EDIT 1/4/17. Due to a recent Facebook post, I wanted to change some wording on this post. As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.
Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”
There was post recently on the Special Interest Group (SIG) 13 email blast. An SLP was asking what to do with a noncompliant patient.
When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged. The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.
My belief system is not the same, fortunately for my patients!
First, think about this. Aren’t the
noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about? The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make. They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe. The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety. That is the patient that may be most at risk for aspiration pneumonia.
In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity. I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.
The best thing we can do for our
noncompliant patients is to educate and rehabilitate. Why not make them safer with the consistency they choose?
The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care. If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow. I recently wrote a post about oral care which you can find here.
It’s important to remember that we want the patient to succeed with the diet they choose to consume. We can recommend a safe diet and we can advise but we have to focus on the rehabilitation. Just remember, not everybody that aspirates develops aspiration pneumonia. There are functional aspirators.
You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia. Just because that patient does not choose the diet you recommend does not mean you give up on them. If they are willing to put in the work and give you some time (they will have to buy-in to your program) THOSE are absolutely patients with whom we should work.