Feeding and Swallowing

Overview of Issue

In the presence of feeding or swallowing issues, a patient’s decision not to adhere to a recommended diet or treatment plan or a family’s decision to provide contraindicated foods may have implications for the patient’s safety (e.g. morbidity related to dysphagia). In these instances, it is the responsibility of healthcare providers to adequately educate the patient and their family about the rationale for the recommended diet or treatment plan and the consequences of choosing not to follow it. When ethical issues arise, other members of the multidisciplinary team (e.g. bioethics) should be involved as appropriate.

Key points

• Before making diet recommendations, it is important that healthcare professionals know and respect the patient’s values and preferences.

Things to Consider

• Request a capacity assessment, when appropriate to establish the patient’s competence to make informed decisions (e.g. Does the patient have the capacity to understand the reasonable foreseeable consequences of eating contraindicated food?). Depending on the organization, this may be the most responsible practitioner (MRP) or other disciplines making the request.
• The physical/psychological ramifications to the patient (and possibly healthcare providers) if the patient receives contraindicated food.
• The patient’s/family’s values and beliefs in determining what, if any, dietary restrictions are placed on the patient.
• The social importance of food (e.g. demonstrates membership in families and communities).
• Consult an ethicist about ethical dilemmas which may arise regarding the provision of solid food to a patient with swallowing issues (particularly for contraindicated feeding of solids at end of life).
• Support healthcare providers who are personally and/or professionally opposed to a plan of care (i.e. permitting the patient to eat contraindicated foods despite choking hazards and/or who experience value-conflicts when patients choose alternative feeding routes). Involving bioethics or using an ethics framework will assist in identifying and working through the moral distress of staff. In this instance, alternative healthcare providers should be identified to provide care.

Background on Feeding and Swallowing

• Anything that interferes or impairs with any normal swallowing phases is defined as dysphagia, which may cause morbidity and mortality (Palmer, Drennan & Baba, 2000).
• Swallowing and feeding disorders occur with multiple medical diagnoses across the age spectrum. Incidence and prevalence vary among diagnostic groups.
• Coughing, choking, delay in swallowing, drooling, and leakage of food or liquid from the mouth are examples of feeding and swallowing issues.

Strategies for Feeding and Swallowing Issues

• Ensure the patient receives a dysphagia risk assessment (e.g. clinical swallowing and feeding evaluation). Document the assessment and include in the patient’s health record.
• Work with the interdisciplinary team responsible for feeding issues; consider a modified diet texture and liquid viscosity based on biting, chewing and eating behaviours.
• Collaborate with patients and their families to develop high-risk eating, drinking and swallowing care plans.
• Provide opportunities for teaching and counselling families about what their family member can safely eat or drink.
• Conduct team and family meetings to discuss a plan of care in the patient’s best interests (e.g. is there a compromise all can live with?).
• Consider alternative routes for provision of nutrition/ hydration (e.g. tube feeding).