Prognosis in dysphagic patients who are eating and drinking with acknowledged risk: results from the evaluation of the FORWARD project

An exploration of the experiences and attitudes of healthcare professionals towards enteral tube feeding for adults living in the community following stroke

BACKGROUND

Guidelines recommend enteral feeding via gastrostomy should be considered for adult survivors of stroke with dysphagia who cannot eat or drink sufficiently for >4 weeks. Many people continue long-term tube-feeding via this route in the community where healthcare professionals contribute to their care and nutritional management, although little is known about their experiences of or attitudes towards enteral feeding in this situation. The present study aimed to explore the experiences and attitudes of healthcare professionals working with this patient group.

METHODS

Healthcare professionals were invited to complete a questionnaire devised for the study which comprised closed and open questions about tube-feeding including their patients' participation in feeding processes and mealtimes and how these might be improved. Responses to closed questions were analysed descriptively and free-text responses analysed using thematic analysis.

RESULTS

Fifty-seven participants met the inclusion criteria. They identified patients' quality of life (77% of respondents) and nutritional support (75%) as the most important aspects of tube-feeding. Good communication and training with healthcare teams and carers were considered important. Their patients' participation in tube-feed administration and mealtime involvement were described as variable and potentially beneficial, but both were related to patients' choice and health impairment. Blended tube-feeding was considered an option by 89% provided practical and safety conditions were met.

CONCLUSIONS

Participants' experiences of and attitudes towards tube feeding in adults living with stroke in the community in the sample in the present study are varied and focussed on individual patients' needs, safety and professional standards.

Shared decision making in dysphagia

The term 'risk feeding' usually applies where a person continues to eat and drink despite aspiration. This term has been increasingly challenged. Risk feeding has connotations of risk-taking behaviour and may conflict with healthcare values of keeping people safe. 'Risk' is difficult to quantify in dysphagia and interventions to reduce risk are not risk-free. The relationship between aspiration and pneumonia is complex, as are the success of the interventions designed to prevent them. Attempts to eliminate risk may lead to heavy restriction with unsatisfactory evidence, at a cost to quality of life. The Royal College of Speech and Language Therapists (RCSLT) has introduced a framework for multidisciplinary, person-centered decision making: Eating and Drinking with Acknowledged Risk. Every decision we make carries risk and as humans we balance these based on our personal values and goals. This is supported by the Mental Capacity Act 2005 and it is our role to achieve this for our patients. This article discusses these complexities and describes the RCSLT framework, with particular focus on the role of the nurse.