Fast Facts and Concepts # 128; The Speech Pathologist And Swallowing Studies

Author(s): Carol Monteleoni, MS CCC-SLP

Speech pathologists can facilitate communication among members of the medical team, and between the team and the patient/family, to make treatment decisions that honor patient wishes. Speech pathology services, for symptom control to enable the individual to maintain activities of daily living, and basic functional skills, are reimbursable under the Medicare Hospice Benefit. Swallowing studies are used to evaluate a patient’s ability to safely ingest oral food and oral secretions, yet the role of swallowing studies to facilitate optimal care near the end of life is not clear. This Fast Fact will review the indications and contraindications for a swallowing study and the role of the speech pathologist.

Potential Indications for a swallowing evaluation (Bedside or Instrumental)

• Acute stroke or other neurological condition affecting oral motor function
• Tracheostomy or recent endotracheal extubation
• Changes to oropharyngeal anatomy secondary to tumor, surgery, trauma, etc.
• Observed difficulty swallowing food or liquid
• Recurrent upper respiratory infections or pneumonias
• Reduced oral food intake; Unexplained weight loss or fever

Contra-indications for swallowing evaluation (Instrumental only)

• Imminent death—death expected within 2 weeks (See Fast Fact #3)
• Death expected within weeks from any progressive terminal illness
• Reduced level of arousal (e.g. coma/obtundation)

Types of swallowing studies

• Bedside dysphagia evaluation involving in-depth feeding/swallowing history, oral peripheral examination, and trial swallows of various food consistencies. Bedside evaluation can not rule out silent aspiration.
• Instrumental swallowing evaluation via modified barium swallow (videofluoroscopy), fiber-endoscopic evaluation of swallowing (FEES), or fiber-endoscopic evaluation of swallowing with sensory testing (FEEST). All of these instrumental assessments require the patient to be alert, cooperative, and able to follow simple commands.

Speech Pathologist Role

The decision to perform a swallowing evaluation should be made based on the overall Goals of Care and expected prognosis. Consultation with your speech pathologist prior to ordering an evaluation can help clarify how you will use any new information. If performed, the speech pathologist will evaluate the swallow and recommend feeding strategies which may include:

• appropriate food consistencies
• positioning of the head and neck
• timing of meals and family involvement

Note:
Decisions regarding feeding management should not be made based solely upon the speech pathologist’s assessment of swallowing dysfunction, which may be a sign of the final stage of life in many terminal conditions. Feeding tube placement decisions in this population should not be based on the likelihood of aspiration. In patients with advanced dementia and other terminal conditions, feeding tubes have not been found to reduce the incidence of aspiration and can significantly impair the dying patient’s quality of life. (see Fast Facts #10, 84)

References:

1. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA 1999; 282:1365-1369.
2. Levy A, Dominguez-Gasson L, Brown E, Frederick C. Technology at End of Life Questioned. The ASHA Leader 2004, July 20: pp. 1, 14.
3. Ahronheim JC. Nutrition and hydration in the terminal patient. Clinics in Geriatrics. 1996: 12(2): 379-391.
4. Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ 2004; 329: 491-494.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Monteleoni C. Fast Facts and Concepts #128: The Speech Pathologist and Swallowing Studies December 2004. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.

 Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is use

Creation Date: 12/2004

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Non pain symptoms & syndromes; dementia; Other neurologic disorders; gastrointestinal diseases & nutrition

Keyword(s): Non pain symptoms & syndromes

Specific Disease and Organ System Category(s): Dementia; Other neurological disorder; Gastrointestinal Diseases & Nutrition