Decisions Decisions: How to make better dysphagia decisions

By George Barnes MS, CCC-SLP, BCS-S

Edited by Allie Mataras MA, CCC-SLP, CBIS

Big shout out to Doreen Benson MS CCC-SLP for help with acquiring this research!

We’ve all been there. Patient is admitted with a diagnostic list that can fit a textbook and risk factors that swirl around our head making any sort of logical consideration nearly impossible. Our gut tells us that there is risk. But how much risk? And how much is that gut instinct worth? Should we go off of our clinical experience? The research? Or what the patient is telling us? The answer is… Yes.

Why can’t I make a decision?

Decision making in dysphagia management is SO difficult because we are forced to weigh multiple factors simultaneously, generate solutions and alternatives, and consider what we aren’t considering (the dreaded unknown unknowns). It’s a tornado of information and we are stuck in its eye, watching cows and barnyard doors flying around us (I’m not from the Midwest, I just assume everything I see in the movies is real). What is the best approach to tackling all of this complexity? Well, to have an approach is the best approach.

In healthcare there is a BIG push towards systematic decision making. And for good reason. Medical errors account for close to 100,000 deaths each year. Poor decision making is expensive. In time, in money...in lives. Healthcare isn’t the only industry where decision making matters, but the stakes are certainly higher than in most other industries. Everyday decisions tend to be made from the gut. Rarely do we sit down and weigh all of the pros and cons when we are choosing between hot and cold cereal in the morning. We just go with what feels right. Which is fine and makes perfect sense for breakfast cereal because the stakes are so low (unless it’s for a four-year-old in which case make sure you’re making the right choice). But if we are constantly making gut decisions in dysphagia management and avoiding a more systematic approach, then we have a problem.

Think Slow

In Daniel Kahneman’s prominent book, “Thinking Fast and Slow” he teaches us about system one and system two thinking. Thinking fast, or using system one judgment is that “gut” decision making we just touched upon, which is actually a really amazing neural function. It allows us to make snap judgments in the blink of an eye that are often incredibly reliable and accurate. This type of thinking is invaluable and serves us in many situations such as in emergencies when we have to act quickly. Slow, or system two judgment is the more calculated approach where we sit down and consciously weigh a myriad of factors in order to look at the whole picture in a thoughtful way. One is not better than the other. What’s important is knowing which one to use and when. And in dysphagia management? We actually need both. Going through the data in a systematic way, but using your deeply ingrained clinical knowledge and experience to guide you when it becomes time to make that final decision. Snap judgments are OK and even useful, but only if we’ve done our homework first. For example, if all of your data is pointing in one direction and your gut is telling you the opposite, don’t ignore it. Question that decision and reassess. They say data is king. But don’t let that king rule every decision you make.

Thinking Rationally

Slow systematic thinking starts with rational questions and rational thought processes. Let’s say we are trying to determine if a patient has esophageal or oropharyngeal dysphagia. Just the simple act of asking this question is setting us on a journey towards irrational thinking. Here’s why: It’s entirely possible and often probable that a patient has neither esophageal NOR oropharyngeal dysphagia (or BOTH for that matter). Or we may see that a patient is aspirating and wonder how long it will be before they get pneumonia; totally forgetting that the link between dysphagia and aspiration pneumonia is not linear. It sounds simple on paper, but in the heat of the moment when we are weighing different factors, it helps to remind yourself of the complex relationships that square dance within the human body. To rephrase Hickam’s dictum, a patient can have as many different causes and effects of dysphagia as she damn well pleases. It is our job to parse out all the different factors and potential causes in order to determine what is happening and why. This can get really confusing really fast. And thinking fast is not going to give us the desired outcome. In the case of aspiration pneumonia, the relevant risk factors need to be necessary and sufficient in order to anticipate the outcome. What do I mean by necessary and sufficient? Let’s read a little more...

Necessary and Sufficient

The necessary and sufficient causes of an adverse outcome are what we are trying to pinpoint when drawing the big picture for our patients. For example, aspiration of harmful contents is necessary… but not quite sufficient for aspiration pneumonia. Aspiration of harmful contents, inability to clear those contents, and immunodeficiency are the necessary and sufficient criteria. This is a really important concept and one that is often overlooked. When we see somebody coughing consistently on liquids, it gives us a visceral feeling that leads quickly to a diet change to stop the aspiration at all costs (Thinking fast). We are forgetting that this suspected aspiration (if confirmed) is necessary, but insufficient and by itself may cause no issues at all (Thinking slow). If we jump to conclusions without first looking at the whole picture we can fall victim to a bias called anchoring. We “anchor” our thoughts to dysphagia and see every other piece of information through that lens. Instead we should assume dysphagia is “innocent before proven guilty.” Anything can be happening with the patient and with any number of causes. Dysphagia may be an important piece. Or it may not be. We need to take a look at all of the other risk factors to determine if the criteria is actually sufficient.

Below is a comprehensive list of the research-based risk factors for aspiration pneumonia (references below):

Risk Factors for Aspiration Pneumonia

Aspiration of potentially harmful contents:

• Cognitive deficits

• Dysphagia

• GI complications (PPI)

• Will require feeder

• Tube feeding

• Poor oral health

• Requires suctioning

• Poor positioning

Reduced pulmonary clearance:

• Weak cough

• Supplemental O2

• Pulmonary disease

Impaired immune response

• Medically complex

• Medically unstable

• Generalized weakness

• Frailty

• Age

• Polypharmacy (5 or more)

• Nutrition risk

• Current infection

• Reduced mobility

In the next few blogs I’m going to show how I use this information to make clinical decisions on a variety of case studies. What I hope it will do for you is to encourage slow thinking. To look at the whole picture using all of the information we can get. It’s not fail proof, but I do think it’s better than what we are doing now (Thinking too fast).

Again, this is not to say that fast thinking doesn’t have a place in our practice too. Daniel Kahneman flags an important warning to his readers who religiously follow a system two approach. Don’t mistakenly think that all we see is all there is. There is always important information we don’t know. Information that we can’t know. No matter how much chart reviewing and data collection we do. That’s why it’s important that we don’t get too caught up in the data or we will fall victim to analysis paralysis. System one still has its clout. Which is why simply looking at the patient and spending time with them is invaluable, no matter what the monitor next to them says. But this process only works after and never before slowly thinking about all the factors at play. When the stakes are high, slowing down is always going to be worth our while.

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References:

De Jager, C. P. C., Wever, P. C., Gemen, E. F. A., Van Oijen, M. G. H., Van Gageldonk-Lafeber, A. B., Siersema, P. D., Kusters G., Laheij, R. J. F. (2012). Proton pump inhibitor therapy predisposes to community-acquired Streptococcus pneumoniae pneumonia. Alimentary Pharmacology and Therapeutics, 36(10), 941–949.

Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104–109.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69–81.

Laheij, R. J. F., Sturkenboom, M. C. J. M., Hassing, R. J., Dieleman, J., Stricker, B. H. C., & Jansen, J. B. M. J. (2004). Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. Journal of the American Medical Association, 292(16), 1955–1960.

Lo, W. L., Leu, H. B., Yang, M. C., Wang, D. H., & Hsu, M. L. (2019). Dysphagia and risk of aspiration pneumonia: A nonrandomized, pair-matched cohort study. Journal of Dental Sciences, 14(201), 241–247.

Loeb, M., McGeer, A., McArthur, M., Walter, S., & Simor, A. E. (1999). Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Archives of Internal Medicine, 159(17), 2058–2064.

Manabe, T., Teramoto, S., Tamiya, N., Okochi, J., & Hizawa, N. (2015). Risk factors for aspiration pneumonia in older adults. PLoS ONE, 10(10).

Miyata, E., Tanaka, A., Emori, H., Taruya, A., Miyai, S., & Sakagoshi, N. (2017). Incidence and risk factors for aspiration pneumonia after cardiovascular surgery in elderly patients. General Thoracic and Cardiovascular Surgery, 65(2), 96–101.

Quagliarello, V., Ginter, S., Han, L., Ness, P. Van, Allore, H., & Tinetti, M. (2005). Nursing Home Pneumonia Risk Factors • CID.

Son, Y. G., Shin, J., & Ryu, H. G. (2017). Pneumonitis and pneumonia after aspiration. Journal of Dental Anesthesia and Pain Medicine, 17(1), 1.

Terpenning, M. S., Taylor, G. W., Lopatin, D. E., Kerr, C. K., Liza Dominguez, B., & Loesche, W. J. (2001). Aspiration pneumonia: Dental and oral risk factors in an older veteran population. Journal of the American Geriatrics Society, 49(5), 557–563.

Yu, K. J., Moon, H., & Park, D. (2018). Different clinical predictors of aspiration pneumonia in dysphagic stroke patients related to stroke lesion: A STROBE-complaint retrospective study. Medicine (United States), 97(52).