family about swallowing status as well as complications they are experiencing at the time of your consult, and they clearly demonstrate that they do not comprehend the information presented to them on multiple occasions and in multiple ways, what would you recommend?
Leslie: Think broader: Discuss the life goals that someone has, and also the life fears. Where are the misunderstandings? It is interesting how a deeply held odd thought can influence our values and even intake of information. It is our job as communication specialists, right? We are the only profession with that in our title—to enable people to understand things. The better we get as clinicians, the better we are able to explain anything to anyone. And you will get to a point of, “Yes, I get it now. OK, so what do we do?” or, “I get it and I still don’t agree with you,” which is OK. That’s what we have to do legally—ensure informed decision-making. We must not confuse patients having a different opinion to patients not understanding, but it can take quite some teasing out.
Deb Ross: What should the SLP do when (in an acute-care facility) the decision to tube-feed or not seems to be made because the length of stay is so short and it’s easier to place a person who is not going home, when they have a G-tube [gastrostomy tube] rather than an inadequate PO intake or an NGT [nasogastric tube]. Any key phrases to use with families, doctors or case managers during discussions? Any key documentation tips?
Leslie: It is not our job ever to advise on what route non-oral supplementation of diet or liquids should take. I get the G-tube push; it is endemic in western Pennsylvania. Our scope of practice says that we should know about comorbidities and tubes and feeds to help us understand the bigger picture. But we should not overstep our role, nor be bullied into making the decision. It is the physician and patient/family who must decide. We can offer informed expert opinion on things—and again, think big picture, life goals, likely outcomes. Sometimes it is going to be the way of things. But we should not have stepped over our professional-scope boundary.
Megan Logan: With cases like these, I usually state, “Recommend to consider an alternate means of adequate nutrition/hydration” in my documentation. I then discuss with the physician, and they are the ones who determine the decision and then speak with family. Is this not in our scope of practice?
Leslie: Yes. I would always write something along the lines of, “Here are my findings on clinical/instrumental... Given my knowledge of the aerodigestive tract, blah blah, these factors indicate increased risk of X, Y and Z...” And I always think about the obvious (or not): Is the patient conscious enough to even eat, no matter how peachy the swallow is? So I might say “unlikely to be able to maintain adequate nutrition/hydration orally. In view of the other illness/situation factors: A, B ..... My recommendation is that you consider non-oral supplementation.” And offline I would most certainly hunt down that physician and explain this and other thoughts that I may have, because on occasion I have known more than the brand, shiny new doctor staring at me big-eyed. But I would urge them that it’s their job to figure this out, even if in the past I have seen this and this with a certain type of case.
Dawn Barrett: What suggestions do you have for therapists trying to balance busy caseloads and high productivity requirements while taking time to talk to the patients and build a rapport needed to facilitate follow-through with our plan of care?
Leslie: It is going to come down to your professional ethical judgment. If we cannot show that we did our utmost to engage the patient, involve them in decisions, and understand consequences, then we are liable for not ensuring informed consent—whether that is about choosing the lemon mousse or major things like oral intake and no thickeners. Personally, I find it very hard to work with someone who I have not [built a] rapport with, and although this does happen occasionally, I know I have at least tried to build a relationship. The better my rapport investment on the front end, the easier I work with patients or they with me! The literature shows us that the likelihood of getting sued for malpractice for physicians is closely correlated to the nature of their relationship with the patient and not how gross (and things can be really bad) the perceived (or real) malpractice was.
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June 2015
Volume 20, Issue 6