Should you use dysphagia waivers?

July 15, 2014
Rachel Wynn

Somewhere in my career my thoughts about dysphagia (or diet) waivers changed gradually. Although I was told they don’t hold up in court, I was also reminded over and over that dysphagia waivers must be completed. As I completed waiver after waiver with families and elders, I began to feel waivers are not only unnecessary but they may also reduce therapy outcomes.

Can dysphagia waivers cause harm?

First, waivers create a divide between therapists (or nurses) and elders and their families. I feel waivers communicate it’s my decision not the elder’s decision. This couldn’t be further from the truth. My job is to give elders and their families the tools and information to make good decisions. A good decision for one family may not be a good decision for another family. I feel a dysphagia waiver tries to objectively determine what is a good decision. But it’s not my call. Because each person is different, I respect a more conservative approach and more liberal approaches to determining diet consistency (as long as it’s informed).

Second, in some places signing a waiver means treatment ends. So the waiver is communicating, ‘it’s my way or the highway’. What good will come from this? If we stop treatment, how are we supposed to improve quality of life? (Though I will clarify, it is fine for elders and families to decide they don’t want treatment.) I have seen several people who don’t want feeding tubes. While my evaluation may indicate they are at significant risk for aspiration with any food or liquid by mouth, it’s my job to honor their desire for no feeding tubes and recommend strategies to reduce their aspiration risk as much as possible and help them improve safety with eating through rehabilitation. If treatment stopped just because they didn’t want alternate means of nutrition, potential for rehab and improved quality of life stop too.

An informed consent approach

One of my other concerns about dysphagia waivers is they focus on an instance of education rather than continual education. I work hard to foster an environment of empowered decision making for elders and families. I do this by explaining current status, recommendations, treatment task objectives, etc. every day in a way elders and families understand. People should understand, what is aspiration? And what is aspiration pneumonia? And what are the potential outcomes in developing aspiration pneumonia?

A dysphagia diet is a type of treatment. Automatically assuming that someone will adopt the dysphagia diet when we recommend it violates elder’s rights. It’s a treatment just like medications, procedures, etc. In my documentation I note informed consent for diet texture consistency changes. And as I mentioned above regarding the education, I make sure it is truly informed consent. When a family or elder does not consent, I document that I informed them of risks, recommendations, etc. and what their response was. I might end up with a note that looks like this (for someone that also has cognitive impairment and relies on family for decision making):

“Per bedside swallow evaluation Mr. Jones is at high risk for aspiration when drinking thin liquids. No overt signs or symptoms of aspiration or penetration were seen with nectar thick liquids. Education provided to family and Mr. Jones regarding risks for aspiration and aspiration pneumonia. Family reported concern regarding dehydration, as this was an outcome of a prior instance of thickened liquids when Mr. Jones refused to drink thickened liquids. Family does not want to begin a nectar thick liquid diet. SLP recommends no straws with thin liquids and aggressive oral care to reduce risk of aspiration. Family receptive to no straw and oral care recommendations. Continue skilled SLP services to improve safety with PO intake and reduce risk for aspiration.”

Because it’s a continual discussion there isn’t a specific moment where I decide not to use a dysphagia waiver; it just doesn’t occur to me anymore. I am documenting status, progress, recommendations, and responses every day. Not only should that hold up better in court than an instance of education, but it’s an approach that fosters empowered decision making which respects the elders we serve.

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