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Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with signifi cantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The signifi cance and applicability of these fi ndings is discussed.

Dysphagia after stroke is common and has a significant impact on disability, institutionalisation and mortality. Patients who cannot achieve nutrition from food and fluids orally should be considered for a modified diet and/or tube feeding, taking into account their wishes and best interests. This article describes the issues in managing such patients, including feeding with acknowledged risk. The specialist stroke nurse plays a central role in the successful implementation of these strategies, particularly with regard to patient and carer education, monitoring and compliance.

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