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Discussion

Do we serve a tray

I have a gentleman who can not eat without choking. One bite and he needs to be suctioned. He is alert and oriented and has signed for DNR, DNI, no IVs, no hospitalization, no artificial feeding. He knows if he doesn't eat, he will die and is ready for God to take him home (his words).

My speech therapist has written an order that he be supervised but not fed. She thinks if we feed him we are putting ourselves at risk since we know he's going to choke.

I say people have the right to self determination and he has decided.

Anyone want to weigh in on what you'd do in this situation?

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    So the Speech Therapist has not attempted any modifications to his diet to see if he can swallow thickened foods (pudding or jello)? or is he incapable of swallowing any food and the only alternative is G- tube which he refuses?

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    I'd agree. If this patient is A&Ox4 and competent to make his own decisions, then he has every right to eat. If I were the patient, I'd tell the speech therapist to go to hell.

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    Ya, why haven't they changed the diet. There is a difference between not wanting interventions and not providing the appropriate type of food. If it were me I would talk to the supervisor.

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    Let me clarify: if he refuses to eat the modified diet that is his choice, but it should at least be provided.

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    In this case I think an order stating 'okay to eat for comfort' and maybe a waiver signed saying he's going against STs recommendations, but then I'd feed the guy!

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    • Guides

    Years ago when I worked as an RCM, I had a resident who had had several strokes and needed pudding-thick liquids and pureed foods; otherwise he choked on almost everything. He was, however, A&O x 4 and he refused the modified diet, stating that life wasn't worth living if he couldn't have the foods he enjoyed. We talked to the doctor and the speech therapist, both of whom agreed to change his diet to "as tolerated".

    Well, let me tell you, we all got plenty of chances to hone our Heimlich techniques, but the care plan was in place and all appropriate documentation was done. Occasionally after a bad choking episode I'd ask him if he still wanted the regular diet, and he always said Yes. Ironically, it wasn't food but another series of strokes that took his life a couple of years later, and I've always been glad we went along with his wishes.

    So, in the case of the OP, I'd say get an order for diet as tolerated, care plan it, document that the resident was educated on the risks, and then feed the poor man what he wishes.

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    What happens when you spell it out for him?

    Ie: "If you choke on this, you're going to suffocate, and I am going to have to give you the Heimlich, which will probably break some of your ribs".

    Have you tried pushing mechanical soft foods, like eggs, grilled cheese, etc? Are there any compromises to be had? I had a pt like this, and he ended up chokin on the damn french toast sticks. Those things were hard as a rock! What about requesting his (regular diet) food be prepared a certain way? (Lots of butter on the grilled cheese to make it soft, etc.)

    Are there any nurses/aids who he really likes who could reason with him?

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    I think if he is capable of making his choice to eat then I would have him sign a waiver to protect the facility and then let him eat. Get the MD order for his diet, then care plan his choice to eat and nursing interventions. Document each meal what he ate and the outcome.

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    I will always regret that we did not allow my father to eat something solid that he wanted to before he died. If the man wants real food let him have it. Get an order and document to cover yourselves. We are all going to die of something so why deny this man something that is a natural human want/need?

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    • Author

    I think you all misunderstood. He had a tray of pureed food with honey thick liquids. He could feed himself...we didn't feed him.

    Luckily, this morning at 530am he got his wish and went to heaven.

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    If he wanted me to feed him, I'd feed him.

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    Happy to hear he got his wish. Choking on honey thick pureed food is no way to live.

    But we did have a similar case in which we had a resident who failed a Modified Barium Swallow evaluation miserably. They strongly recommended that she be kept NPO and wanted her family to consider a G-tube. They said absolutely not and wanted her kept on regular food even though she risked aspirating. Our speech therapists ordered a puree diet and 1-1 feed with the suction machine next to her. Thankfully we didn't need it. When I was working I would feed her myself with 1/3 teaspoonfuls for each bite. She did pretty well with that.

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