Dennis C. Tanner, PhD
William R. Culbertson, PhD
Dysphagia in adults affects their quality of life and can lead to life-threatening conditions. The authors draw on both 30 years of experience as clinicians and also on expert testimony in adult, dysphagia-malpractice cases to make five recommendations with the aim of preventing dysphagia-related deaths. They discuss the importance of informed consent documents and suggest the following nursing actions to reduce these often unnecessary tragedies: consider the importance of diet status; understand and follow speech-language-pathologists’ recommendations; be familiar with the dysphagia assessment; be responsive to the need for an instrumental assessment; and ensure dysphagia communication is accurate and disseminated among healthcare professionals. They conclude that most negative dysphagia-management outcomes can be prevented and that nurses play a pivotal role in this prevention.
Citation: Tanner, D., Culbertson, W., (April 23, 2014) "Avoiding Negative Dysphagia Outcomes" OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 2.
Keywords: dysphagia, swallowing, malpractice, dysphagia assessment, dysphagia treatment, safety, rehabilitation, nutrition, collaboration, speech-language pathologist, healthcare team, interdisciplinary communication, electronic charting, informed consent, dysphagia-related deaths
The important role nurses play in avoiding negative dysphagia-management outcomes and potential malpractice lawsuits cannot be overstated. The important role nurses play in avoiding negative dysphagia-management outcomes and potential malpractice lawsuits cannot be overstated. Broadly defined, dysphagia is the “impairment of the emotional, cognitive, sensory, and/or motor acts involved with transferring a substance from the mouth to stomach, resulting in failure to maintain hydration and nutrition, and posing a risk of choking and aspiration” (Tanner, 2007a, p. 3). Dysphagia can be life-threatening, particularly in elderly patients (Altman, Gou-Pei, & Schaefer, 2010; Roy, Stemple, Merrill, & Thomas, 2007). Chang et al. (2013) reviewed the death certificates of patients who were described as having died from a stroke; they reported that 5% had died as the result of aspiration pneumonia and 1% had died as the result of choking. In an earlier study, Schmidt, Holas, Halvorson, and Reding (1994) reported that the occurrence of pneumonia was more than 7.6 times greater in stroke patients who had aspirated than in those who had not aspirated. Dysphagia occurs in both pediatric and adult patients; treatment protocols for patients of different ages vary based on the patient’s developmental, cognitive, and physiological status. This article will focus on the disorder as it occurs in adults.
In this article, we begin by considering the importance of informed consent in making decisions related to dysphagia. Next, we will discuss five strategies nurses can employ to promote positive dysphagia-management outcomes for adult patients who have, or are suspected of having, dysphagia. These recommendations, if followed, could prevent most negative dysphagia-management outcomes. These recommendations include:
- Considering the patient’s diet and supported-nutrition status
- Understanding the speech-language pathologists’ recommendations
- Developing a working familiarity with the goals, objectives, and procedures of dysphagia management
- Acting in response to instrumental dysphagia assessment recommendations
- Ensuring effective communication among members of the healthcare team
We will conclude by reiterating the important role of the nurse in managing dysphagia and avoiding negative dysphagia outcomes.
Informed Consent Related to Dysphagia Management
The need to preserve life through airway protection is sometimes in tension with the patient’s desire to preserve a quality of life that is the same as it was before the onset of current health conditions. Consuming food and liquid includes the pleasures of smelling, tasting, and orally manipulating nutrients. For this reason nurses and their colleagues in speech-language pathology must consider both the safety of patients and their gustatory wishes. After due consultation, nurses and other providers need to respect the wishes of competent patients, their family members, and/or a patient surrogate if a patient is not competent (American Nurses Association, 2013). An informed consent document is then posted in the patient’s care record.
It is essential that patients comprehend the dysphagia-management alternatives before signing informed consent documents. It is essential that patients comprehend the dysphagia-management alternatives before signing informed consent documents. Brett and Rosenberg (2001) reviewed medical records relating to gastrostomy tube placements in a community teaching hospital; they reported that only 1 out of 154 patients’ records documented a treatment-specific discussion regarding the tube placement. Patient consent needs to be obtained before implementation of any assessment or treatment procedures, particularly those which involve the possibility of radical, lifestyle alterations, such as those that may occur in cases of dysphagia. The most stringent level of consent, specifically that which includes signatures of patients or their surrogates on written documents, should be obtained before any dysphagia treatment is implemented. Refusal of dysphagia treatment should also be documented in writing. The mere lack of a refusal does not imply consent. It is a best practice for practitioners to ensure that patients and/or their surrogates fully understand the risks associated with dysphagia and the treatments for dysphagia. This understanding requires both a careful explanation and the answering of questions, while accommodating to any particular communicative challenges and/or cultural differences. The completion of an informed consent form, along with documentation in the patient’s record that includes a detailed, signed note, is needed for culmination of the informed consent process (Sharp & Bryant, 2003).
The mere lack of a refusal does not imply consent. Over the course of many years of clinical experience involving the evaluation and treatment of adult patients with dysphagia, we authors have noted that certain dysphagia-management strategies have been more successful than others. Unfortunately, less successful strategies have resulted in loss of life and subsequent malpractice lawsuits. In all of these lawsuits, nurses played a pivotal role in the dysphagia management and were involved in the defendant's responses to the plaintiff’s allegations. In the majority of these cases, the plaintiffs retained an expert witness to testify in regard to the competency of the dysphagia management. Having seen the devastation negative dysphagia-management outcomes have had on patients, families, and healthcare professionals, we have committed to providing continuing education focusing on dysphagia management to relevant healthcare professionals (Tanner, 2010; 2009a; 2009b; 2007a; 2007b; 2006; Tanner, Culbertson, & Christensen, 2008). Respectful of the important role nurses play in the treatment of adult patients with known or suspected dysphagia, we offer five recommendations for consideration by all nurses. These recommendations, if followed, can prevent most negative dysphagia-management outcomes. We will discuss each recommendation more fully below.
Consider the Importance of Diet, Non Per Os, and Enteral Nutrition Status
...the risk of negative dysphagia management outcomes is substantially reduced when patients are not fed by mouth. It is important for nursing staff members to pay close attention to the diet and intake-route recommendations made by speech-language pathologists and dieticians and to verify the source and rationale for these recommendations. In our experience, all of the deaths resulting from diagnosed dysphagia could have been prevented simply by placing the patients on NPO (“non per os,” or “nothing by mouth”) status. Enteral nutrition via intravenous, nasogastric, or percutaneous- endoscopic-gastrostomy tube could have reduced the risks of aspiration and choking substantially while providing patients with needed hydration and nutrients. Although it is possible to aspirate reflux and suffer aspiration and choking with enteral-supported-nutrition tubes in place, the risk of negative dysphagia management outcomes is substantially reduced when patients are not fed by mouth.
Enteral nutrition does, however, pose its own risks, including improper tube placement, infection, perforation, hemorrhage, obstruction, necrosis, abscesses, and fistulas (Gomes, Pisani, Macedo, & Campos, 2003; Schattner, 2003). Because NPO status might understandably have a negative impact on a patient’s quality of life, the balance between patient safety and quality of life is an important consideration. As noted above, it is necessary to consider the patient’s wishes, and if the patient is not competent, to consider the wishes of this patient’s surrogate, in the decision-making process.
...the balance between patient safety and quality of life is an important consideration. In most of the dysphagia legal cases in our experience, misunderstandings about diet recommendations and follow-up by nursing personnel were found to have played roles in the patients’ deaths. This is why we so strongly encourage nurses and dietary personnel to follow supported-nutrition recommendations and to observe patients closely to assure that they are indeed tolerating a specified, supported-nutrition regime.
The following malpractice-case examples illustrate the importance of this close observation. Two malpractice cases involved patients choking to death from attempting to ingest peanut butter sandwiches. In both cases, the diet ordered was a ‘soft diet.’ Nursing and dietary personnel assumed that peanut butter, being soft, was acceptable for oral intake for these patients with swallowing disorders. Unfortunately, peanut butter sandwiches are actually dry, sticky, hard to manage, extremely difficult to remove from patients’ airways and/or oral cavities (Garcia & Chambers, 2010), and present significant challenges to all patients with swallowing disorders. It is important to realize that diet recommendations intended to reduce the risk of aspiration pneumonia and choking are better handled by some dysphagia patients than others. In Garcia and Chambers’ study (2010), the ease with which a patient tolerated pureed or chopped food, and/or a thick liquid depended on the type of dysphagia and the swallowing stages at which the swallowing deficits occurred.
In the best case scenario, nursing staff will observe patients and their swallowing behaviors at frequent intervals during meals, to see how their patients manage recommended food consistencies before, during, and after the swallow. Such observation will promote safety and may well lead to important, life-saving changes in meal time management.
Understand and Follow the Speech-Language Pathologists’ Dysphagia Recommendations
speech-language pathologists are also experts in the management of food and liquid intake. “It is the position of the American Speech-Language-Hearing Association (ASHA) that speech-language pathologists play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and supported nutrition disorders” (ASHA, 2001, p. III-1). This ASHA position statement has created pivotal clinical and legal roles for speech-language pathologists as members of the dysphagia-management team. Speech-language pathologists are qualified to assume this responsibility because of their knowledge of the aerodigestive tracts. Speech and swallowing share many neurological substrates and anatomical functions (Culbertson & Tanner, 2012). Today, as many as 90% of speech-language pathologists work in healthcare settings, and more than 10% of speech-language pathologists employed in schools serve individuals with dysphagia (Krueger & Conlon, 2006).
Speech-language pathologists evaluate the stages of the swallow and make recommendations to physicians, nurses, dieticians, and family members regarding dysphagia management. In the legal cases in which we have been involved forensically, speech-language pathologists had often made timely and appropriate recommendations. These unfortunately were ignored, misunderstood, or dismissed by other healthcare professionals, a factor often resulting in or contributing to the negative dysphagia-management outcomes.
Safe nursing care includes a consultation with a speech-language pathologist... regarding a patient’s ability to tolerate oral-supported nutrition in any form. The best outcomes occur when nurses recognize that the role of the speech-language pathologist involves much more than helping patients recover, improve, or adapt their speech and language functions. Although the title, speech-language pathologist, would suggest this professional addresses only speech and language problems, speech-language pathologists are also experts in the management of food and liquid intake. Safe nursing care includes a consultation with a speech-language pathologist whenever doubts arise regarding a patient’s ability to tolerate oral-supported nutrition in any form.
Become Familiar with the Goals and Procedures of the Dysphagia Assessment
A swallowing event begins with the voluntary intake and preparation of the food bolus and follows with a sequence of conscious and unconscious motivations and movements. Once underway, deglutition becomes successively more reflexive; and once the food bolus has moved past the pharynx, the swallowing event becomes an autonomic action (Tanner & Culbertson, 2012).
‘Deglutition,’ the Latin for ‘to swallow down,’ consists of interconnected stages: the oral preparation (buccal) stage, the pharyngeal stage, and the laryngeal-esophageal stage. These stages are controlled to a great extent by centers in the cerebral cortex, although parallel central nervous system representation is probable as well (Hamdy, 2006). Swallowing at the oral stage can be under voluntary control; some voluntary control is also possible at the pharyngeal stage. Swallowing functions at the laryngeal and esophageal stages are mostly involuntary. The Table below presents the structures, functions, movements, and behaviors assessed at each of the three stages of the swallow (Tanner, 2009a, pp. 10-11).
Table. Assessment Functions at Three Swallowing Stages (Adapted from Tanner, 2009a, pp. 10-11).
Oral preparation and transportation stages
- Acceptance of food and liquid
- Bolus formation
- Lip seal
- Tongue mobility
- Mandibular movements
- Propulsion of bolus along palatal vault
- Initiation of swallow reflex
- Velopharyngeal closure
- Gag reflex
- Initiation of pharyngeal peristalsis
- Coordination of the swallowing stages
- Airway protection
- Velopharyngeal closure
- Laryngeal elevation
- Voice quality changes
- Glottal valving
- Cough reflex
- Cough and throat-clearing productivity
- Delayed swallow reflex
Typically, speech-language pathologists perform two important swallowing assessments: a clinical bedside screening and an instrumental evaluation. Unfortunately, little specific functional information about sucking, chewing, and swallowing can be gained at the patient’s bedside during the bedside screening (Terre & Mearin, 2006).
Frequently aspiration occurs when a liquid or solid material is held or ‘pooled’ in the pharynx... To form a more accurate assessment of a patient’s swallowing competence, speech-language pathologists often recommend an instrumental evaluation. This evaluation is particularly important for patients suspected of a so-called ‘silent aspiration.’ Aspiration occurs when the patient inspires during or following the swallow, and may be noted by reflexive coughing upon contact of the aspirated material with the respiratory epithelium. Frequently aspiration occurs when a liquid or solid material is held or ‘pooled’ in the pharynx, particularly in the glossoepiglottic valleculae, which are the depressions in the epithelium between the tongue and the epiglottis, or else in similar epithelial pockets, which are located near the laryngeal entrance and known as the pyriform sinuses. Neurological inhibition, either sensory or motor, caused by stroke or other neurological disease, can result either in abnormal propagation of sensory information from the upper respiratory tract to reflex centers and/or in paralysis of the pharyngeal muscles. Under such conditions, patients will exhibit minimal or absent coughing responses to material in the airway; a response called the ‘silent aspiration.’ The propensity for silent aspiration can only be determined during instrumental assessment (Terre & Mearin, 2006).
Most registered nurses are well versed in the reasons and goals of the dysphagia evaluation. However, it is also very important for nurses to be both aware of the life-preserving purpose of the dysphagia evaluation and also aware of and responsive to innovations in the discipline of speech-language pathology. Safe patient care depends upon this awareness
Be Responsive to the Need for an Instrumental Dysphagia Assessment
...the best approach for appropriate care is to recognize the indications for instrumental assessment and implement the follow-up as soon as possible. Instrumental examination of swallowing includes videofluoroscopy, endoscopy, ultrasound, manometry and electromyography (ASHA, 2004). The American Speech-Language-Hearing Association has delineated the signs and symptoms indicating a need for instrumental dysphagia examination (See Figure).
The modified barium swallow study (MBST), also called the swallowing study (VSS), and the fiberoptic endoscopic examination of swallowing (FEES) are commonly used instrumental tests. Each has its advantages and disadvantages.
In contrast, the fiberoptic-endoscopic examination of swallowing involves passing a thin, flexible, fiberoptic tube through the patient’s nose to view the swallow. Risks associated with the procedure are the same as with any introduction of an object into the airway, including discomfort, gagging and/or vomiting, vasovagal syncope, epistaxis, mucosal perforation, adverse reactions to topical anesthetics, and laryngospasm (Nacci et al. 2008).
The MBST assessment most commonly involves lateral and anterior-posterior views, with dynamic, fluoroscopic tracking of a barium medium from the oral cavity to the upper esophageal sphincter. It is conducted in the radiology department. Depending on the patient’s diagnostic requirements, he or she may be given an oral serving of liquid barium, a barium paste, and/or barium coated or soaked food. A video recording is made of the swallow, and the speech-language pathologist may request modifications of the procedure for diagnostic and therapeutic purposes. Risks accompanying the MBST include exposure to ionizing radiation and patient reaction in the presence of esophageal blockage.
Figure. Signs and Symptoms Indicating the Need for Instrumental Swallowing Examination (based on ASHA, 2000).
- Signs and symptoms are inconsistent with findings on clinical examination.
- There is a need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis.
- Confirmation and/or differential diagnosis of the dysphagia is needed.
- There is either nutritional or pulmonary compromise leading to a question of whether the oropharyngeal dysphagia is contributing to these conditions.
- The safety and efficiency of the swallow remains a concern.
- The patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment.
In a Turkish study, Gerek, Ataly, Cekin, Ciyiltepe, and Ozkaptan (2005) found that visualization of the pharyngeal internal anatomy was only possible with the endoscope. The MBST was most efficacious in detecting aspiration and pooling; observing specific swallowing events, such as hyoid and laryngeal elevation and relaxation of the upper esophageal sphincter; and in revealing esopahageal pathologies.
Instrumental evaluation was not recommended by medical staff in the majority of legal cases involving aspiration pneumonia and negative dysphagia management, either because it was deemed too expensive or for other unstated reasons. In all of the cases reviewed by the authors for expert testimony, the presence of infiltrates in the patients’ lungs on autopsy clearly showed they had aspirated food particles and/or liquids prior to their deaths.
In summary, the best approach for appropriate care is to recognize the indications for instrumental assessment and implement the follow-up as soon as possible. Nurses are invaluable in calling attention to the possible need for instrumental assessment.
Ensure Dysphagia Communication is Accurate, Complete, and Disseminated Among All Healthcare Professionals
In our experiences with malpractice cases, professional communication among and between healthcare professionals, facilities, family, and the patient may have been at issue. Plaintiffs often alleged that dysphagia diagnostic and treatment orders, referrals, recommendations, and test results were not communicated in a clear and timely manner among facilities, clinicians, and healthcare professionals. Defendants asserted that professional communication was standard and customary, and did not contribute to the alleged negative dysphagia management outcome.
The standard of practice for speech-language pathologists treating patients with dysphagia, as is the case with other healthcare professionals, includes the necessity of accurate and current records of dysphagia management. "Clear and comprehensive records are necessary to justify the need for treatment, to document the effectiveness of that treatment, and to have a legal record of events" (ASHA, 1994, p. 355). The requirements for clinical record keeping related to the speech-language-pathology assessment include the following (ASHA, 1994):
- Date of initial assessment/reassessment
- Initial functional status of client in present facility based upon:
- Baseline testing (using standardized and non-standardized measures)
- Interpretation of test scores/results
- Other clinical findings (including those from other specialists)
- Documentation that speech-language-pathology evaluations considered a client’s hearing status
- Statement of prognosis
- Recommendations based on the client’s functional needs (including referrals as appropriate)
- Signature and title of qualified professional responsible for the assessment (and that of the medical record transcriptionist, if different)
...a frequent and avoidable cause of negative dysphagia-management outcomes is a breakdown in communication between nurses and speech-language pathologists... There is much variation in healthcare facilities’ lines of communication between nurses and speech-language pathologists. Some facilities place a high priority on adequate and effective communication while others only minimally address professional communication. Speech-language pathologists’ recommendations for diet changes, feeding route status, aspiration and choking precautions, and other therapies are made regularly in the patient’s medical record and should be read and addressed daily. In addition, patient care conferences addressing ‘at-risk’ dysphagia patients should occur weekly and involve physicians, nurses, dietary staff, speech-language pathologists, and others, such as occupational therapists, home health staff, and radiology personnel, if warranted. Braun-Jantzen, Sarchuk and Murray (2009), have noted that a frequent and avoidable cause of negative dysphagia-management outcomes is a breakdown in communication between nurses and speech-language pathologists, particularly in cases where the patient has a communication disorder and cannot adequately express his or her needs.
In our experience, the speech-language pathologists’ notes and recommendations are often read only by an attending physician, who then issues a written order for implementation or modification of the treatment plan, particularly if the plan involves modification of feeding status or of diet consistency. In many facilities, speech-language pathologists are not on site daily; weeks or months sometimes pass between visits, especially if none of the patients at a given site require daily, direct treatment by the speech-language pathologist. Given large caseloads and changing staff over several shifts, it is not unlikely that gaps in communication between speech-language pathologists and nurses can occur. In the treatment of dysphagia, however, such gaps can bring dire consequences. Follow-up communication between speech-language pathologists and nurses is indeed a challenge.
We have found it practical to consult in person with nurses and other health-related professionals whenever a change in treatment approach appeared warranted. We have worked to assure that a visible ‘flag’ be placed on a patient’s healthcare record, or at some other central location, so that nurses on different shifts can be duly advised.
A promising development for promoting interdisciplinary communication is the advent of the electronic charting system. The use of computerized records allows electronic notices to be posted for any patient for whom orders may have changed; these onscreen ‘flags,’ indicating a change in orders, can be made visible to all nursing shifts. Similarly, electronic check boxes can indicate that change notices were seen by appropriate personnel. A routine follow-up check of the records by the speech-language pathologist, coupled with a conference with the nurse in charge at the time of the next speech-language pathologist visit, can be used to verify implementation of the new order.
Communication between nursing staff, patients, or their surrogates, and all allied health practitioners is the norm for best practices in healthcare. Nurses can and should continue their pivotal role as the hub around which the communication among patient-care partners revolves. Individual healthcare treatment teams should devise a workable plan to ensure that speech-language pathologists’ treatment recommendations are followed, especially in cases of dysphagia management.
Most negative dysphagia management outcomes can be prevented. Most negative dysphagia management outcomes can be prevented. Nurses are pivotal in the proper management of dysphagia and are likely to bear clinical and legal responsibilities for negative outcomes. Negative dysphagia-management outcomes can be avoided through the following practices: (a) considering the importance of diet, non per os status, and tube-supported nutrition in dysphagia patients; (b) understanding and following the speech-language pathologists’ dysphagia recommendations; (c) being familiar with the goals, objectives, and procedures of the dysphagia assessment; (d) being responsive to the need for an instrumental dysphagia assessment; and (e) ensuring dysphagia communication is accurate, complete, and disseminated among and between healthcare professionals.
Nursing is the hub of patient care, every day, and around the clock. Hence it is imperative that nurses maintain open communication with speech-language pathologists regarding concerns such as supported-nutrition status; results of instrumental diagnosis in cases of patient dysphagia; and especially in cases where there is also a communication disorder. Particular attention to effective communication between nurses and speech-language pathologists is essential, even when a speech-language pathologist is not on site.
Dennis C. Tanner, PhD
Dr. Tanner is Professor of Health Sciences, Speech-Language Sciences and Technology, at Northern Arizona University in Flagstaff, AZ. He serves as an expert witness in medical malpractice cases involving swallowing disorders. Dr. Tanner has presented courses on avoiding dysphagia malpractice litigation at conferences of the American Speech-Language-Hearing Association and the Oklahoma Speech-Language-Hearing Association, and has published two books and several journal articles on the topic. Dr. Tanner earned both his Bachelor of Science Degree in Speech Communication and his Master of Science degree in Speech Pathology and Audiology from the Idaho State University in Pocatello, ID. His Doctor of Philosophy in Audiology and Speech Sciences was awarded by Michigan State University in East Lansing, MI.
William R. Culbertson, PhD
Dr. Culbertson is a professor in the Department of Health Sciences at Northern Arizona University in Flagstaff, AZ. He has had extensive clinical experience with adults who experience neurogenic communicative disorders; he has also co-authored scholarly articles, an anatomy and physiology textbook and workbook, and several clinical assessment instruments for both adults and children. Dr. Culbertson earned his Bachelor of Arts Degree in Psychology and Speech and Dramatic Arts from the University of Richmond in Richmond, VA, his Master of Science in Education Degree with an Emphasis in Communication Disorders from Old Dominion University in Norfolk, VA, and his Doctor of Philosophy in Audiology and Speech Sciences Degree from Michigan State University in East Lansing, MI.
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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published April 23, 2014
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