Avoiding Risk-Aversion: Can 3 simple questions change a patient’s life?
Where do we stand if the way we practice falls on a spectrum from uber-liberal to ultra-conservative? Do you emphasize improving independence, or is safety the goal to be achieved at all costs? I know this is a loaded question, but it needs to be asked because we have fallen far to one end of this spectrum and need to start crawling back. Which side do you think that is? Yup, too conservative (you read the title, didn't you? Cheater!)
It depends.
When you think about this phenomenon, your gut reaction might be to say, "Well, it depends. I don't treat every patient the same. I'm more liberal with some and more conservative with others depending on their risk factors and clinical presentation." And that's great. We should all be doing this. But it's a general mindset that the field of speech pathology (and healthcare as a whole) is under. Avoid specific patients, and think big picture for a minute—the forest, not the trees, if you will.
The mistakes I've made
About 90% of the errors I make in my recommendations occur not when taking an unreasonable risk but when trying to avoid it entirely. Zero-risk bias is the tendency to prefer certain things that can theoretically guarantee us a risk-free scenario. It's why we get that extra insurance on our plane tickets, even though it can be expensive and is rarely needed. It's natural to think this way, and we all fall victim to it. Buying useless insurance you'll never need isn't great, but it's also not going to ruin anyone's life. Fear-based medicine, on the other hand, can.
Risk aversion
A study was done in which a group of people were asked how they would like to reduce risk. Two variables were considered (Risk A and Risk B). The participants had the chance to…
Reduce the risk from 50-25% in Risk A or
5%-0% in Risk B.
The vast majority of the participants chose #2 to reduce the risk from only 5% to 0%, missing an opportunity to reduce the total risk by an additional 20%, which they could have done in #1.
In dysphagia management, this may come in the choice between reducing the risk of aspiration by 5% or reducing the risk of dehydration by 25%. Which would you choose? It seems obvious when you think of it like this, but we encounter similar daily scenarios when deciding whether to thicken our patient's liquids. This may provide a slight risk reduction in aspiration and pneumonia (or no benefit, depending on who you ask) but carries a significant risk of dehydration. You're not reducing overall risk. You're just sort of sending it from one place to another.
Unfortunately, we don't like thinking in terms of percentages. We want a guarantee, which, of course, is impossible. We can never guarantee that someone won't develop aspiration pneumonia, just as we can't guarantee someone will live until they're 100. Our expectations can become far out of reach of our capabilities as practitioners. It is wise to bridge that gap early.
A better way
A much better approach is to look at the whole picture. Discuss with your interdisciplinary team, especially the patient, to determine the implications of your recommendation for the entire patient (not just their swallow). Here are some questions we might consider asking:
Will she follow the recommendation, and will she be able to maintain adequate intake?
Is she already teetering at the edge of dehydration and malnutrition?
What are the risks of aspiration pneumonia, and will our recommendations significantly reduce that risk?
These questions can help get us out of our silo and away from the tunnel vision of dysphagia so we can understand the full context in which we are making a recommendation and the implications it may have on the whole patient. It reminds us that we aren't fixing a leaky faucet but managing a patient with complex, interrelated, and dynamic factors that combine in unfathomable ways. Making a recommendation, monitoring closely, and adjusting as needed is often the best approach in such an environment. I've found this helpful for my patients, and I hope this approach does the same for you.
*New course offered for ethics credit: Let Us Eat: The ethics of swallowing in older adults at high risk
