Swallow study in ES Dementia patient

[americanTrain]

How would you approach this situation. A family member comes to you after many weeks of

pt occasionally coughing while eating. Pockets food in mouth and sometimes coughs with thin liquids.

Family member requests a swallow study to be done. Why I ask, we already know what the problem is. She is having trouble swallowing. She is on hospice, why would we need to put her through stressful tests and sometimes lengthy tests just to find out what we already know. I asked her what would she do about it anyway after getting definate diagnosis of difficulty swallowing, would she place a feeding tube for nutrition. She says definately not, so what are we gaining here, but to put hospice patient through the mill. That in my opinion is not comfort care. I doubt medicare would pay for it either.

I always like to be present when a pt eats or is fed to see if they are having any difficulty swallowing. I havent been certified in a bedside swallow study, but I know a problem when I see it.

The symptoms are almost always seen in end stage disease process with dementia . I recommended

that we thicken the fluids and puree the diet on a 3 day trial basis with a nurse or cna always

present during meals to intervene if she should start to aspirate. Also to avoid straws. To my knowledge, aspiration has not occured at this time. Unless it was silent. Lungs always clear and respirations even and unlabored. Pt resides in nursing home and DON and ADON agree with this approach. What would you have done?

Family member ok with trial, but if it doesnt work, still wants swallow study done.

[AtlantaRN, RN]

WHy put a patient through the test when we already know the outcome? Your facility would incur the cost as it is directly related to patients terminal diagnosis. you are doing right by thickening fluids as most folks get choked on thin liquids. Doing the swallow study is outside your plan of care, they can be discharged--have the swallow study done, then put them back on service.....it is what it is, patient is following the normal course for end stage dementia.

[tewdles, RN]

If the hospice medical director and case manager do not agree that a swallow study is appropriate for this patient it will not be ordered. If the family feels strongly that it needs to be done they will have to revoke their hospice benefit, or arrange to have it done in a fashion which will allow them to pay for it themselves.

Have you tried inviting the family member (presumably the MDPOA?) to an IDT meeting?

[americanTrain]

Yes, I have invited the family to IDT's.

This is a family

that is not new to hospice, as we took care of another family member as well. I think its just an

education process, as diagnosis of the father was so extremely different. The family will often hear thier friends say, and give advice; "well, why have they not done a swallow study yet? " Other LTCF residents

have it done, "but they ( are not on hospice)/ / I will continue to teach, because this is what I love to do.

I just wanted to know that someone else agreed with my approach. I will be addressing this

in our next IDT, and again, invite the family to attend. I always do this with all of my pts families

and they never attend. Maybe just a timing issue. But if my mom was on hospice, I'd attend,.

at least every couple of months. Right around recert time?

I will see tomorrow how the patient did on the diet change over the weekend. And so right, that

they may opt to revoke and test anyway. A choice that's always there.

[tewdles, RN]

well, good luck...keep yourself strong. Families such as this are an emotional trap for hospice nurses...

Make sure that MSW is sharing some of the teaching responsibilities with you for this case particularly as they apply to care options.

[americanTrain]

Yes, I have a few families that are emotional traps for me, thank God I have

a wonderful SW who answers her cell anytime I call. And will meet me in a

moments notice.