If you’ve worked in dysphagia long enough, you’ve probably heard it too.
“I just want some water.”
“My mouth is so dry.“
“The thickened drinks just don’t hit the same.”
They just want water—cold, clear, simple water.
I can’t count the number of patients who have said that to me over the years. Patients who are NPO. Patients on thickened liquids. Patients who haven’t had a sip of plain water in days, weeks, or even months. Their mouths are dry, their lips cracked, their motivation low. And almost every time, when I ask what they miss most, the answer is the same:
“A glass of cold water.”
It’s one of the reasons I’ve always appreciated the Free Water Protocol—the approach many people know as the Frazier Water Protocol.
While the name varies, the purpose is the same: to support hydration, dignity, and patient-centered care while still maintaining safety.
What Is the Free Water Protocol?
The Free Water Protocol is designed for patients who are:
- NPO
- on thickened liquids
but who may safely have regular, thin water outside of meals under specific conditions.
The key principles include:
✔ Water is allowed between meals
Patients may drink regular thin water at least 30 minutes after eating.
✔ Oral care comes first
Good oral hygiene is the foundation of the protocol.
Patients must complete excellent oral care (brushing teeth, cleaning the oral cavity) before having water.
✔ No water with medication or food
Medications still require the prescribed liquid consistency.
Water should not be used to wash down food or pills.
✔ Therapist oversight is essential
This is not a one-size-fits-all protocol.
The SLP and care team determine eligibility based on:
- cognitive status
- mobility
- ability to handle oral secretions
- medical complexity
- instrumental assessment results
When used appropriately and monitored well, research has shown that free water protocols can be safe, support hydration, and improve patient satisfaction until the patient is ready for thin liquids at all times.
Why Water Matters More Than We Think
We talk a lot about aspiration. Risk. Textures. Penetration. Efficiency.
But hydration is often the quiet, overlooked piece of the puzzle.
Patients on thickened liquids often:
- drink less
- become dehydrated
- experience dry mouth, which worsens oral health
- feel socially isolated at meals
- lose motivation to drink altogether
And dehydration isn’t a small issue—
it impacts cognition, mobility, renal function, skin integrity, and overall recovery.
Water is not only physiologically important. It is psychologically important.
I’ve seen patients light up when they get their first sip of cold water under the protocol.
That first swallow often feels like freedom:
a sense of normalcy in a world where everything has felt restricted.
For many of our patients, water is more than hydration.
It gives them a sense of living and being able to participate in something most others take for granted.
The Evidence Behind the Protocol
Studies of free water protocols (including the Frazier Water Protocol) have shown:
- No significant increase in pneumonia rates when proper oral care and screening criteria are followed.
- Improved overall hydration.
- Higher patient satisfaction and quality of life.
- Increased therapy engagement and compliance.
In other words—
water doesn’t automatically equal danger when given intentionally, with parameters, and with the clinical reasoning of an SLP behind it.
When the Free Water Protocol May Not Be Appropriate
Not every patient is a candidate. Some conditions may be contraindications, including:
- severe cognitive impairment preventing adherence
- absent or ineffective cough
- active aspiration pneumonia
- medically fragile patients with unstable respiratory status
- severely reduced mobility or bedbound patients (depending on facility guidelines)
- poor oral hygiene or inability to complete adequate oral care
Just like every intervention in dysphagia management, clinical judgment is everything and when able, patient and family should be included in the decision-making.
A Patient-Centered Tool in Our Clinical Toolbox
The Free Water Protocol is not a magical fix or a universal solution.
But it is:
- humane
- evidence-informed
- hydration-supportive
- meaningful to patients
And sometimes it gives our patients exactly what they’ve been asking for:
A simple glass of cold water.
A moment of comfort.
A small piece of normal in the middle of a very medical world.
If the majority of patients I’ve worked with over the years could cast a vote, I’m convinced they’d all say the same thing:
“Please… just let me have some water.”
And when the evidence supports it, and the conditions are safe, I’m grateful that we can sometimes say:
“Yes—you can.”
References:
Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9.
Kokush, E. M., Patel, R., Boardingham, C. E., Rothman, B. F., Ward, J., McKay, O. A., … & Glass, N. E. (2024). Assessing knowledge, usage, and perceptions of the frazier free water protocol: a pilot study. Journal of Surgical Research, 293, 381-388.
Gillman, A., Winkler, R., & Taylor, N. F. (2017). Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia, 32(3), 345-361.
Bernard, S., Loeslie, V., & Rabatin, J. (2016). Use of a modified Frazier water protocol in critical illness survivors with pulmonary compromise and dysphagia: a pilot study. The American Journal of Occupational Therapy, 70(1), 7001350040p1-7001350040p5.
Thompson, A., & De Bolfo, J. (2025). Implementation, Indications, and Rationale for Modified Free Water Protocols in Paediatric Dysphagia: A UK Survey. medRxiv, 2025-11.
Dysphagia Ramblings 
Leave a comment