This text-based course is a transcript of the event, “Decision Making for Alternate Nutrition and Hydration; Part II,” presented by Denise Dougherty, SLP.
>> Denise Dougherty: This is part two of my presentation. If you have not taken Part 1, I would recommend you take a look at that. It comes at this decision from the patient and the family standpoint, looking at religion and culture, which is a big part of the decision-making process. Today we are going to come at it from the professional aspect and we are going to look at what we decide, make recommendations and why we make those choices. Then we need to customize what we are going to do for this individual. Part 2 will pick up with the professional. Hopefully when we have done our assessments, we have done the bedside, we have done any instrumental assessments that we believe is appropriate, so that we know the status of the swallow, we know how disease processes work and the impact it is going to have on the ability to maintain the patient’s needs safely by mouth.
We know what the patient is going to have to deal with as far as particular options. They may not, from a family or a patient's standpoint, like those recommendations. If there is a difficult time coming up with a plan, we need to figure out how we are actually going to put this plan in place since we disagree or have different opinions.
We will also talk about benefits and burdens. There are some good things that come out of a feeding tube and there are some bad things. We need to always look at it from the pros and cons, the good and the bad. If you e-mail me, I will be able to send you some forms. One of them is the benefits and burdens of PEG tube placement versus oral intake. It does a nice job of explaining the good and the bad in different disorders.
When we look at different decision-making tools, basically there are many different flowcharts that have been constructed from the medical professions looking at who should or should not get a feeding tube. You are going to see some discrepancies as we go through those. We are going to also take a look at what is considered to be the most evidence-based decision-making tool for placement of the feeding tube. We need to have this discussion rather than the doctor just taking it upon himself to say, “This is what we are going to do, end of discussion.”
Then we will take a look at some things we mentioned last time, informed consent versus informed refusal. The key here is informed. The patient is free, at least in the area of the country that I work in, to do whatever they want. They do not have to take our recommendations, but we want it to be an educated informed decision and one that we have actually done a really good job of documenting. Waivers do not hold up in court. We will talk about better ways to do that, but they may choose to go against the recommendations. Where I work patient rights trump safety. That is not always the case. In some areas of the country, patient safety trumps patient rights, and this is what you are going to get like it or not.
