Working with rather than against speech & swallow therapists #ThickenedLiquidChallenge

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:

• The Hospice and Palliative Care Team taking the challenge
• Alex Smith taking the challenge
• Eric Widera taking the challenge
• Dawn Maxey taking the challenge
• Ken Covinsky taking the challenge
• Allen Tong taking the challenge
• Mike Steinman taking the challenge
• Nancy Lundebjerg taking the challenge
• AAHPM staff taking taking the challenge
• San Francisco VA ACE team taking the challenge
• Christian Sinclair from Pallimed taking the challenge
• Suzanne Gordon taking the challenge
• Home Base Primary Care taking the challenge
• UCSF Interprofessional Geriatrics and Palliative Care Elective taking the challenge
• Gigi Trabant taking the challenge
• SFVA iPACT team taking the challenge
• Holly Yang from Pallimed taking the challenge
• Paul Tatum and David Oliver taking the challenge