Management of feeding decisions in hospitalised adults with severe oropharyngeal dysphagia

Developing a care bundle for children who are eating and drinking with acknowledged risk: A Delphi study with speech and language therapists

BACKGROUND

There is minimal research and no formal written guidance for speech and language therapists (SLTs) managing children eating and drinking with acknowledged risks (EDAR). Many SLTs lack confidence due to the complexity of these cases medically, ethically and emotionally. Guidance is recommended to aid paediatric EDAR management.

AIMS

To establish consensus amongst expert paediatric SLTs regarding core components of a care bundle guiding the management of children who are EDAR.

METHODS & PROCEDURES

A two-round online modified Delphi technique was used. An expert panel of UK SLTs working across paediatric settings (education, hospital, community) were recruited using snowball sampling. Both rounds comprised 36 statements related to potential components of a care bundle, which participants rated on a 7-point scale (strongly agree to strongly disagree), and one open-box question. Consensus was calculated using predetermined criteria (percentage, median and interquartile range) and the final list was ranked by level of importance (mean).

OUTCOMES & RESULTS

A total of 35 participants completed round 1, with 31 completing round 2 (88.6% response rate). Thirty out of 36 statements achieved high to very high consensus. The nine statements reaching very high consensus covered topics such as documentation, capacity, safeguarding and person-centred care.

CONCLUSION & IMPLICATIONS

There is a high level of consensus amongst SLTs about core components for a paediatric EDAR care bundle. This study provides a useful starting point for the future development of a care bundle to manage children who are EDAR.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited research and guidance for SLTs managing children who are EDAR. In adult populations, care bundles have been introduced with positive effects (e.g., better patient outcomes, increased standardisation of care and clinician confidence) and are seen as a promising avenue for paediatrics. What this study adds to the existing knowledge To the research team's knowledge, this is the first published Delphi study on SLT opinion around a care bundle for paediatric EDAR. There were high levels of consensus amongst UK SLTs and the results highlighted documentation, capacity, safeguarding and person-centred care as key areas in practice. Finally, the results provide a ranked list of components UK SLTs felt are important for developing a care bundle. What are the practical and clinical implications of this work? This study could be a useful starting point for creating a care bundle to support the management of children who are EDAR.

South African speech-language therapists' practices regarding feeding tube placement in people with advanced dementia

BACKGROUND

 Studies related to tube feeding in people with dementia (PWD) remain a contested topic, neglecting the importance of speech-language therapists' (SLTs) role in dysphagia management. Furthermore, SLT practices and beliefs regarding tube feeding in people with advanced dementia in an upper-middle-income country, such as South Africa, are unexplored.

OBJECTIVE

 This study aimed to determine the practices and beliefs of SLTs in South Africa regarding tube feeding placement in PWD.

METHOD

 A self-compiled online survey was distributed using social media platforms and was completed by 83 South African SLTs with experience in swallowing and feeding management of PWD.

RESULTS

 Most SLTs (78.8%) strongly believed they play a vital role in the decision-making regarding feeding tube insertion in PWD. This role is often met with several challenges, such as limited support from other healthcare professionals. Speech-language therapists with more experience and increased involvement in palliative care appeared to be more confident in supporting and counselling families of PWD on tube feeding. Many SLTs still recommend tube feeding despite its known negative consequences for PWD.

CONCLUSION

 The findings indicate a need for continued professional development for South African SLTs on feeding decisions in advanced dementia to increase knowledge and confidence in clinical practice. Speech-language therapists require guidelines by professional bodies and further dialogue amongst healthcare professionals to guide difficult feeding decisions in people with advanced dementia.

Health professionals' perceptions of complex feeding decision-making in school-aged children

AIM

Whilst prevalence of paediatric feeding disorders is high amongst children in specialist schools, there is little guidance for professionals supporting families with a child feeding orally with established risk of aspiration. We sought perceptions of the complex feeding decision-making process amongst health professionals supporting families in the specialist school setting in New Zealand.

METHODS

An observational, cross-sectional, national online survey of speech-language therapists was followed by in-depth interviews with seven health professionals associated with one specialist school.

RESULTS

Survey responses from 32 speech-language therapists showed inconsistency in assessment processes and how family, children and school staff are involved in feeding decisions, with 71% reporting a doctor had been involved. Respondents were not confident in their ability to predict aspiration risk, with 41% reporting that they could often determine risk, 41% sometimes and 16% never. Sixty-three percent of respondents indicated that level of risk was written in a report for a child and 50% reported that every child at high risk had a management plan. Speech-language therapists valued professional supervision, but it was not always available. Health professionals were broadly positive about the collaborative nature of decision-making in most but not all situations. They described communication, access/institutional and emotional barriers to timely, shared decision-making.

CONCLUSION

These findings demonstrate variability in how families are supported to make complex feeding decisions. Health professionals identified a need for clearer processes and strengthened communication between family, school and health professionals. Trusting relationships are critical if all families are to be well-supported.

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

BACKGROUND

patients with a permanently unsafe swallow may choose to eat and drink with acknowledged risk (EDAR). Informed decision-making and advance care planning depend on prognosis, but no data have yet been published on outcomes after EDAR decisions.

METHODS

the study was undertaken in 555 hospital inpatients' (mean [SD] age: 83 {12}) EDAR supported by the Feeding via the Oral Route with Acknowledged Risk of Deterioration care bundle between January 2015 and November 2019. Data were collected prospectively on clinical characteristics, dates of discharge, readmissions and death (where relevant). Kaplan-Meier survival functions and readmission risks per surviving patient per month were calculated.

RESULTS

mortality is 56% in the first 3 months after discharge but then mortality risk sharply decreases. The 3-month survival in EDAR patients was more likely in those <75 years of age, those with Parkinson's disease or a structural oral lesion as the dominating cause of dysphagia and those with mental capacity regarding EDAR decisions. Readmission risk in the 3 months post-discharge is 21% but reduces to 12% thereafter (P < 0.001). Thirty-eight percent of readmissions are secondary to EDAR-linked conditions such as chest infections and reduced oral intake.

CONCLUSION

there is a high mortality and readmission risk after an EDAR decision but much of this is frontloaded into the first 3 months, with a relatively favourable prognosis thereafter. This may be an appropriate time-point to reassess the plan for eating and drinking such that it continues to reflect the most appropriate balance of risk, comfort and nutrition.

Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review

BACKGROUND

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests.

OBJECTIVE

This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol.

METHODS

PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed.

RESULTS

8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology.

CONCLUSION

There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

Clinical decision-making for complex feeding decisions: A national survey of current approaches and perspectives

OBJECTIVES

Decision-making around dysphagia management is becoming increasingly challenging due to the complexity of contexts associated with an ageing population. The current study explores current decision-making practices used by speech language therapists (SLTs) surrounding contexts related to palliative care, dementia, neuro-degenerative diseases, guardianship/family decisions, and other issues relevant to ongoing care of individuals with dysphagia.

METHODS

An exploratory prospective electronic survey of SLTs was conducted. A total of 202 respondents were eligible for inclusion.

RESULTS

Only 55% of respondents reported their workplace had a standard approach to documentation. Only 19% reported their service had a defined policy to support decision-making, with only 28% reporting the existence of patient information brochures.

CONCLUSION

Limited formal guidance or practice standards exist in the setting of complex dysphagia management, which limits the consistency of practice and clinical efficiency. This insight into current practices and perspectives supports the development of clinical guidelines.