The Diet Police: A title nobody wants, but we all have
I am a retired diet policeman. I never received a party or a big send-off. In fact, it happened silently one day a couple of years ago while I caught a gentleman slipping outside of his diet restriction. “Wee-oowww”. The sirens were blaring and the lights were flashing because Frank just ate a cookie on his 91st birthday while on IDDSI 4. It happened so suddenly. I didn’t even think about it. I ran over to the plate, took it from under him while he was about to go for another bite, and scolded him on the senseless risks he was taking. Everybody in the dining room looked at me like I was a monster. But I was no monster. I was only a member of the robust group of SLPs known as The Diet Police.
Does diet modification work?
Modified diets do work with a subset of the patient population and can even be life-saving when utilized properly. Research shows that they reduce the risk of aspiration and preventing foreign contents from going into the lungs can reduce the risk of pneumonia if the patient has other risk factors as well. However, in many cases changing the diet does little to help the patient. The ability of thickened liquids to reduce the risk of pneumonia, for example, is questionable. This research (or lack thereof) should give us pause. Especially with the fact that thickening liquid is the SLP’s number one approach to managing aspiration pneumonia.
How did we get here?
First, do no harm. I can spend four blogs unraveling those four words, but don’t worry, I’ll keep it simple. It is our role, as medical practitioners, to heal and not harm. Simple right? We got into this field to help and not to hurt. But the obsession to keep the patient from any harm whatsoever can actually have the opposite effect. Like holding a fragile egg with so much care as to not let anything hurt it, sometimes we break the egg with the intensity of our embrace. For example we recommend thickened liquids for people who won’t drink them; giving our patients the unintended consequence of dehydration and malnutrition which can have huge implications for our patients (A previous blog with Dr. Ianessa Humbert, Thick Fix goes into the pros and cons of thickened liquids in more detail). But the fact that people don’t like and tend not to eat/drink modified diets is not news to us. It’s well documented for both solids and liquids. Put simply: People don’t want you messing with their food. So why do we continue to pretend like this isn’t the case and recommend modified diets regardless of their impact on reduced oral intake, quality of life, and functional outcomes? The reason, while certainly complex and multi-faceted, may simply be that we are scared.
Why so scared?
Like all people, SLPs are emotional beings. We want to do what’s right and we want to protect the patient at all costs. In the absence of teeth or with the observation of oral residue, we fear choking. Extended mastication? They’ll never finish a full meal. Coughing? No no, let’s put an end to that. And it’s not just SLPs. In fact, frequently the only reason we are in the room with the patient is because a nurse was concerned about increased coughing during meals. Bring the risk down to zero. That’s the goal, right? In a perfect world maybe. But I assure you, this world is not perfect and 0% risk is simply not practical. Thinking it is, comes from our irrational side. Our emotions. Our fear. “But we HAVE to reduce the risk as much as we can, right? Isn’t that our job?” Well, it’s part of our job to reduce risk, yes. But at the core, it’s our job to treat the patient, not the risk. Two very different things.
How do we reverse this pervasive mindset?
First, we figure out what it is we are trying to accomplish. Part of this is answering the question behind the doctor’s order (usually not written in the order itself, but instead is the reason the order was written in the first place which can take some digging to figure out depending on your facility). “Would this patient benefit from a feeding tube?” “Can we start PO?” “Could pneumonia be caused or exacerbated by their dysphagia?” These are tough questions. Complex to the core. Complex questions require complex answers. However, we often answer these questions by looking for what we assume is already there. Confirmation bias can steer us in the wrong direction. Our brains, consciously or unconsciously, jump to conclusions like coughing = aspiration = pneumonia and thickened liquids = no pneumonia. You can also think about it in terms of the Streetlight Effect. In short, this effect is illustrated by a man looking for his keys who only searches in the ten square feet under the street lamp because it’s dark everywhere else. The conclusion of the story? He never finds his keys. And we will never find the answer to our clinical questions if all we are looking at is the streetlight of dysphagia. Stopping aspiration at all costs. When those costs end up being far worse than the dysphagia itself.
As practitioners, it’s important that we become analytical. It’s important to have an adequate understanding of the anatomy and physiology not just of the swallow, but of the cardiopulmonary system as well. To fight for instrumental studies in order to figure out what’s actually going on. To use the numbers from research to guide our care and support our decisions. To take a step back and look at the whole picture from multiple viewpoints (using our interdisciplinary team). To get us out of our silos and into the mix. The body is complex. And so should be our decision-making process.
This all will help us answer the real question being asked of us. What is the patient’s goal and how do we help them reach it? Often this is in line with those same answers we are trying to find based on the doctor’s questions, but sometimes it isn’t. The patient is the north star, guiding everything we do so a big chunk of our time should be spent trying to figure out and/or help them figure out what their goals are. In short, we have to listen to the patient. I’d love to think we are already doing this, but since the majority of our therapy is spent modifying diets (an intervention most patients despise), it makes me think we’re not.
Will we get sued?
Maybe. But probably not. ASHA doesn’t keep any national records on this, but it appears to be incredibly rare that an SLP gets sued as the primary defendant in a case. But we can get wrapped up in big cases again doctors and hospitals. Scary? Yes. But in most cases, the only thing we have to fear is fear itself. I mean this quite literally. The fear of litigation is only going to lead to unnecessary restrictions, which can lead to more harm and an unhappier patient (one who is more likely to sue). Instead, let’s be proactive. Speak to the patient about goals, preferences, alternatives, risks, and benefits. Stay up to date on the research via continuing education in dysphagia. Use instrumental studies to guide our treatment and monitor progress instead of relying on inaccurate clinical judgments and assumptions. Help the patient weigh different decisions and make the one that is right for them. Understand not just the swallow, but the whole patient. Help them reduce their risks by looking beyond the swallow and working with the team to formulate a comprehensive approach to their care (e.g. improving oral care, mobility, positioning, and the ability to self-feed). Finally, document everything like our job depends on it. Your plan, reasoning, progress, changes, and discussions. Because if it does end up in court, it’s your documentation they’ll be reviewing; not your intentions.
Retire your diet police badge
What may have at one point been a badge of honor is now ready to be stored away in a drawer somewhere only to be taken out again as a reminder of what we don’t want to be. You’ve realized that this badge is more like handcuffs, keeping you from doing the real work that has to be done to properly care for the patient and their needs. It’s given us tunnel vision, kept us under the streetlight, and has blinded us from seeing the whole picture. It’s time to retire, step out of our silos, and treat the patient. Because if that’s not our purpose, then what is?
