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Langeroudi H, Feint G, Smith CH. Developing a care bundle for children who are eating and drinking with acknowledged risk: A Delphi study with speech and language therapists. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024. [PMID: 39315542 DOI: 10.1111/1460-6984.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 08/19/2024] [Indexed: 09/25/2024]
Abstract
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.
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Affiliation(s)
- Heideh Langeroudi
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Georgina Feint
- Evelina London Children's Community Speech and Language Therapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
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Poon FMM, Ward EC, Burns CL. Identifying prioritised actions for improving dysphagia services in Singapore: Insights from concept mapping with patients and caregivers. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024; 59:1018-1031. [PMID: 37936543 DOI: 10.1111/1460-6984.12977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/13/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Person-centred services are inherently related to patients/caregivers' needs. However, the extent to which dysphagia services within Singapore meet consumer needs is largely unknown. Involving patients/caregivers in service evaluation/redesign deepens the understanding of consumer needs. This process also increases the success of implementing service enhancements through relevant and meaningful change. AIM This study aimed to identify aspects of dysphagia services, within acute and subacute settings in Singapore, perceived as highly important and easy to change by patients/caregivers. METHODS & PROCEDURES Using concept mapping methodology, 5 patients and 11 caregivers reflected on their experiences of receiving dysphagia care and proposed 59 unique suggestions to improve dysphagia services within Singapore. Then, each individual sorted the suggestions into groups based on similarity and rated each statement for its perceived importance and changeability for service enhancement. Data were analysed using multidimensional scaling, hierarchical cluster analysis, and bivariate analysis to generate clusters of conceptually similar suggestions and a prioritised list of suggestions for service enhancement. RESULTS Twelve clusters were identified, with most rated as more important than changeable for service improvement. Participants prioritised 23 (39%) of the suggestions as highly important and easy to change, and these focused on ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. CONCLUSION These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients/caregivers. WHAT THIS PAPER ADDS What is already known on this subject Little is known about patients and caregivers' experiences and expectations of receiving dysphagia services in Singapore. Consulting them in service review and improvement deepens understanding of their needs and increases the success of implementing meaningful service enhancements. What this study adds to existing knowledge This study shows that patients and caregivers in Singapore identified a wide range of dysphagia service issues and prioritised a list of suggestions for service improvement. They prioritised four key areas for service optimisation: ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. What are the clinical implications of this work? This research highlights the importance of considering the consumers' perspectives in service review and redesign. Patients and caregivers in Singapore identified four prioritised areas for service enhancements. These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients and caregivers.
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Affiliation(s)
- Flora M M Poon
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Rehabilitation, Ng Teng Fong General Hospital and Jurong Community Hospital, National University Health System, Singapore, Singapore
| | - Elizabeth C Ward
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia
| | - Clare L Burns
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Speech Pathology & Audiology Department, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Queensland, Australia
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Poon FMM, Ward EC, Burns CL. Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-14. [PMID: 38439695 DOI: 10.1080/17549507.2023.2297653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
PURPOSE Optimising dysphagia service delivery is crucial to minimise personal and service impacts associated with dysphagia. However, limited data exist on how to achieve this in Singapore. This study aimed to develop prioritised enhancements that the speech-language pathology workforce perceived as needed to improve dysphagia services in Singapore. METHOD Using a concept mapping approach, 19 speech-language pathologists (SLPs) and 10 managers listed suggestions for dysphagia service optimisation. Within their groups, the collated suggestions were sorted based on similarity, and individually rated on a 5-point scale based on importance and changeability. Using cluster and bivariate analysis, clusters of similar suggestions and prioritised suggestions for service optimisation were identified. RESULT The SLPs and managers proposed 73 and 51 unique suggestions respectively. Six clusters were identified for each group, with similar themes suggesting agreement of service improvements. All clusters were rated as more important than changeable. The managers perceived services as easier to change. The SLPs and managers rated 37% (27/73) and 43% (22/51) of suggestions, respectively, as high priority, with similarities relating to workforce capacity and capability, support and services access, care transitions, and telehealth services. CONCLUSION Prioritised enhancements identified by SLPs and managers provide direction for dysphagia service optimisation in Singapore.
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Affiliation(s)
- Flora M M Poon
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Rehabilitation, Ng Teng Fong General Hospital and Jurong Community Hospital, National University Health System, Singapore, Singapore
| | - Elizabeth C Ward
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
| | - Clare L Burns
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Speech Pathology & Audiology Department, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
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Martin M, Kendall S, Uveges MK. Traumatic Brain Injury, Dysphagia, and the Ethics of Oral Intake. AACN Adv Crit Care 2023; 34:255-262. [PMID: 37644626 DOI: 10.4037/aacnacc2023789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Michael Martin
- Michael Martin is Professional Development Director, Tufts Medical Center, Boston Dispensary Building, 29 Bennet St, Boston, MA 02111
| | - Sarah Kendall
- Sarah Kendall is Professional Development Director, Tufts Medical Center, Boston, Massachusetts
| | - Melissa Kurtz Uveges
- Melissa Kurtz Uveges is Assistant Professor, Boston College, Connell School of Nursing, Chestnut Hill, Massachusetts
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Koomson D, Freeth H, Goodwin A, Srivastava V. Hard to swallow? A review into dysphagia care in patients with Parkinson's disease. Br J Hosp Med (Lond) 2023; 84:1-4. [PMID: 36848163 DOI: 10.12968/hmed.2022.0497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The National Confidential Enquiry into Patient Outcome and Death reviewed the quality of dysphagia care provided to patients with Parkinson's disease admitted to hospital when acutely unwell. It highlights both clinical and organisational changes that should be made to improve patient care and outcomes.
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Affiliation(s)
| | - Heather Freeth
- National Confidential Enquiry into Patient Outcome and Death, London, UK
| | - Alexander Goodwin
- National Confidential Enquiry into Patient Outcome and Death, London, UK
| | - Vivek Srivastava
- National Confidential Enquiry into Patient Outcome and Death, London, UK
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Readmissions to hospital following a decision to eat and drink with acknowledged risk. Geriatr Nurs 2023; 50:90-93. [PMID: 36689850 DOI: 10.1016/j.gerinurse.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023]
Abstract
People with a dysphagia may eat and drink with acknowledged risks (EDAR). The FORWARD care bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) is used at our hospital to support patients who are EDAR. This two-year retrospective study of patients supported by FORWARD aimed to determine incidence of EDAR-related readmissions and effects of discharge location and documented preferred place of care in advance care plans. Of 316 patients supported by FORWARD, 200 were discharged alive. 63% (n=126) were not readmitted within six months. Of 74 patients readmitted, 49% had an EDAR-related readmission. Significantly fewer patients wishing to remain at home had EDAR-related readmissions (7%, n=4) than those without a documented preferred place of care (23%, n=30, p<0.01), suggesting advance care plans are effective. Significantly more (23%, n=29) patients discharged to private homes had EDAR-related readmissions than those in nursing/care homes (10%, n=6, p<0.05), which could suggest residential care provides more support.
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Weaver MS, Geppert CMA. Sometimes a difficult decision to swallow: Ethical dilemmas when patients with dysphagia who lack capacity want to eat. J Pain Symptom Manage 2023; 65:e97-e102. [PMID: 36272543 DOI: 10.1016/j.jpainsymman.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Meaghann S Weaver
- VHA National Center for Ethics in Health Care (M.S.W., C.M.A.G.), Washington, District of Columbia, USA; Department of Pediatrics (M.S.W.), University of Nebraska Medical Center, Omaha, Nebraska, USA.
| | - Cynthia M A Geppert
- VHA National Center for Ethics in Health Care (M.S.W., C.M.A.G.), Washington, District of Columbia, USA; Departments of Psychiatry and Internal Medicine (C.M.A.G.), Ethics Education, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Atkinson K. Shared decision making in dysphagia. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S21-S24. [PMID: 35797077 DOI: 10.12968/bjon.2022.31.13.s21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Katie Atkinson
- Highly Specialist Speech and Language Therapist, Northern Care Alliance NHS Foundation Trust, Manchester
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Carvalho IP, Dores AR. Clinical Communication in Rehabilitation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127268. [PMID: 35742516 PMCID: PMC9223282 DOI: 10.3390/ijerph19127268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Irene P. Carvalho
- Medical Psychology Unit, Clinical Neurosciences and Mental Health Department, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Correspondence:
| | - Artemisa R. Dores
- Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-465 Porto, Portugal;
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, 4099-002 Porto, Portugal
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Jackson B, Wong C, Miles A. Health professionals' perceptions of complex feeding decision-making in school-aged children. J Paediatr Child Health 2022; 58:791-795. [PMID: 34791752 DOI: 10.1111/jpc.15834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Bianca Jackson
- Speech Science, University of Auckland, Auckland, New Zealand
| | - Celine Wong
- Speech Science, University of Auckland, Auckland, New Zealand
| | - Anna Miles
- Speech Science, University of Auckland, Auckland, New Zealand
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Sommerville P, Hayton J, Soar N, Archer S, Fitzgerald A, Lang A, Birns J. Prognosis in dysphagic patients who are eating and drinking with acknowledged risk: results from the evaluation of the FORWARD project. Age Ageing 2022; 51:6530456. [PMID: 35180285 DOI: 10.1093/ageing/afac005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Sommerville
- Department of Stroke Medicine, Guy’s and St Thomas’ NHS Trust, St. Thomas’ Hospital, London SE1 7EH, UK
| | - Jonathan Hayton
- Department of Stroke, Guy’s and St. Thomas' Hospital, London, SE1 7EH, UK
| | - Naomi Soar
- Department of Speech and Language, Guy’s and St Thomas' Hospital, London SE1 7EH, UK
| | - Sally Archer
- Department of Speech and Language, Guy’s and St Thomas' Hospital, London SE1 7EH, UK
| | - Adam Fitzgerald
- Integrated Local Services, Guy’s and St Thomas' Hospital, London, SE1 7EH, UK
| | - Alex Lang
- South West London Health and Care Partnership, NHS South West London CCG, London, SW19 1RH, UK
| | - Jonathan Birns
- Department of Stroke Medicine, Guy’s and St Thomas’ NHS Trust, St. Thomas’ Hospital, London SE1 7EH, UK
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Gabriel LB, Rossetto EDM, Martins VB, Berbert MCB. Speech therapy aspects in patients’ palliative care. REVISTA CEFAC 2021. [DOI: 10.1590/1982-0216/202123610421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Purpose: to describe the speech therapy aspects of patients treated by the palliative care team in a hospital. Methods: an observational and cross-sectional study, performed from medical records of patients treated under Palliative Care Program, in a hospital, from July to September 2018. Information from the anamnesis and speech-language assessments, which were analyzed by frequency measures, were collected. Results: the sample was composed by 41 medical records, including 25 males and 16 females, with an average age of 61.2 years and hospitalization average time of 20.7 days. Oral feeding was present in 73% of the sample. It was observed that 24% of the patients had impaired expressive language, 56% had reduced maximum phonation times and 34% showed altered mobility phonoarticulatory organs. For swallowing, 22% showed difficulty in some consistency. A nutritional feeding was verified in 74% of the sample and the remaining was making use of comfort feeding. In relation to assistance, 46% of the sample was under management, 7% in therapy, and the remaining did not have follow-up indication. Conclusion: relevant alterations to orofacial motricity, voice, language and swallowing were found in patients under palliative care.
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Affiliation(s)
| | | | | | - Monalise Costa Batista Berbert
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
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Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review. J Am Med Dir Assoc 2020; 21:1852-1861.e8. [DOI: 10.1016/j.jamda.2020.05.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 01/19/2023]
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Emmerich K, Müller-Simianer E, Penner H, Zieschang T. Dysphagietherapie in der Geriatrie: Abwägungen zwischen Lebensqualität und Risiko – eine qualitative Studie. Ethik Med 2020. [DOI: 10.1007/s00481-020-00597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Radford C, Marshall J, Herbert A, Irving H, Weir K. Risk Feeding: An Australian Pediatric Palliative Care Perspective. ACTA ACUST UNITED AC 2020. [DOI: 10.1044/2020_persp-19-00032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Purpose
This article explores the challenges of risk feeding from an Australian Paediatric Palliative Care perspective. There is currently limited evidence to guide risk feeding in pediatric clinical practice. Therefore, this article uses evidence from the adult palliative and end-of-life care context (extrapolating to pediatric application), in addition to the authors' clinical experience in supporting children and their families with risk feeding. Recommendations for the clinical management of pediatric risk feeding are discussed, including the suggested focus for families and the interprofessional team along the different phases of the palliative care continuum.
Conclusion
There is currently limited information to guide decision making regarding risk feeding in pediatrics. Overall, in the absence of evidence-based practice guidelines, it is the authors' recommendation that a risk feeding plan is developed in consultation and collaboration with the family, treating physician, and interprofessional team. Further research is required to support guidance for clinicians working in this area.
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Affiliation(s)
- Claire Radford
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Jeanne Marshall
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Anthony Herbert
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Helen Irving
- Children's Health Queensland Hospital and Health Service, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kelly Weir
- Gold Coast Hospital and Health Service, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review. Dysphagia 2020; 36:54-66. [PMID: 32239275 DOI: 10.1007/s00455-020-10107-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
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.
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Schwarz M, Coccetti A, Cardell E. Clinical decision-making for complex feeding decisions: A national survey of current approaches and perspectives. Australas J Ageing 2019; 39:e110-e118. [PMID: 31364801 DOI: 10.1111/ajag.12708] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Maria Schwarz
- Speech Pathology Department, Logan Hospital, Loganlea, Queensland, Australia.,School of Health and Rehabilitation Science, University of Queensland, Brisbane, Queensland, Australia
| | - Anne Coccetti
- Speech Pathology Department, Logan Hospital, Loganlea, Queensland, Australia
| | - Elizabeth Cardell
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Murray A, Mulkerrin S, O’Keeffe ST. The perils of 'risk feeding'. Age Ageing 2019; 48:478-481. [PMID: 30939597 DOI: 10.1093/ageing/afz027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 11/13/2022] Open
Abstract
'Risk feeding' policies, for when people continue to eat and drink despite a perceived risk of choking or aspiration have become common in recent years. We argue that 'feeding' is demeaning language if referring to a person who is eating and drinking rather than to a healthcare technique and that 'risk-anything' is not how decisions are reached. It is true that patients with dysphagia are often unnecessarily designated nil-by-mouth (NBM), especially after a decision has been made that tube feeding is not indicated or is unwanted. However, risk-feeding policies may perpetuate common misperceptions that there is a straightforward relationship between aspiration and pneumonia and that interventions like NBM or tube feeding will reduce the risk of pneumonia. Such policies may reduce the potential for individualised and flexible decision making: many people's swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. There is also the potential for delays in providing food, fluid and medications if meetings must be held and risk-feeding paperwork completed and signed by someone with the necessary seniority and confidence. Further debate and discussion is required before risk-feeding policies become an established standard of care.
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Affiliation(s)
- Aoife Murray
- Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland
| | - Siofra Mulkerrin
- Department of Speech and Language Therapy, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, UK
| | - Shaun T O’Keeffe
- Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland
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Abstract
PURPOSE OF REVIEW To present current literature regarding swallowing function in advanced age, including healthy ageing, dysphagia and trends in multidisciplinary team service delivery. RECENT FINDINGS Normative studies support swallowing efficiency but greater variability in healthy advanced age, through to 100 years old. Deviations from normative data and symptoms of dysphagia leading to aspiration or nutritional risk, imply swallowing disorder, rather than simply the ageing process. Quantitative and qualitative studies are emerging that promote management of swallow dysfunction for an ageing society, including innovative assessment, home treatment, swallowing exercise and optimized mealtimes. SUMMARY Current literature on swallowing function in advanced age provides multidisciplinary perspectives and initiatives, with clear commitment to improving quality of life for older adults. The diversity of the older population and serious consequences of swallowing difficulties calls for routine screening tools for swallowing impairment and malnutrition risk. Representation of 'oldest old' in future normative studies is essential to guide swallowing management in adults over 85 years old.
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Hansjee D. An Acute Model of Care to Guide Eating & Drinking Decisions in the Frail Elderly with Dementia and Dysphagia. Geriatrics (Basel) 2018; 3:geriatrics3040065. [PMID: 31011100 PMCID: PMC6371181 DOI: 10.3390/geriatrics3040065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 11/16/2022] Open
Abstract
People with dementia frequently develop dysphagia (swallowing impairment), which causes them to be at high risk of aspiration pneumonia, resulting in hospital admissions. These individuals are advised against alternative nutrition and hydration as this does not eliminate the risk of developing chest infections. The purpose of this study was to establish the impact on length of stay by having a protocol to guide eating and drinking despite aspiration risks (risk feeding). A risk-feeding protocol was developed and implemented in a hospital setting. The quality improvement methodology of Plan-Do-Study-Act (PDSA) was employed to evaluate the impact of a protocol on the length of stay in patients with dementia and aspiration pneumonia. Annual audits (2016-2018) on the time taken from admission to when a route of nutrition was established were conducted, with adaptations made to the protocol. There was a reduction in nutrition planning times with each year. On closer evaluation of the data, improved nutrition planning times for this cohort impacted on a shorter length of stay. Having a model of care in place to guide feeding decisions in dementia coordinates care, as demonstrated in timely decision-making. For patients who are admitted with aspiration pneumonia and dementia, a decreased length of stay is evident.
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Affiliation(s)
- Dharinee Hansjee
- Lewisham & Greenwich NHS Trust, Queen Elizabeth Hospital, London, SE18 4QH, UK.
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McHutchison L, Miles A, Spriggs D, Jayathissa S. Management of feeding decisions in hospitalised adults with severe oropharyngeal dysphagia. Australas J Ageing 2018; 37:E120-E126. [DOI: 10.1111/ajag.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Anna Miles
- Speech Science; University of Auckland; Auckland New Zealand
| | - David Spriggs
- Auckland Hospital; Auckland District Health Board; Auckland Mail Centre; Auckland New Zealand
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