Clinical Decisions with Patients with Dysphagia: Are We Complicating Rather Than Improving Their Health and Quality of Life?
John R. Ashford, Ph.D., Education Director and Co-Owner
Clinical decisions for patients with dysphagia are to do no harm to the patient, and, moreover, it is too lessen or totally relieve suffering, and to improve the physical, mental, and/or social aspects of living. Good clinical decisions surrounding swallowing safety and efficiency rely upon 6 key elements: (1) knowledge of normal swallowing and airway protection anatomy and physiology; (2) expert, evidence-based, professional knowledge of normal swallow functions, their complexities, and disorders; (3) rich clinical experiences with patients with similar disorders; (4) a good understanding and appreciation of the patient’s health history; (5) unbiased evaluative tools and analytical skills; and (6) a full appreciation for professional ethics.
Expert knowledge of normal swallowing and dysphagia is foundational in making clinical decisions, and requires much more than the typical university graduate survey course and subsequent internships. In an ideal academic training world, a second, and more advanced dysphagia course with literature study rigor and medical focus would better prepare the fledging clinician. Alas, we do not live in that ideal world and further independent study and training beyond the graduate level are required. Continuing education courses and conferences, specialty training, mentorships, and/or self-study become the next level of knowledge acquisition. Expertise in swallowing function and its disorders must be steeped in knowledge of detailed anatomy, biomechanics, muscle physiology, mechanical physics, neurology, dietetics, and the basic medical sciences. Knowledge and understanding of common human illnesses across the age spectrum and their impact on physical, social, and mental functions are mandatory. Without continued life-long learning, increasing expertise and experiences, and staying professionally current are ultimately reflected in poor patient care and outcomes. Example: multiple clinical research studies have put the nail in the coffin for using tactile-thermal stimulation as an efficacious dysphagia treatment. Yet, it continues to be taught in university programs and widely practiced clinically.
- Clinical Experience
Clinical experience is a gradual, slow-cooking process adding to good decision skills overtime. Time provides real-life patient interactions that explain, demonstrate, temper, and even alter previous academic knowledge and experiences. Clinical experience is the house built upon the foundation of academic knowledge and requires ample time to construct using the mortar mixture of continual education and adaptation. Experience cannot be learned from a book, or from supervisors, or quizzing “more experienced” clinicians. Rather, the best clinical teachers are the patients themselves. As my mentor used to say to me, “Let’s go see what Mr. Smith can teach us today.” Patients and their health conditions are occurring without bias from other influences, experiences or education, and are rich with education. Not a day should go by that a clinician, young or old, should not learn something new from patient care. Failure to grasp valuable “learning” moments comes from being blinded by knowledge rigidity, reliance on faulty intuitive thinking, and professional snobbery. Not recognizing clinical experiences as perpetual and valuable learning opportunities, and not synthesizing these experiences into working knowledge for decision making, significantly impacts patient intervention, recovery and their quality of life. Example: Automatically prescribing thickened liquids and puree diet consistencies for a patient who coughs during meals. Is this aspiration or just a cough? These decisions complicate primary health conditions may possibly promote dehydration and malnutrition.
- Patient History
Dysphagia is a disorder symptomatic of a larger, more complex primary health condition. It never stands alone. As such, clinical decisions rely upon an intimate knowledge of the patient’s health history and current diagnoses reveal the underlying primary cause of dysphagia. Knowledge of when these events occurred in the patient’s life timeline and their severity provide insight into the potential complications they may or may not be contributing to the current illness. Not knowing the patient’s history lends itself to conjecture and erroneous thinking resulting in decision errors that inevitably penalize the patient. Example: A elderly patient is admitted for possible TIA. The SLP visits him at bedside without reviewing his chart. After administering a screening test designed to detect if dysphagia is present or not, the SLP orders an immediate diet change to thickened liquid and puree diet. This decision immediately and radically altered every element of the patient’s well-being, and injected an additional, unproven problem into the care plan for the physician and staff to address. The patient is now considered more ill than perhaps he really is.
Suspected disorders of swallowing require an in-depth assessment administered by a knowledgeable, specially-trained, and experienced clinician. Assessment for, and of, dysphagia is paramount to decision-making to discover and determine its limits and severity, and for making informed clinical decisions for intervention, if needed. Assessment, and the required analyses that must follow, must not be cursory. Swallowing is a very complex, reflexive neurosensory-motor event generating timed sequences of neuromuscular force and pressure to convey necessary hydration and nutrition from the mouth to the stomach. The primary purpose of a comprehensive dysphagia assessment is not to determine if the patient aspirated or not, but to determine whether hydration and nutrition can be taken orally in a safe and efficient manner, and in adequate amounts to sustain life. Aspiration, laryngeal penetration, and residue are but after-the-fact consequences of a faulty swallowing mechanism. They are not, in and of themselves, the problem. Faulty swallowing can be an intermittently occurring event, or a continuous, every-swallow event. Probing analyses of the biomechanical subcomponents of the swallowing event reveal the underlying physiological problems causing these faulty events. And, more often than not, they are directly associated with the systemic consequences of the patient’s primary illness or disease. Dysphagia is but one outward symptom of the current primary medical condition. In-depth analysis insight and understanding cannot come from simple observational screenings using food trials designed to detect dysphagia through subjective responses of coughing, throat clearing, eye-watering, and runny nose. If dysphagia is a suspicion, based upon results from appropriate screening tools, instrumental assessments (FEES, VFSS) should (or must) be the next required step. Their use is to reveal and confirm the dysphagic disorder, and its characteristics and intricacies. If the biomechanical mechanisms cannot be directly observed and analyzed, then no decisions should not be made regarding water intake, diet consistencies, or alternative feeding, i.e. “If you can’t see it, you cannot analyze it, and you cannot talk about it.” Failure to directly observe and analyze repeated test trials leads to intuitively-deduced decisions based upon unsupported results. Such decisions ultimately penalize the patient, alter quality of life, and possibly add the complicating consequences of dehydration, malnutrition, pneumonia from aspiration, and choking risks. Practices derived from faulty decisions may be viewed as malpractice through patient neglect and abuse.
Clinical decisions providing the highest level of care are made from a working knowledge of the patient’s current and past medical histories, from current knowledge of the patient’s condition using recognized assessment tools and data-supported findings, and from incorporating professional knowledge and experiences with standard clinical practices. Ethical questions are raised when the patient’s well-being and daily life are readily compromised by questionable clinical decisions which cannot or do not advance the patient’s improvement. Example: A patient, currently on a puree and thickened liquid diet is administered an instrumental assessment. Recorded observations and post-study analyses showed the patient can safely and efficiently swallowing all food consistencies. However, the facility SLP decided not to advance the patient to a regular diet. The rationale: because he “had dysphagia in the past, and, even though he has a normal swallow now, may redevelop dysphagia in the future and could possibly aspirate. I’d rather be safe than sorry later.”
Swallowing is a very complex, reflexive neurosensory-motor event generating timed sequences of neuromuscular force and pressure to convey necessary hydration and nutrition from the mouth to the stomach for processing. In addition, these events continuously push secretions through the oropharyngeal cavities as maintenance and preventative functions to rinse its surfaces of debris and to control pathogens. When dysphagia develops as a result of a major health impairment event, these functions may be altered with the potential for development of dehydration, malnutrition, pneumonia, and/or choking asphyxiation. For management of swallowing disorders, clinical decision-making is a complex process dependent upon good academic preparation, rich clinical experiences, good assessment tools, consistent and evidence-based clinical skills, and a high appreciation for clinical ethics. Decisions are made to do no harm and to improve the quality of human life, from the very young to the very old, which is worthy of our best efforts always.
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