Puree and Nectar Forever: Taking the fear out of fear-based medicine
A blue fish swims past two red fish and says, "Hey! How's the water today?" One of the red fish turns to the other and says, "What the hell is water?"
If we were fish, then our habits, routines, and group culture would be the water. We've lived in it and done what we do for so long that it becomes hard or even impossible to think of other ways to practice. But we need to—for ourselves and our patients.
Puree/nectar Forever
I once saw an 86-year-old female in the nursing home who appeared to be within functional limits. She was on a pureed diet with mildly thick liquids since, in her words, "forever." It turns out she was placed on this diet four and a half years prior without a reassessment. Picture your least favorite food back in school. Maybe it's fish fingers (that was mine). Now imagine eating that every day, breakfast, lunch, and dinner, for all four years of high school. And an additional 6 months, just in case you weren't completely fed up with it. That's what this little lady had experienced. The best part (or worst, depending on how you look at it) is that we did an MBSS on her only to find out her swallow was completely functional and she could be placed on a regular/thin diet, which is what we did immediately.
How could we let this happen?
So, how does something like this happen? Of course, the issue is not that simple, and is caused by multiple factors, including poor access to instrumental studies, an overemphasis on aspiration, a lack of understanding of the research, and an inadequate understanding of the pathogenesis of aspiration pneumonia.
Fear-based medicine is a product of defensive medicine and a paternalistic approach to healthcare. While the recent promotion of shared decision-making has improved the situation, it isn't even close to where we want it to be.
Three Things to Consider
The solution starts with recognizing the problem. We are swimming against the current (back to our fish analogy) by promoting patient autonomy and incorporating it into the decision-making process. There are three things to consider in the current we are swimming against.
There are signs that malpractice lawsuits are on the rise.
SLPs have spent years convincing our healthcare colleagues that aspiration is a considerable concern worth paying close attention to
Overly cautious practice patterns may escalate within an interdisciplinary team framework.
The first two are self-explanatory, so let me spend a minute on #3. When functioning optimally, an interdisciplinary team utilizes the wisdom of crowds. Each member fills in the others' gaps to make a stronger whole than the sum of its parts. If one person is biased because of a recent experience, an article they recently read, or even because they are tired or hungry, the other group members will help balance that weak point by moving the person's judgment closer to the middle. There is power in numbers, and we can use this power to obtain better judgment and improve care.
While a team approach can be invaluable and is often ideal in tackling the highly complex problems that arise in healthcare, they have some drawbacks. One of these drawbacks is caused by a collective action problem. When everyone acts in the patient's best interest, things can go as well as we described. However, the whole system crumbles to the ground when each person is concerned about themselves out of fear of a malpractice lawsuit, losing their license, or being judged by their peers for a poor decision.
It's like when you have a community, and everyone must fish in the same pond. If we work together and agree to only take a few fish per week, the population will replenish itself, and over time, there will be more fish for everyone. But if we act selfishly, the fish run out faster than Red Lobster on a Saturday night (I know, fish again).
Alone, we can accomplish so little
As Helen Keller once said, "Alone, we can accomplish so little; together, we can accomplish so much." If we are all working toward the same goal of achieving what's most important to the patient, the potential is limitless. If all team members (including the patient and family) decide on one approach and document their support, the risk to any individual is almost nonexistent. Instead, we often get stuck inside our heads and become concerned about avoiding the worst-case scenario and getting sued. We go inside our little hermit shells and fail to work together toward progressing the patient. In an ironic twist, the latter often puts us at the highest risk of lawsuits and loss of licensure.
The extreme of any one thing may eventually become its opposite. Defensive medicine is essentially defenseless. Ultraconservative recommendations to avoid harming the patient and getting sued ultimately increase those very risks.
So what's the answer?
It starts with being brave and being the one person in the group to stand up for what's most important to the patient. Provide a reason to the other team members who want to avoid a recommendation that carries any risk at all, which, of course, comes at the expense of improving the patient's recovery. Educate the team on the risk factors of aspiration pneumonia and how to manage those risks to improve the chances of success.
None of this is easy. They are daunting tasks for even the most experienced of clinicians. However, nothing worth doing comes easily, and I would argue there is no more worthy goal in our career than to stand up for the patient and help them achieve their goals no matter how it looks to everyone else. What it takes is the time to speak to the patient and family, guide them to the best decision, and then advocate for it by working through the interdisciplinary team. This may even be risky in some ways. But I'd argue that not taking this risk is far more riskier in the long run.
*New course offered for ethics credit: Let Us Eat: The ethics of swallowing in older adults at high risk
