NPO Except for Meds: Is this a safe recommendation?
Bob, a 59 YOM with Parkinson’s Disease comes into the hospital with altered mentation. Multiple tests are being run and one of those tests is for a swallow evaluation secondary to concerns of neurological changes. You see the patient with a clinical evaluation and things are not looking pretty: Poor responsiveness, generalized weakness, and coughing with wet vocal quality on all PO trials. Bob does not appear to be safe to eat or drink. You recommend nothing by mouth (NPO) for safety and plan on following up with an instrumental study as soon as an opening is available. But before you leave the doctor stops you and asks, “Well, what are we supposed to do about his medications? He needs them. Can we at least do NPO except for meds in the meantime?”
How would you respond?
First, ask yourself how you would feel and what you would do if asked this question. Really, take a minute to think about it…
Finished? OK. Did you imagine the pressure you’d feel to make a recommendation that you didn’t feel was appropriate? I know I would. And I have. But let’s think about the rationale for making such a recommendation. For Bob, one can argue that the risk of not receiving certain medications (i.e. Sinemet) is higher than the risk of aspirating. Certainly the doctor might make that argument. But the doctor is not the dysphagia expert. You are. If the patient has a high risk for aspiration and we are concerned that whatever we feed the patient will either end up in the airway (poor safety) or stuck in the pharynx (poor efficiency), then why would we expect that the medication is going to its intended destination?
If a patient can’t swallow, where do the meds even go?
The stomach is meant to absorb and handle the chemical compounds and reactions of medications as it is coated with a protective layer of mucus and bicarbonate secreted from the pancreas. The caustic effects of a medication may cause severe damage to the upper and lower airways if the patient is unable to effectively swallow that medication. This may result in inflammation, severe stenosis of the airways, and even death. So not only is your patient not receiving the benefits of the medication, we are actually causing some serious damage to the sensitive tissues of the pharynx, larynx, trachea, lungs, and even the esophagus if we are suspecting esophageal dysphagia as well. PO meds are meant for the stomach. Nowhere else.
What if you’re on the fence?
If, say, the picture isn’t as clear as Bob’s case above, then you may want to consider diving a bit deeper. Let’s say Bob was more alert and only occasionally presenting with signs of aspiration. We don’t want to recommend something that may be unsafe, but we certainly think he should be able to swallow something. An in-depth discussion of the pros/cons of any clinical decision with the interdisciplinary team (IDT) is always recommended, but is especially important when confronted with a complex case with multiple factors and multiple options. Some discussion questions to bring up with the IDT may include:
Can an instrumental study be completed? When? If not, why not?
If a swallow study can’t be completed, might it be safe to advance the patient to some level of PO from the results of your clinical assessment? Consider the risk of aspiration, silent aspiration, and dehydration/malnutrition when making this decision.
What are the patient’s risk factors for aspiration pneumonia and how do these play into the risk profile?
How long can the patient safely go without their medication?
Can the medication be administered via an alternative source, at least temporarily (IV or NGT)? Do the risks of that food source outweigh the risks of PO?
Takeaways
NPO except for meds is sort of contradictory, isn’t it? If a patient is NPO except for meds, they aren’t actually NPO. In fact, they are taking in something that is potentially more dangerous to the lungs than food or liquid. And on the other side of the argument, if they are safe to take meds by mouth, why aren’t they safe to take other consistencies throughout the day (i.e. small amounts of ice, water, and/or puree as tolerated with supervision)? This question and the others posed in this article will hopefully lead you to a thoughtful consideration for what’s best for the patient and give you a loose outline to use with your IDT when making some tough calls. Remember, you’re not alone. A good team is greater than the sum of its parts and you’ll need that large sum when addressing these multi-faceted questions.
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