Edited 1/4/17: In light of a recent Facebook discussion and continued learning (thanks to my amazing patients), I’ve made a few updates to this post. Like all things in dysphagia management, my beliefs and practices evolve as I grow—and that’s a good thing.

Let’s talk about a word that pops up way too often in dysphagia care: noncompliance.

There was a recent discussion on the Special Interest Group (SIG) 13 group where an SLP asked what to do with a noncompliant patient. It brought me back to the early days of my career when the general guidance was: “If they’re noncompliant, discharge them.” The logic? Physicians discharge for noncompliance, and our licenses could be on the line.

But thankfully, my beliefs have changed—because of my patients.

Is It Really Noncompliance?

Maybe it’s time we reframe this label. Rather than calling patients “noncompliant,” what if we recognized them as individuals exercising their right to choose?

Here’s the truth: the patients who choose to go against our recommendations may actually be the ones who need us the most.

Let’s say you recommend a modified diet or thickened liquids to reduce aspiration risk. If a patient refuses and continues drinking thin liquids, are they unsafe? Maybe. But they’re also likely going to continue doing what they want, with or without you. That makes them the patient you can’t afford to walk away from.

Why Discharging Isn’t Always the Right Move

Sure, compliant patients are “safe” on paper—they’re following your recommendations, they’ve got caregiver oversight, and maybe they’re in a facility that enforces the diet. But what about the cognitively intact patient at home who says they’ll follow the rules, then sneaks regular food and thin liquids the moment you walk out the door?

Yep—I’ve seen it time and time again.

Some of my patients have told me they’re on thickened liquids at home, only for their spouse to casually mention during a visit that they’ve been drinking soda all week. (Cue internal scream.)

But here’s the thing: our role isn’t just to prescribe consistency levels and walk away. Our job is to educate, support, and rehabilitate. If a patient is going to continue drinking thin liquids, let’s do everything we can to make them safer while doing it.

Education First. Always.

If my patient is cognitively able, one of the first things I teach them (and their caregivers) is the importance of oral care. The research is clear: aspiration pneumonia is more about what’s in the aspirate (bacteria from the mouth) than the act of aspiration itself.

You can read my full blog post on oral care.

By improving oral hygiene and focusing on rehabilitative therapy, we help our patients build strength and strategies—so they can eat what they choose more safely.

Functional Aspirators Exist

Not everyone who aspirates gets pneumonia. There are people walking around who aspirate every single day and remain pneumonia-free.

I’ve seen patients who aspirate everything on an MBSS, then go home and eat cheeseburgers without issue. Does that mean I give up on them? Absolutely not.

In fact, those are the patients I want to work with the most. Because they’re telling me:
“I’m willing to put in the work if you’ll help me do it safely.”

And that, to me, is the very definition of a motivated patient.

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Bottom line?

Dysphagia therapy is not a one-size-fits-all prescription. It’s about meeting the patient where they are, educating them about the risks, and helping them make informed decisions—even if those decisions don’t match our initial recommendations.

Let’s stop discharging for noncompliance and start supporting patient choice with clinical skill and compassion.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

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