Ethical Dilemmas Swallowing and Swallowing Disorders Case Article Questions The attached files has an ethical case article and the questions to answer. 1.B

Ethical Dilemmas Swallowing and Swallowing Disorders Case Article Questions The attached files has an ethical case article and the questions to answer. 1.Brief intro into your case
2.What were your initial thoughts/considerations?
-Take yourselves through the Knowledge, Cognitive steps, and Attitudes/beliefs for this
case.
3.Any questions posed by the article
4.Your recommended Plan of Care for this client and steps you would take to approach
the dilemma (contact with whom? what you might say?)
5.Recommended solution from the case history article
Swallowing and Swallowing Disorders (Dysphagia)
(Dysphagia)
ris, Jeri Miller, Joseph Murray,
Adrienne Perlman, Christina
Smith, Beth Solomon, Barbara
Sonies.
Four types of instrumental assessment and biofeedback tools for
swallowing will be presented by
lecture, illustration, and hands-on
experience. The procedures are
fiberoptic endoscopy, videofluorography, EMG, and ultrasound.
Saturday 8-11 a.m.-Short Course
#12. Reflux and Airway Protection across the Age Span: Clinical
Considerations (Room to be announced.)
Faculty: Joan Arvedson, Diane
Bless, Charles Ford, JoAnne
Robbins, Chandar Singaram.
An interdisciplinary team will,discuss diagnostic procedures, GER
treatments and their outcomes. Interactions among GE reflux, airway protection, and voice will be
considered.
Saturday, 12 noon-3:00 p.m.-Short
Course #20. Measuring and Evaluating Outcomes in Dysphagia
(Room to be announced.)
Faculty: Susan Langmore, Jay
Rosenbek, Colleen McHorney,
JoAnne Robbins, Barbara Jacobson.
Existing research and relevant tools
that measure outcomes related to
dysphagia and dysphagia treatment will be presented and applied
to clinical practice. Outcomes discussed will include physiologic
impairment, health, cost, and quality of life.
Sunday 8-9:30 a.m. Seminar # 93.
Interdisciplinary Decision-making in Adult Dysphagia Management: Case Presentations Convention Center, Room 207
Faculty: Michael Groher, Bonnie
Martin-Harris, Fred McConnell,
Chandar Singeram.
This interdisciplinary group of presenters (GI, ENT, and SLPs) will
present cases and panel members
November 1997
1997
3
November
3
and the audience will be asked to
comment about management of the
case.
Division affiliates will also be
interested in a Special Session entitled: Update on ASHA’s Specialty Recognition Program,
Thursday 12 noon-1:30 p.m., presented by the ASHA Clinical Specialty Board (Convention Center,
Room 102).
An overview of the process and
current status of applications will
be presented followed by an open
forum for questions.
mitted to the rehabilitation hospital after a short stay in acute care
due to an exacerbation of chronic
progressive Multiple Sclerosis
which she had had for the past 15
years. When a clinical evaluation
of Mrs. J.’s swallowing was performed, she was determined to have
a severe dysphagia and it was questioned whether she should eat by
mouth or not. A videofluoroscopic
swallow assessment confirmed that
the patient’s swallowing impairwas significant secondary to
severe ataxia, weakness and sen-
ment
deficit. The recommendation
that Mrs. J. be placed on a diet
of pureed solids and thick liquid.
Liquids should be taken by spoon
only and Mrs. J. needed to use a
chin tuck when swallowing to further eliminate aspiration. Mrs. J.
was also physically dependent and
required a staff member to help her
sory
was
Lynne C. Brady
Ethical Dilemmas
The Case of Mrs. J.
The previous ethics column
dealt with the issue of caregivers
who are not able to follow through
with recommendations and strategies, putting a patient at risk. This
column will address a related topic;
one that has no straightforward
answer (certainly, no ethical dilemma does), one that may have as
many approaches as there are facilities in which we are employed.
What should your recommendation be if your patient can tolerate an oral diet only if specific techniques are used and the patient is
supervised closely and given cueing/assistance? Additionally, you
have concerns that the staff members who typically handle meal supervision (at least during the evenings or on weekends) are not able
to provide this supervision. The final piece that can make this an urgent dilemma is that you feel the
patient should have an alternative
nutrition source in place if he/she
is not able to have this supervision
each time he/she takes food/liquid.
Consider the case of Mrs. J.
This 46-year-old woman was ad-
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eat.
The primary speech-language
pathologist treating Mrs. J. was very
concerned about her swallowing
safety. She implemented all modes
of communicating to the nursing
staff the patient’s swallow status as
well as the level of supervision
needed to follow through with all
the swallowing strategies. The
nursing staff was responsible for
meal supervision for at least one
meal a day during the week. The
methods of communication were
1. a computer message to the
nursing staff;
2. written instructions placed in
a folder in a backpack (used
specifically for swallowing
status and information) hung
on the back of the patient’s
wheelchair; and
3. contacting Mrs. J.’s nurse coordinator in person to discuss
the recommendations.
Two days later the speech-language pathologist was present during lunch on the patient’s floor. She
noticed Mrs. J. sitting with a nursing aide who was watching the pa-
Swallowing and Swallowing Disorders (Dysphagia)
Swlown
an
wloigDsres(Dshga
tient swallow liquids through a
straw. The next moment, Mrs. J.
began to cough and experienced
nasal regurgitation of the liquid.
The nursing aide was quite upset.
When reminded that Mrs. J should
not be drinking with a straw, the
nursing aide shouted that ‘if the
patient had difficulty so severe, she
should not be eating. ”
There are many questions to
consider in response to Mrs. J.’s
case Because this is quite a complex
situation and a dilemma that we
confront often, I thought it might
be good to have some feedback on
how different speech-language pathologists would analyze this ethical issue and what they think the
responsibilities of the entire treatment team are. I would like to propose the following queries but
please do not confine your discussion to only these if you wish.
1. What is the ethical responsibility of the primary speechlanguage pathologist in making recommendations for p.o.
intake in the case of Mrs. J.?
2. How does the severity of
Mrs. J.’s dysphagia play a part
(i.e. the fact that she currently
does not have a feeding tube
and that she can manage p.o.
intake only if certain strategies are adhered to)?
3. What are the ethical responsibilities of all team members
in carrying out the recommendations of consultants or other
team members who have expertise in a certain aspect of
patient care (i.e. swallowing,
mobility, pharmaceuticals,
etc.)?
Please send your responses to
Cathy Lazarus at 312-908-8035, or
claz@nwu.edu. Afull discussion of the
dilemmas present in the case ofMrs. I.,
including your comments, will be
printed in the upcoming newsletter.
November 1997
4
oebr19
Mike Groher
Outcomes/Quality Assurance
The Joint Commission on Accreditation of Hospitals is putting increasing demands on medical centers to show how interdisciplinary
monitoring can improve quality of care. Nan Musson and her colleague
Michael Silverman provide an example of an interdisciplinary team monitoring project that resulted in considerable cost savings to their hospital
An Example of an Interdisciplinary TQM/
CQI Project: Prescription of Liquid
Nutritional Supplements
Nan D. Musson and Michael A. Silverman
Department of Veterans Affairs
Geriatric Research, Education and Clinical Center
VA Medical Center, Miami, FL
This TQM/CQI project was
designed to improve prescribing
and utilization of liquid nutritional
supplements. Outpatients receiving nutritional supplements were
assessed by an interdisciplinary
team. Patients not meeting the criteria for continued use were referred for nutritional counseling
and monitoring.
Major causes for nutritional
decline can be divided into three
categories: social, psychological,
and medical. Social causes may include social isolation, poor financial status, or decline in ability to
complete independent activities of
daily living, while psychological
factors may include depression,
alcoholism, or anorexia. Medical
causes of nutritional decline include
disorders that interfere with selffeeding and swallowing (i.e., cerebrovascular accident, Parkinson’s
Disease, Alzheimer’s Disease,
chronic obstructive pulmonary disease or candidiasis), disorders that
increase metabolism (i.e., hyperthyroidism) or disorders of malabsorption (i.e., gluten enteropathy). In
addition, over-prescription of
medications or restricted diets can
increase the risk for iatrogenic decline in nutrition.
Nutritional supplements may
be self-purchased or prescribed as
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an intervention for any social, psychological or medical cause of nutritional decline. Skilled marketing
has influenced the public percep-
tion of the purpose and consumption of supplements. Nutritional
supplements should not serve as
an alternative or replacement to a
balanced diet. Nutritional supplement use has variable indications
for implementation, route of delivery, and duration of use. A comprehensive interdisciplinary assessment may be required to determine the potentially multifactorial
cause of a nutritional decline and
to provide appropriate intervention and monitoring of the use and
benefits of nutritional supplements.
In this project, criteria for the
use of nutritional supplement were
established by an interdisciplinary
team. Nutritional supplements
were only recommended if medically indicated for patients with
oropharyngeal dysphagia, esophageal dysphagia, or for those at
nutritional risk. Patients identified
with social or psychological causes
of nutritional decline were referred
to the Social Work or Psychology/
Psychiatry Services respectively.
Some cases required combined
medical, social and psychological
intervention and counseling.

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