PO or NPO? How do you decide when the stakes are high?

Aaron is a 44-year-old with an acute TBI, brain hemorrhage, and severe right-sided weakness. He was intubated for three days and extubated two days before your swallow evaluation. It's early on a Sunday morning, and you haven't even had your coffee yet. As you read through the chart, you jump as your work phone rings and startles you.

"So what do you think?" The resident asks.

"Hey, I just received the order. I'm looking through the chart, and then I'll be in in a few," you answer.

"OK, no worries, but please let us know as soon as possible. The team is deciding whether to reinsert a nasogastric tube (NGT)."

As a medical SLP, there's a good chance you've run into some version of this scenario, and if you haven't, you inevitably will one day soon. I can't tell you how many times I've come across this situation in my 12 years practicing dysphagia management, and even though I've made many tough decisions, they never seem to get any easier. This is why I've decided to fall back on a decision-making process to help me sort out the most critical variables, the viable options, and the best decision.

Back to the Patient

You walk into the ICU, and everyone turns to look at you. It's as if the music cuts like an old western, and you're getting ready for a showdown, which may be an excellent way to label this situation. A showdown with medical complexity. You vs several bad decisions. And you need to wrestle with all of them to determine which is best.

You enter into Aaron's room. The light shines through the light shades and onto the patient's face, but he doesn't stir or respond. You knock on the door and call out his name, "Aaron? Aaron, can you hear me?" You see that he is lethargic but eventually rousable with some effort. He opens his eyes and doesn't respond right away. The room is deafeningly quiet except for the subtle beeping of the monitor nearby. His respiratory rate is 28, and his heart rate is 111. It could be better, but it doesn’t disqualify him from PO trials. After a minute of Aaron variably responding to questions/commands, he closes his eyes and falls back to sleep.

"He's been like this for the past few days," The resident says. “We were finally able to successfully extubate him Friday night after you left for the day and he recently pulled out his NGT.”

"Have you tried to give him anything to eat or drink?"

"Nope, we waited until you got here. Thanks for coming right away."

The Assessment

You did a full cranial nerve assessment on Aaron and noticed significant deficits in oral motor function on the right side. He takes PO trials of ice without issue. Aaron coughs immediately after a 3 oz water test but has no problems when retested again with a few more trials of thin liquid, including another 3 oz water test. As he eats/drinks more, his alertness and mentation improve slightly. He is well outside of normal limits for mastication as indicated on the test of mastication and swallowing solids (TOMASS) but appears to present with adequate control and clearance with pureed solids.

So... PO or NPO? He's lethargic but wakes up. What are the risks of feeding him? What are the risks of keeping him NPO? What are the benefits of both options and do they outweigh the costs? We can't get an MBSS until tomorrow, and the team wants to decide on an NGT today. You don't know what to do.

How to Decide

We often resort to a snap judgment when there are so many variables to consider. We rely on our education, training, and experience to lead us in the right direction. But Daniel Kahneman, the late renowned psychologist and researcher, tells us in his seminal book, "Thinking Fast and Slow," that using our intuition may not be as beneficial as we think. This is especially true when there are multiple variables to consider and many moving parts in a highly complex case, such as Aaron's. So, if we can't rely on our intuitive judgment, what can we rely on?

In this case, the best approach is a structured one such as this:

1. Identify the problem: Aaron is NPO and needs vital medications and nutrition to treat his fragile state. We hypothesize that there is a high risk of aspiration, choking, and aspiration pneumonia. You'll need an instrumental study to get more information, but it's a weekend, so the soonest you can get an MBSS is tomorrow (if that). You need to choose between PO vs. NPO with an NGT.

2. Assess the factors: The most critical factors include his mentation, dysphagia, respiratory status, need for nutrition/hydration, and Aaron's wishes.

3. Generate a potential approach: Puree and thin liquids with 1:1 supervision and discontinue diet if significant signs/symptoms of aspiration arise.

Let's try to quantify the risk (This is done with a loose interpretation of the literature detailed below).

⦁ Risk (aspiration pneumonia, other complications, etc.): 8-10%

4. Consider alternatives: Continue NPO and place NGT

⦁ Risk (aspiration pneumonia, other complications, etc.): 30-32%

How did I come up with these percentages? It isn't an exact science, but quantifying the information allows you to think through the most important factors to better make sense of so much complexity. To help me quantify these values, I reviewed relevant literature (Yes, this takes time, but you can keep the data handy for when you inevitably need to make a similar decision in the future). What we need to get are the base rates. This will give us an anchor (starting point) when quantifying the risk.

What's the risk of PO intake?

The base rate for aspiration pneumonia in patients after TBI may be 3.6%, according to this study. This is dependent on multiple variables. The study had a large sample of 2,545 patients but was done in a rehabilitation unit, so those patients were probably more stable than Aaron. Further, he was intubated, and these patients weren't. Given this information, I adjust the overall risk from 3.6% to 5%.

While we can't confirm whether he is aspirating without a modified barium swallow study, to be conservative in our calculations let's assume he is. Data presented in this landmark study by Dr. Susan Langmore et al. suggests that confirmed aspiration on a swallow study may double the risk of developing aspiration pneumonia, which now becomes 10%.

Lastly, we will not mindlessly feed him and hope for the best. We can reduce his risk with 1:1 supervision, strict aspiration precautions, and a restricted diet, such as the one we recommended. With this information, we use the above 8-10% risk range for PO intake.

What's the risk of an NGT?

This study reported that the risk of aspiration pneumonia for patients with NGT is higher than those without (31% vs 10% respectively). Some of this difference may be attributed to the worse cognitive and functional status in the NGT group. Nevertheless, the numbers are still helpful for our decision, especially as Aaron does have both cognitive deficits and significantly decreased function overall. Further, the risk with Aaron may be on the higher end because his poor mentation may lead to an increased risk of tube dislodgement, which is a significant factor involved in the risk of aspiration. Given this information, we put his risk associated with an NGT at 30-32%, as noted above.

The more research, the better?

If you wanted to continue there, you could research the question further and see what information you came up with. I know, I know... Who has time for this? But if you do, you can compare and contrast studies and even use multiple studies to adjust your risk profile. For example, digging a little deeper into the literature might lend you with this article on aspiration pneumonia risk in TBI. The risk here is 17.7%, significantly higher than the 3.6% marked in the previous study. But the sample size is much smaller (396 vs. 2,545).

Further, one of the two highest risk factors identified in the 17.7% study is none other than... the presence of an NGT. Well, ain't that a doozy? The other factor is a Global Coma Scale (GCS) score of less than 8. Aaron received a 12. Based on this information alone, I wouldn't adjust the 8-10% risk, but it's important to note that the presence of NGT was one of the most important risk factors for aspiration pneumonia for patients after TBI.

Host factors

You can review the research further to investigate what the literature says about other relevant host factors for Aaron. For example, you may want to check the risk factors for aspiration pneumonia or choking. Aaron is relatively young and has no other medical history, which puts him in a good position regarding cardiopulmonary clearance, susceptibility to infection, and overall recovery. So, we don't need to adjust the risk further based on his host factors. However, it's common for patients to have multiple relevant risk factors for which we'd have to change the risk further (i.e., advanced age, CVA, CHF, and COPD).

How about the benefits?

You, of course, need to weigh these risks against the potential benefits. Both options successfully provide nutrition, hydration, and medication. When discussing these options with the patient and his wife, you ask them what's most important in their care. You find that they would like to do whatever it takes to avoid a feeding tube, given the potential discomfort and fear of needing it long-term. You explain that PO intake at this time will probably not increase his risk compared to an NGT but instead may decrease it according to research. Aaron's wife then decides to forgo an NGT until we have more information regarding his swallow.

Not All Research is Created Equal

The numbers we acquire will only be as good as the quality of the source. And, unfortunately, it will never be perfect. There are limitations in the studies referenced above, and they don't perfectly reflect Aaron's clinical scenario. Research, in general, is an imperfect process. Different articles will tell us different things about the same question, even if they study the same population. Plus, many of the variables we study are interdependent, and many others are entirely unknown. Oh, and did I mention most of these variables constantly change in real life? This means the base rates we get from the research will be inherently flawed. But suppose the diagnosis is correct and the literature is of high quality. In that case, it will still hold value as a starting point and is certainly better than our blind assumptions, which are plagued by biases and heuristics.

A Third Option

You don't have to stop at one alternative. It's best to devise as many alternatives as possible and work through the pros/cons of those choices. A third option in Aaron's case, which exists in every case, is to do nothing. In other words, keep him NPO and wait one more day without the NGT. The medical team often wants to move forward with an NGT if vital medications are needed, if they are concerned about hypoglycemia, or if there is a concern about the nutrition/hydration needs not being met. But, in Aaron's case, one more day at the status quo could have at least been discussed. Some questions to ask that may help you determine if doing nothing is, in fact, the best thing:

⦁ What medications are needed at this time?

⦁ Is there IV access?

⦁ Does he have diabetes?

⦁ Are there signs of dehydration?

And discuss

You discussed your thinking with the doctor and the resident team, and everyone agreed that the best option, at least for now, is to move forward with a PO diet until we get more information on his swallow status tomorrow after the MBSS. Thankfully, no decision needs to be permanent. Like sailing a ship in a storm, we can adjust when the weather changes and ensure we stay on target to reach our destination.

One limitation of this process is that not everyone appreciates a run-down of probabilities. Some get distracted and frustrated by the numbers. People, especially patients, sometimes prefer absolute statements or even guarantees (i.e., “This is the best course, so let's move forward with this option”). In these cases, it's best to sort out the details first and then come to them with what we think holds the most value for the least amount of risk while giving them other options as alternatives to our recommendation.

What happened?

The next day, Aaron starts to look a little better. He's more awake, and his communication is improving. Deficits were identified during his modified barium swallow study. Still, it's determined that he can safely and efficiently take a diet of IDDSI minced and moist solids, level 5, and thin liquids as tolerated with compensatory strategies and exercises.

It's easy to imagine an alternative situation where you fail to work through all of these critical factors, for example, under-weighing the risks and over-weighing the benefits of an NGT. The NGT could have been placed, which may have increased his dysphagia, prevented him from mobilizing the swallow, and led to even further decline the next day instead of the gross improvement we saw.

Conclusion

This is just one example of how I have handled situations like this. There are, of course, times when an NGT is the best choice and wholly warranted. Say Aaron was more lethargic and weak, and signs/symptoms of aspiration persisted past his initial trial. Or what if Aaron had some of those other relevant risk factors we discussed, such as advanced age with a history of cardiopulmonary disease and respiratory insufficiency? This different clinical scenario may have changed the outlook of his risk and our ultimate decision.

Yes, this process takes time, but it can be made into an efficient system ingrained into your daily routine. And think about it... If we don't use base rates to make our decisions, then what's the alternative? Guessing? Dr. Jerome Grooper tells us that a misinterpretation of the risk often leads to overtreatment and underestimating the dangers of that treatment, possibly causing the therapy to have more harm than the disease. To make the best decision, we must avoid snap judgments and mental shortcuts that will inevitably lead us astray. By studying and quantifying the most critical factors and options, we can move away from a reflexive approach and move closer to the more calculated and thoughtful approach that patients with medical complexity deserve.

Enjoy learning about clinical decision making? Consider taking our short course, Complex Decision-Making in Dysphagia Management to learn more.

Disclaimer: I am neither a statistician nor an expert researcher. This is an informal process I have derived from extensive reading on the topics of research, statistics, risk assessment, and decision-making. Risk does not equal reality. Instead, it's a theoretical framework that may shed light on the multiple alternatives we must choose between when working with patients with medical complexity. This should be one of several approaches incorporated into a comprehensive evaluation. Our responsibility to clinically assess and integrate data from swallow studies and discuss those results at length with the interdisciplinary team, including the patient, remains imperative. Utilizing risk management techniques such as the one described in this article is another tool to improve clarity when the situation is complex.

Big thanks to the many incredible clinicians who helped review this article for me, including Dr. James Coyle PhD, CCC-SLP, BCS-S, ASHA Fellow, Doreen Benson MS CCC-SLP, and Ed Bice, M.Ed., CCC-SLP.