The perils of ‘risk feeding’

Murray, Aoife; Mulkerrin, Siofra; O'Keeffe, Shaun T

doi:10.1093/ageing/afz027

Cited by 26 publications

(10 citation statements)

References 17 publications

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“…Minimising the risk of aspiration dominated the discourse of many of our participants, despite the widely accepted notion that not all aspiration leads to aspiration pneumonia (Langmore et al, 1998). This narrative reflects a potential tension between involving patients in shared decision making while attempting to minimize risk, as also discussed by others (Murray et al, 2019;O'Keeffe, 2018). Interestingly, in the present study, more experienced clinicians described a more deliberately patient-centred approach compared with a more conservative, risk-averse approach described by their more junior colleagues.…”

Section: Discussionmentioning

confidence: 90%

Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions

Murray

Maloney

Underdown

et al. 2022

Intl J Lang & Comm Disor

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Background The free water protocol (FWP) is an alternate management strategy for patients with dysphagia, who would otherwise be nil by mouth or prescribed thickened fluids, allowing them to drink and potentially aspirate water under strict guidelines to minimize the risk of adverse consequences. The FWP is not widely implemented in acute settings, and it is unclear whether this is due to the complexity of patient presentations, clinician decision‐making or barriers related to the setting. Aims To explore the perceptions and decision‐making process of clinicians about using FWPs to manage dysphagia for patients admitted to acute stroke and general medicine. Methods & Procedures A qualitative, critical realist approach was adopted to allow for in‐depth exploration of the perspectives of four dietitians, seven medical officers, eight registered nurses and 17 speech and language pathologists (SLPs) from three hospitals in a capital city of Australia. Data from semi‐structured interviews were analysed using the Situated Clinical Decision‐Making Framework (CDF). Outcomes & Results Participants were cautious about FWP for patients with neurological conditions, head and neck cancer, dementia, poor immunity, chronic or recurrent respiratory illness, and certain types of stroke. Medical status and the implications for aspiration were paramount, particularly respiratory status, oxygen supplementation, cognitive status, fatigue and mobility. Participants considered patient quality of life, preferences and choices for care, but indicated that factors influencing safety often outweighed patient preference for water. Indirect factors affecting decision‐making included the roles of the multidisciplinary team, individual clinical experience and attitude to risk, and availability of supervision. Conclusions & Implications Despite the benefits of FWPs in other settings, in acute stroke and general medicine, clinicians erred on the side of safety and, in most cases, would not implement an FWP. Future clinical research is needed to systematically design high‐quality and feasible clinical trials to determine the benefits and safety of FWPs for patients with dysphagia in these settings. This would lay the foundations for guidelines to support the complex clinical decision‐making regarding patient suitability for FWPs. WHAT THIS PAPER ADDS What is already known on the subject FWPs are an alternate management strategy for patients with dysphagia, with systematic reviews recommending their use for adults in inpatient rehabilitation with a low risk of pneumonia. However, evidence from the acute setting is sparse, leaving clinicians unsure about which patients might benefit and which may inadvertently be exposed to increased risk by an FWP. What this paper adds to existing knowledge Participants from all interviewed disciplines agreed that SLPs lead the decision‐making process and as such act as ‘gatekeepers’ for access to an FWP. The decision‐making process is complex, and participants acknowledged that disease conditions and il...

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Section: Discussionmentioning

confidence: 90%

Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions

Murray

Maloney

Underdown

et al. 2022

Intl J Lang & Comm Disor

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“…Issues have been raised regarding the RCP guidance on EDAR, with concerns towards the risk management approach being standardised than an evidence-based informed consent approach [6]. With EDAR guidance being published, it is our responsibility as clinicians to ensure patients' rights are protected, while also devoting attention towards the potential barriers such as staff anxiety and knowledge [16]. Adverse events such as pneumonia or choking may be another concern when considering EDAR.…”

Section: Discussionmentioning

confidence: 99%

Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties

Yoshimatsu,

Hansjee,

Markowski

et al. 2024

Eur Geriatr Med

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Purpose Older patients with pneumonia are commonly restricted from oral intake due to concerns towards aspiration. Eating and drinking with acknowledged risks (EDAR) is a shared decision-making process emphasising patient comfort. As part of our project to find the barriers and facilitators of EDAR, we aimed for this initial study to see how frequently EDAR was selected in practice. Methods We performed a retrospective cohort study at an acute hospital where EDAR was initially developed, of patients aged ≥ 75 years-old admitted with pneumonia and referred to speech and language therapy. Results Out of 216 patients, EDAR decisions were made in 14.4%. The EDAR group had a higher 1-year mortality than the modified/normal diet groups (p < 0.001). Pneumonia recurrence rate did not differ significantly between the groups (p = 0.070). Conclusion EDAR decisions were comparatively less common and most were associated with end-of-life care. Underlying reasons for the low EDAR application rate must be investigated to maximise patient autonomy and comfort as intended by EDAR while minimising staff burden.

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“…Continuing careful feeding by mouth is probably appropriate in many cases. Staff may worry about the risk of aspiration and feel that the patient should be ''nil by mouth,'' 44 but the enjoyment of food and social interaction are likely to weigh in the patient's best interest. Health-care workers need to be able to balance compassionate care with ethical professional standards.…”

Section: Ethicsmentioning

confidence: 99%

To What Extent Does Clinically Assisted Nutrition and Hydration Have a Role in the Care of Dying People?

Carter

2020

J Palliat Care

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The question over whether to administer clinically assisted nutrition and hydration (CANH) to a dying patient is controversial, with much debate concerning this sensitive issue. The administration of CANH poses clinical and ethical dilemmas, with supporting and opposing views. Proposed positive effects of CANH include preventing thirst, delirium, hypercalcemia, and opioid toxicity. However, CANH has been shown to increase the risk of aspiration, pressure ulcers, infections, and hospital admissions as well as potentially causing discomfort to the patient. Guidance from several national bodies generally advises that the risks and burdens of CANH outweigh the benefits in the dying patient. However, an individualized approach is needed, and the patient’s wishes regarding CANH need consideration if they have capacity and can communicate. Otherwise, sensitive discussions are required with the family, enquiring about the patient’s prior wishes if there is no advanced care plan and acting in the patient’s best interests. The ethical principles of autonomy, beneficence, non-maleficence, and justice need to be applied being mindful of any cultural and religious beliefs and potential misperceptions.

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The perils of ‘risk feeding’

Cited by 26 publications

References 17 publications

Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions

Patient suitability for free water protocols in acute stroke and general medicine: a qualitative study of clinician perceptions

Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties

To What Extent Does Clinically Assisted Nutrition and Hydration Have a Role in the Care of Dying People?

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