I am dealing with some drama with a patient on hospice for end-stage Alzheimer's at an ALF (darn ALFs!) and was wondering if the community could give me some feedback.
Pt is total assist for all ADLs and has significant dysphagia, yet her husband comes in faithfully three times a day to feed her (and with that I'm sure a lot of you know exactly where this is going!) Diet is pureed.
Recently, pt has had incr coughing, gurgling while feeding. She pockets and takes minutes to swallow. Otherwise afebrile, lungs sounds clear. Facility can NOT thicken, but I ordered thick-it and did nectar-thick teaching with spouse. Unfortunately, while he always smiles and nods and gives me return demonstration, every time I come to the facility, the staff complain that he is not thickening enough, feeds her way too fast and will sit with her for over an hour trying to get her to eat. I sit with him, reinforce teaching, and the cycle begins again.
Earlier this week, pt began coughing and vomiting up liquid at breakfast. Facility freaked out and spouse became angry bcs they refused to feed patient until I assessed. I found her asymptomatic, but ordered a swallow eval to make everyone happy.
Swallow eval concluded what we all know. Patient is at significant risk for aspiration. They recommended pleasure feeding w precautions. Now the facility is basically asking me to police this spouse and are saying that if they see him attempting to feed her too fast or not thicken appropriately, they are going to call Elder Services.
It's important to note that ALFs in my state are SOCIAL MODEL, which means they are considered a "home" environment, NOT a medical environment.
I'm thinking of maybe writing up some sort of "aspiration contract" that the spouse could sign indicating that he understands the risks of aspiration should he continue to be noncompliant. Anyone ever done something like that? Samples?
But beyond that, I don't think there is much I can do... I don't feel comfortable "policing" this guy. If the facility wants to call ES or tell him he can't come in at meal times, I guess that is their prerogative. But I feel like the spouse has verbalized an understanding of the risks and there isn't a way to "force" him to comply, unless I recommend his wife be moved into a skilled setting (as she has no symptoms, it's not like I can GIP or inpatient her).
If this was a home patient, I think I would do my best with teaching and reinforcement, but at the end of the day, I would drive home and leave it to the powers that be. If it was in a SNF, the staff would be able to thicken food appropriately and follow through on interventions in a way the ALF can't. Is there anything I can/should be doing here that I'm not???