SWALLOWING DIAGNOSTICS AND TREATMENT ETHICS: 

Additionally, the healthcare industry has been relentlessly taught that patients typically have difficulty self-advocating (asking questions about their care and verbalizing what they want), however, as a whole the industry continues to use communication techniques that are often demeaning and highly technical in wording. This is unacceptable as it can lead to improper diagnosis, treatment, and even unnecessary procedures. Currently, the SLP field is being pushed into utilizing more evidenced-based practice – this is a good thing! Yet, insurance companies and patients continue to pay for subpar care because they do not know how to self-advocate. The links below are provided to help you better understand your rights, learn how to self-advocate, and understand current research regarding the SLP field. 

– PATIENT RIGHTS:

           American Medical Associations statement on rights: https://www.ama-assn.org/delivering-care/ethics/patient-rights

           U.S. government statement on rights: https://www.hhs.gov/answers/health-insurance-reform/what-are-my-health-care-rights/index.html

–  SELF ADVOCACY: 

           Self-study toolkit with video: https://www.ohsu.edu/oregon-office-on-disability-and-health/taking-charge-my-health-care-toolkit

           Narrative on self-advocating: https://www.realsimple.com/health/preventative-health/self-advocacy-at-doctor-appointments

– DYSPHAGIA ETHICAL CONCERNS: 

           Myths: https://tactustherapy.com/dysphagia-myths-busted/

           Our Stance: Many documents and blogs online not written by practicing SLPs purport that a clinical swallow evaluation is done in order to assess oral and pharyngeal anatomy, function, and sensation. However, Smart Dysphagia Imaging as well as many other clinicians and researchers believe that a clinical swallow evaluation is INSUFFICIENT to diagnosis dysphagia, identify aspiration, and create a plan of care for patient’s with pharyngeal dysphagia. 

Imagine you are riding your bike and take a tumble onto the sidewalk. Your arm immediately hurts and you visit your doctor who then palpates or touches your arm and immediately says “Ok, you broke your arm. We will put you in a caste till you can demonstrate that you can use your arm. You do not need an x-ray because I have x-ray vision in my fingers.” This would sound preposterous yet this is frequently happening to patients with suspected dysphagia. A clinical swallow evaluation is capable of identifying risk factors for dysphagia and/or pulmonary decline as well as a patient’s candidacy for instrumental swallow assessment (FEES or MBSS). A clinical swallow assessment is an excellent and necessary precursor to an instrumental assessment as many patient’s may actually be experiencing symptoms that would be best handled by a different professional such as ENT or GI thus negating the need for instrumental assessment. Unfortunately many patients have only had access to a clinical swallow evaluation and may have wrongly been recommended modified diets or feeding tubes in the absence of FEES or MBSS completed by a competent SLP. 

In a study completed at the Veterans Medical Center of Nashville in conjunction with Vanderbilt University, researches found some troubling information about clinical swallow evaluations. Clinicians are frequently utilizing testing components or screens that have poor inter- and intra- rater reliability as well as questionable sensitivity for identifying aspiration. For example, clinicians frequently asked patients to cough volitionally , however, they did not have or follow any clear definitions or tools for identifying “abnormal” coughing. Additionally, they found only 50% of all test components were judged reliably by a single team of SLPs completing clinical (bedside) swallow evaluations. These inconsistencies can diminish healthcare providers and patient’s trust in the field of speech-language pathology as well as cause harm to patients physically, emotionally, and financially. In order to provide more accurate assessments and clinical significant recommendations, our team utilizes the gold standard method of FEES to determine the presence or absence of dysphagia. 

While this information can be disturbing, there are tools that can be utilized during a clinical swallow evaluation and even an instrumental evaluation to help guide your SLPs next steps that have adequate specificity and sensitivity. It is imperative that patient’s and families are armed with the correct information to understand when appropriate care is being provided. Please continue to check back as we compile more resources for you on this topic! If you have specific questions or concerns on this topic please call or email.

CITATIONS:

Linden P, Kuhlemeier KV, Patterson C: The probability of cor- rectly predicting subglottic penetration from clinical observa- tions. Dysphagia 8:170–179, 1993

Resources for patient’s and families in the ICU (critical care): 

-Podcasts: 

 Walking Home from the ICU by Kali Dayton https://anchor.fm/restoringlife 

Episode with Suzanne Ball SLP, owner https://anchor.fm/restoringlife/episodes/Episode-88-Bring-In-Speech-Language-Pathology-e197qic/a-a6or8bd 

-Websites: 

Introduction to the ICU https://participatorymedicine.org/epatients/2019/07/a-familys-guide-to-critical-care-part1.html

ICU Delirium Caregiver Packet https://www.icudelirium.org/resource-downloads/caregivers-abcde

Resources for patients and clinicians concerned about dysphagia (swallowing difficulty):

-Podcasts: 

Down the Hatch by Ianessa Humbert and Alicia Vose https://soundcloud.com/down-the-hatch

Swallow Your Pride by Theresa Richard https://podcast.theresarichard.com

Speaking Valves and Airway Management with Passy Muir https://www.passy-muir.com/podcast/

-Websites:

ASHA https://www.asha.org/public/speech/swallowing/swallowing-disorders-in-adults/

SLP role in dysphagia https://dysphagiacafe.com/2016/08/31/historical-role-slp-dysphagia-management/

Bedside/clinical swallow evaluation basics https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dysphagia-what-happens-during-a-bedside-swallow-exam

FEES https://www.cedars-sinai.org/health-library/tests-and-procedures/f/fiberoptic-evaluation-of-swallowing.html

Swallowing training for SLPs https://www.stepcommunity.com/pages/home