Wave Goodbye to the Diet Waiver
Diana is a 77 year-old female with a history of Parkinson’s Disease and has been on your caseload for two weeks secondary to dysphagia. Prior to a recent hospitalization for pneumonia she has been eating and drinking without difficulty. She has been on pureed solids and mildly thick liquids since evaluated in the hospital and her dislike for it has grown day by day. For two weeks, Diana has reported that she no longer wants this diet and is ready for advancement. But you are concerned. The swallow study report showed moderate to severe dysphagia with a high risk for silent aspiration on thin liquids and a high risk for residue for solids. You are worried she is going to come down with another pneumonia if she doesn’t take a conservative approach. After multiple days of discussion she is starting to get tired of waiting for improvement. Diana reports that she is officially declining the diet recommendations and would like to begin eating and drinking regular food and liquid again… no matter the risk. You do your best to educate her on your recommendations to continue the current course, but she doesn’t feel like you are listening to her. You discuss the situation with your director and she asks why you haven’t considered doing a diet waiver yet... A diet waiver? What’s that?
What’s a diet waiver?
A diet waiver is a document provided in some medical facilities that asks the patient to sign off on their understanding of the risks associated with eating and drinking a diet deemed unsafe by the interdisciplinary team. Similar to a waiver you might sign while you are going skiing or bungee jumping, it states that the facility cannot be held accountable if anything were to happen to the patient as a result. Sounds pretty legit, right? Well, not really.
Doesn’t hold up in court
A diet waiver in a medical facility does not hold up in court for several reasons. Relatively recently, there has been a big push in healthcare to adopt a more patient-centered approach. This means we, as medical practitioners, are responsible not for telling a patient what is best, but by educating them on a series of options as well as the pros and cons of those options; and then allowing them to decide for themselves what is best. A diet waiver undermines this process and essentially pins the SLP and the medical facility against the patient. It reflects the fading paternalistic nature of healthcare and creates a culture of “Us vs Them.” For this reason it’s best to eliminate phrases like “patient refusal” from our vocabulary because it goes directly against the productive, two-sided conversation we should be having with out patients. A diet waiver leads to instances where the SLP might even be expected to discharge services after the patient signs the form, which would discontinue the guidance and support the patient will need even more once they start navigating a riskier territory.
By putting the needs of the SLP and the facility over the needs of the patient, we are disregarding one of the most important rules in healthcare: Putting patients first. Patient-centered care inside an evidenced based model of medical treatment means that we are utilizing our expertise with the available research to provide support for the patient so they can make a decision that is right for them. A diet waiver completely disregards this cornerstone of effective and ethical healthcare and ends up sacrificing the trust of the patient for a shallow form of legal protection. But does it even offer legal protection?
I Object!
The diet waiver seems like it would at least provide some protection for facilities in the event that a patient aspirated on the consistency of their choice. But it doesn’t. In fact, it may INCREASE the risk especially if it is the facility’s policy to discharge SLP services after the waiver is signed. You see, it’s negligence that should be the concern, not whether the patient chooses to follow your recommendations or not. And failing to provide an essential service to a patient in need of support and guidance for their dysphagia would definitely qualify as negligence. Even if you aren’t discharging the patient, a waiver may be viewed as a form of coercion as it does little to show you are supporting the stated interests of the patient.
Knowledge is power
The information we give to our patients, families, and the entire interdisciplinary team provides them with the power they need to pave their own path forward. We are guides, not dictators. Instead of a diet waiver, do this:
Offer a detailed description of your recommendation and alternatives
Detail the pros and cons of each option
Take account of your patient’s preferences, expectations, and values
Document your discussions in detail
With this process you are doing a much better job of protecting yourself legally and professionally (See the research-based decision-making protocol, FORWARD for a more structured option). Yes, there may be times we don’t agree with the patient’s decision. There may even be harm that results from that decision. But what about the harm involved with the patient being robbed of their agency to make a decision in the first place? Using a diet waiver is much easier than having a long conversation with consideration for multiple, complex factors. But the easy way is rarely the right way. If knowledge is power, then we have the opportunity to make our patients more powerful after a long session of discussion and deliberation than any amount of effortful swallows.
If you’d like to read more on this topic please take a look at this incredibly well-written piece by Elizabeth Thompson Beckley: Patient Wishes Before Risk.
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