The Role of Speech Pathologists in Regards to Determining Feeding Tube Placement
melissa n., SLP
As a Speech Pathologist working in the long term care setting, dysphagia and the effects that it has on a patient and his or her overall health status are a daily battle. In 1999, 46.9% of Speech-Language Pathologists reported that they regularly serve individuals with dysphagia on their caseload. The percentage exceeded 91% for professionals working in hospitals and residential health care settings (ASHA, 2000). The recommendation for “NPO with alternate means of nutrition” is not one that is easily determined, and the decision making that follows for the patient and his or her family is difficult, to say the least. It is essential that Speech Pathologists are well-versed on the advantages and disadvantages related to the placement of feeding tubes and the effects that non-oral nutrition may have on the patient and his or her family psychosocially. The risk of aspiration with oral intake, the quantity of oral intake a patient is exhibiting, and the quality of life for the patient in regards to eating and drinking are factors to consider when determining whether or not a feeding tube placement is appropriate for an individual.
Studies have shown that the risk of aspiration is not alleviated by feeding tube placement. While we sleep, the relaxation of the G.I. musculature places us at risk for aspiration of reflux. When no dysphagia is present, one is able to protect the airway, even during sleep. A patient with dysphagia is unable to protect the airway adequately at times, and therefore, is still at risk for aspiration even when a feeding tube is utilized. Patients and families need to be aware that placement of a feeding tube does not eliminate the risk of aspiration, it reduces it.
Many referrals in the long term care setting are the result of weight loss and decline in quantity of oral intake. Even when dysphagia (“difficulty in swallowing or inability to swallow”) is not the cause, counseling the patient, caregivers and family regarding feeding tube benefits and risks, diet modifications, and nutrition and hydration facts is still a key role for the Speech Pathologist. Although a patient may have swallowing skills which are intact, a Speech Pathologist may be involved in order to educate caregivers and family about strategies to encourage oral intake and about feeding tube risks and advantages. Elderly folks frequently experience loss of appetite or interest in eating accompanied by significant weight loss which may result in illness and/or lack of energy and strength that younger people usually have. Pain or discomfort with eating (caused by dysphagia, indigestion or ill-fitting dentures), as well as “forgetting to eat” or “forgetting HOW to eat” are cognitive deficits which can be addressed through compensatory strategies or environmental modifications. Diminished appetite may indicate pain, worsening heart failure, depression, dementia or the beginnings of pneumonia, and these possibilities should be investigated by interdisciplinary team members. (senoirlinkonline.com) A reduction in oral intake due to physiological or psychological factors may indicate a consideration for feeding tube placement to ensure adequate nutrition and hydration.
“Nothing would be more tiresome than eating and drinking if God had not made them a pleasure as well as a necessity.” (Voltaire) How true!!! For the dysphagic patient, the patient with a poor appetite, or one who, due to a cognitive deficit either forgets to eat, forgets how to eat, or thinks that he or she has already eaten at times, oral intake is a chore. Measures must be taken with this clientele to ensure that meals are as appealing as possible and that the patient is encouraged to eat meals, without making the patient feel forced. On the other end of the spectrum is the patient for whom oral intake is a risk or for whom diet modifications are indicated, and the desire for foods and/or liquids which have been shown to be a risk for aspiration is present. For many patients, food is a source of pleasure, and quality of life and personal choice needs to be considered. Many family members and friends show affection through bringing the patient his or her favorite foods (“food is love”) and the decision as to whether or not a feeding tube should be placed is more complex than just a matter of nutrition and hydration. Quality of life is a key factor in determining whether or not a patient is a candidate for feeding tube placement.
Regardless of the reason, when feeding tube placement is indicated, Speech Pathologists can assist patients, family members, and interdisciplinary team members in decision making by providing information, resources, and emotional support. There are many perspectives from which to consider whether feeding tube placement is the best option for a patient who has feeding or swallowing issues. In the end, it is, as always, what is ultimately best for the patient as an individual, all factors considered, that needs to be determined.
Tell me what you eat, I’ll tell you who you are. ~Anthelme Brillat-Savarin