Friday, November 14, 2014

Working With, Rather Than Against Speech and Swallow Therapists

What bird is with you at every meal? A swallow!
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. A tracheostomy (trach) is placed so that he can breathe on a ventilator through a hole in his neck. The neurology team requests a speech and 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 and 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.

Alex Smith normally blogs at GeriPal. This post appears first on Pallimed as part of a wager on the World Series. For each game lost by the home team (SF Giants for GeriPal, KC Royals for Pallimed), the losing blog must submit a post to the winning blog.

Photo Credit: jurvetson via Compfight cc

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