Dysphagia Treatment: When to Discharge a Patient

Editor's Note: This text is a transcript of the course Dysphagia Treatment: When to Discharge a Patient, presented by Debra Suiter, PhD, CCC-SLP, BCS-S. 

Learning Outcomes

After this course, participants will be able to:

Introduction

I will focus primarily on dysphagia in this course, although many of the principles I discuss can be applied to other patient populations as well. However, because most of my caseload and most of my clinical experience focus on individuals with dysphagia, we will primarily focus on those individuals.

Defining the Problem

To start, I found this quote particularly interesting. It's from a dysphagia text where the author stated, "One of the most challenging issues for a speech-language pathologist is deciding whether to discharge patients from treatment or not offer treatment at all." Many of us with extensive clinical experience acknowledge the anxiety and concern clinicians face when deciding whether to discontinue or not initiate treatment for a patient. Let's discuss these issues.

ASHA offers valuable guidance on the topic, and while 2004 might not seem that old, it provides us with principles for patient discharge considerations, particularly those relevant to swallowing. One compelling reason for considering patient discharge is whether their swallowing function is within normal limits or aligns with their premorbid status. This can be a challenging assessment, especially in cases like mine where I work with individuals who have undergone treatment or surgery for head and neck cancer, leading to dysphagia.

Understanding a patient's premorbid status can indeed be challenging, especially when it's not readily apparent. Effective communication with the patient becomes a crucial tool in such cases, as it allows us to gain insights into their previous health and swallowing function before the illness that brought them in for a swallowing evaluation.

Another important consideration for discharging a patient is the achievement of treatment goals and objectives. However, this raises questions about whose goals we are prioritizing – those of the clinicians or the patients. It's essential to acknowledge that there can be a misalignment between our goals as healthcare professionals and the patient's goals. Thus, deciding whether to discharge a patient is not straightforward and requires careful consideration of these factors.

Consideration of whether to discharge a patient must also factor in whether their feeding and swallowing skills no longer negatively impact their educational, social, emotional, vocational performance, or overall health status, especially in a school setting. Point four from ASHA's guidance adds an interesting dimension, highlighting that the individual's nutrition and hydration needs are optimally met by an alternative means, such as a gastrostomy tube. Additionally, it notes that adequate management of oral and pharyngeal saliva accumulations is essential to assess.

In my practice, which predominantly focuses on individuals with amyotrophic lateral sclerosis (ALS), the possibility of a PEG tube serving as an alternative solution is often considered. However, it's important to acknowledge that achieving adequate management of oral and pharyngeal saliva accumulations might not be a feasible goal for many of our patients, and this is a factor we must consider when making discharge decisions.

Another significant consideration for patient discharge is when the patient or client is unwilling to participate in treatment. In such cases, it becomes necessary to evaluate the situation and consider discharge as an option.

Furthermore, the consistency of treatment attendance is a crucial factor to weigh in this decision-making process. While clinics may have policies in place, it's important to be mindful of external factors like transportation challenges and illnesses that can affect attendance. If treatment attendance remains inconsistent or poor, it may warrant considering discharge as an option.

Patients or their families may also request discharge or express a desire to transfer their services to another provider. In cases where the patient is being discharged to another location and no services are available, this, too, can be a valid reason for considering discharge.

When treatment no longer yields measurable benefits, it presents a complex situation that requires careful evaluation. Several factors come into play, and we must consider whether this outcome indicates that the patient has reached their maximum capacity or if it suggests that the treatment provided is not appropriate for the patient's specific needs.

Another critical aspect to explore is the patient's adherence to a home program. Are they correctly performing the exercises as prescribed, and are they doing so with the recommended frequency? Several variables can influence why treatment may not result in measurable benefits, and it's essential to thoroughly assess the situation before making the decision to discharge, as it may not automatically warrant discharge but necessitates thoughtful consideration.

If a patient cannot tolerate treatment, that could be a valid reason for considering discharge. Additionally, if a patient's behavior interferes with their own improvement or participation, it becomes a factor to assess in the decision-making process.

When it comes to non-compliance versus adherence, these are two distinct concepts. Non-compliance refers to patients not following the treatment plan or recommendations, while adherence implies that patients are following the prescribed course of action. These distinctions are essential to consider when evaluating whether to discharge a patient.

Furthermore, if there are concerns about malingering, a delicate issue that needs to be handled with care, it might be a reason to contemplate discharge. Although we prefer not to think about patients malingering, it is a reality that can occur and necessitates attention.

Clinician-Driven Reasons for Discontinuing Therapy

Why do clinicians discontinue therapy? One reason is that the patient has met our goals, which is bolded because our goals are not necessarily the patient's goals, but that might be why we discontinue therapy.  Is that an appropriate reason? Sometimes yes, and sometimes no. We need to consider whether or not our goals match the patient's goals and whether or not our goals are realistic for that patient.

Another reason clinicians discontinue therapy is if the patient has completed a designated number of therapy sessions. Some therapy programs have very specific numbers of treatment sessions that are supposed to occur during that program. If the patient has reached the end of that number of sessions, then you might need to discharge the patient.

Insurance, as we all know, drives most of what we do. If insurance decides not to cover our services, we need to discuss that with the patient and possibly discharge the patient.  

If there's a disconnect between our goals and the patient's goals, that might be a reason to discontinue therapy.  There can be a real disconnect between what we think are realistic goals and what our patients think are realistic goals.  Additionally, if there are scheduling issues or the patient is not making progress, then it might be time to discharge. We have to ask ourselves, is a patient not making progress because they're incapable of making any additional progress? Did I not choose the appropriate treatment for them? What is causing this patient not to make progress? So, it's not always a reason to discontinue therapy; it may be a reason to re-evaluate what we're doing in therapy, but it certainly can be a reason that some people choose to discharge patients.

The dysphagia literature doesn't offer much guidance regarding when and why we discharge patients. However, in the voice literature, a notable article was published (I believe from Perspectives). This article surveyed clinicians working with individuals with voice disorders, inquiring about the factors influencing their decision to discharge patients.

One primary reason for discharge was completing all prescribed sessions in a specific voice therapy program. For instance, if a highly structured program required four sessions a week for four weeks, and the patient attended all 16 sessions, this could warrant discontinuing treatment. Another reason for discharge was when the speech-language pathologist believed the patient had achieved their therapy goals, even without concrete quantitative evidence to support this assessment. In some instances, no specific reason for discharge was provided, which is particularly interesting.

The lack of clarity surrounding the reasons for discharging patients is a challenge for us as clinicians and can lead to confusion for our patients. With no clear criteria or guidelines in place, determining when to discharge patients from voice therapy becomes a subjective and potentially inconsistent process.

Clinician-Driven Reasons for NOT Discharging

Why might we opt not to discharge a patient and keep them on our caseload for an extended period of time? One reason, and it's a reality faced by many of us, is the pressure for productivity. Facilities often pressure clinicians to maintain a certain caseload to meet operational and financial goals. In some cases, patients may require services from multiple therapy disciplines, and speech therapy might be one of those services. This can result in clinicians experiencing pressure from the facility to retain patients on their caseload.

Determining when to discharge a patient can be a complex and uncertain process. Sometimes, it's challenging to determine if the patient has reached their maximum potential benefit from therapy, especially if they haven't regained the ability to consume an oral diet. When the anticipated improvements from a therapy program haven't materialized as expected, the decision to discharge becomes even more challenging.

Furthermore, clinicians often form strong attachments to patients and clients. We share concerns about their well-being, and there's a natural worry that they, their caregivers, or even we ourselves might think we've abandoned them or given up hope for further progress. This can lead to difficult conversations, especially if the patient hasn't achieved the level of improvement they initially desired by the end of their treatment.

From the same survey, originating from the Voice world, the authors in this specific paper surveyed voice clinicians about the criteria they used to determine patient discharge from therapy. The voice clinicians identified various factors which are also relevant to dysphagia. One factor was the ability to apply voice techniques in conversational speech. When discussing swallowing, we can apply this concept to patients' ability to implement compensatory strategies from therapy sessions to mealtime. Another factor was the patient's capacity to distinguish between effective and ineffective voice production or, in the context of swallowing, to determine the safety of a swallow. That distinction can be challenging for many individuals. Moreover, the patient's ability to demonstrate improvement, whether in voice quality or, in the case of swallowing, the ability to consume a meal without signs or symptoms of aspiration, presents a significant consideration. While specific criteria for dysphagia are lacking, it is conceivable that we can adapt and apply the information presented in this article when working with patients who have swallowing disorders.

As clinicians, we must consider various factors when assessing and treating patients with dysphagia. One crucial factor is understanding the underlying illness or disease process contributing to the patient's dysphagia. This understanding is vital when determining the appropriateness of therapy initiation or discharge.

For instance, the approach to dysphagia in a patient who has recently suffered a stroke differs significantly from that for someone with a neurodegenerative disease like ALS or individuals recovering from head and neck cancer treatment, be it chemoradiation or surgery. Even within the category of head and neck cancer patients, there's a distinction between those who recently underwent treatment and those who completed treatment a decade or more ago. These variations impact the prognosis and the expected recovery, making it essential to grasp the specifics of the underlying illness, its effects on swallowing function, and what realistic goals to set for each patient.

Sometimes, therapy may not be suitable, and active rehabilitation interventions may not be warranted. Instead, our focus may shift toward teaching patients compensatory strategies, which can be a perfectly appropriate approach for some individuals.

The primary consideration when determining the goal of therapy is whether the focus should be on maintenance or improvement in function, as previously mentioned. Additionally, therapy selection should align with the underlying cause of dysphagia. Assessing whether the chosen therapy is suitable for the specific case is crucial.

For example, if a therapy program involves muscle stimulation, it's vital to ensure that the relevant muscles can respond to stimulation. Similarly, when prescribing exercises to increase strength, one must evaluate whether this approach is appropriate. There's a need to be cautious, as introducing certain therapy techniques may risk exacerbating weakness or hastening the progression of dysphagia in some cases.

Understanding the cause of dysphagia is essential. In cases where the etiology of dysphagia is unknown, as is often encountered in outpatient settings, it's a prudent practice to refrain from initiating therapy immediately. Instead, it's important first to gain a better understanding of why the patient is experiencing dysphagia. This step is crucial for determining the appropriateness of treatment and, if treatment is warranted, selecting the most suitable therapeutic approach.

While the ultimate goal of dysphagia management, as stated in the article, is for the patient to achieve adequate nutrition through safe oral feeding, it's crucial to recognize that this goal may not be applicable to all patients.

Not all individuals can return to a point where they can safely consume an oral diet and maintain their nutrition. Each patient's circumstances and prognosis are unique, and as such, the goals of dysphagia management should be tailored to their specific needs and capabilities. It's essential for clinicians to acknowledge that the desired outcome may vary from one patient to another and to work towards setting realistic, patient-centered goals that align with their individual circumstances and potential for improvement.

Defining Goal Attainment

Defining goal attainment in dysphagia management is a critical aspect of providing effective care. As previously stated, not every patient can or should aim for a regular texture diet with thin liquids. The end goal should be determined on an individual basis.

For some patients, the goal may be as simple as enjoying sips of liquid throughout the day for pleasure. For others, it might involve safely consuming a modified diet that ensures adequate nutrition and hydration. The key is to work collaboratively with the patient to identify their specific needs, capabilities, and aspirations and then establish clear, realistic goals based on their unique circumstances.

Ensuring that the patient understands and agrees with the treatment goals is essential before embarking on any therapy program. This approach minimizes misunderstandings and frustrations and fosters a sense of shared purpose between the clinician and the patient. It's not about downplaying the patient's hopes but setting achievable expectations and working toward the best possible outcome given their situation.

What Determines When to Discharge

When discussing dysphagia, how do we determine when to discharge a patient? For instance, if we've chosen a swallowing rehabilitation program focusing on a specific aspect like base of tongue retraction, determined through instrumental assessment to be reduced and causing significant residue, how do we gauge goal achievement? The measure of success will likely be based on functional outcomes. Therefore, we'll need to reassess the patient, ideally using instrumental assessment, before determining whether progress is sufficient.

The key question is, how much improvement in tongue-based movement is necessary? Is it enough if the patient can swallow more effectively but still requires two or three swallows to clear residual material? Or does the patient need to achieve an effortful swallow for the treatment to be considered successful?

Is it ideal for tongue-based movement to reach a point where the patient doesn't require additional compensatory strategies? When working on isometric lingual strength, determining the sufficient level is essential. It's important to recognize that swallowing is a sub-maximal task, meaning you don't need to exert the maximum effort, strength, or pressure your tongue can withstand to swallow safely.

The question then becomes, how much is enough? This assessment should be functionally oriented. Do we examine more global measures, such as penetration and aspiration occurrences, as well as scale scores, to gauge the effectiveness of the treatment?

While penetration and aspiration are important considerations in assessing swallowing function, they do not represent the entirety of the issue. Some individuals may experience significant dysphagia without necessarily penetrating or aspirating; instead, they may have an inefficient swallow, leading to prolonged meal times that hinder them from meeting their nutritional needs via an oral diet. 

In addition to penetration and aspiration, other factors, such as the Functional Oral Intake Scale (FOIS), come into play. FOIS assesses the level of diet the patient can safely consume. Changes in FOIS scores may be valuable when determining whether a patient is ready for discharge, as they reflect the patient's ability to maintain appropriate oral intake and nutrition. 

Again, what's the ultimate goal? Aiming for a full return to a regular texture diet is not always necessary. The goal could be to enable the patient to safely consume an oral diet, even if it involves some compensatory strategies or dietary modifications. We must also consider their ability to take any PO or oral diet. 

How do we determine when to discharge a patient? ASHA states, "Discharge is defensible when the individual, the family, and/or the guardian requests it or requests continuation with another provider." I recommend that this situation warrants a conversation, even though it might be uncomfortable. If the patient or a family member wishes to continue their services with another provider, it's important to understand the reasons behind this request. Engaging in this conversation is entirely appropriate. 

How Long Should It Take to Meet Therapy Goals

Another aspect to consider in dysphagia therapy is the timeframe for achieving therapy goals. In many traditional dysphagia therapy techniques, such as the effortful swallow, base of tongue retraction exercises, and isometric lingual pressure exercises, the emphasis is often on improving strength. It's important to recognize that when starting a strength training program, whether related to speech and swallowing or any other muscle group, the initial changes primarily pertain to how the nervous system activates the muscles rather than significant changes in the muscles themselves.

A patient must typically complete a therapy program for at least five weeks to observe muscle changes. During this timeframe, hypertrophy and a shift to Type 1 fiber types in the muscles can occur. This is particularly relevant to strength training programs.

Therefore, when you determine that a strength training program is necessary for your patient to achieve functional improvements in swallowing, it's essential to ensure that the patient consistently follows the program for at least five weeks before reassessment. In cases where you're incorporating traditional exercises, it's advisable to communicate to the patient that the program should be followed for about six to eight weeks, with a minimum of five weeks. Following this period, you can schedule a repeat instrumental swallow assessment to gauge the program's effectiveness. While complete functional status may not be achieved, you should expect to see some improvement if the program is effective.

When we don't observe the expected improvement in a patient, it's crucial to consider various factors. One key factor is whether strength was the appropriate goal for the patient in the first place. There has been significant discussion in the dysphagia clinical community about whether strength should be the primary focus for many patients. Instead, it may be more appropriate to concentrate on efficiency or endurance in certain cases. Strength might not always be the most suitable goal.

Another factor to evaluate when reassessing a patient and not witnessing anticipated changes is the number of repetitions of the particular exercise the patient completed. Unfortunately, for many of the therapies offered, there's a lack of clear guidance on how many repetitions are necessary for improvement. This highlights a recent shift in dysphagia therapy programs, with more emphasis on determining appropriate dosage for patients.

It's worth noting that the ideal number of repetitions and the required effort may vary from person to person. There's no one-size-fits-all approach in this regard. Additionally, adherence to proper execution of exercises is a significant factor. For exercises like the effortful swallow, which can be challenging to assess at the bedside, ensuring that the patient is performing the exercise correctly can be quite difficult. For instance, it can be hard to determine whether a patient is correctly executing a Mendelsohn maneuver, as variations in tongue movements may mimic the maneuver but not produce the desired therapeutic effect.

Another important aspect to consider is whether the patient is adhering to the home exercise program provided. Many patients are given home exercise programs due to distance constraints, preventing them from returning to frequent therapy sessions. However, it's difficult to determine if they perform the exercises as prescribed and at the recommended frequency.

Adherence to recommendations is a significant concern when it comes to home therapy programs, and it's not uncommon for patients to struggle with compliance. Again, remember that a patient not meeting therapy goals doesn't necessarily indicate that the therapy itself was inappropriate. Various other factors must be considered when assessing the effectiveness of the treatment.

Patient-Driven Reasons for Discontinuing Therapy

Let's explore some patient-driven reasons for discontinuing therapy. One such reason could be if the patient believes they have already achieved their goals. In this case, there may be a mismatch between your perception of their readiness for discharge and their own feelings of accomplishment.

Another factor to consider is when insurance coverage for therapy services ends. If insurance no longer covers the costs, patients may have no choice but to discontinue therapy due to financial constraints.

Occasionally, patients may be unsatisfied with the therapy services they are receiving. This dissatisfaction could arise from various factors, including differences in clinician-patient personalities, discordant goals, or a perceived lack of progress. These issues may prompt a patient to consider discontinuing treatment.

What Do We Do When Patient Goals Differ from Our Goals?

Let's discuss how we establish attainable goals and help patients comprehend what is feasible. We must engage in a thorough conversation with our patients before initiating a therapy program to set treatment goals. In some instances, disagreements may arise. Many of you have likely encountered situations with dysphagia patients where you've conducted an evaluation, concluded that consuming regular textures with thin liquids may not be safe, and made recommendations. However, the patient may express a desire to pursue a different goal, such as returning to a regular texture diet without modifications, and may resist the recommended treatment plan.

In such cases, a respectful agreement to disagree may become necessary. It's important not to abandon the patient but to attempt to negotiate a realistic goal with them whenever possible. However, if an agreement cannot be reached, it may be appropriate to suggest seeking services elsewhere.

Involving Patients in Goal-Setting

In terms of involving patients in goal-setting, a study revealed that just over half of patients, approximately 56%, reported being as involved as they would like to be in decisions regarding their treatment. Shared decision-making is a model in which clinicians and patients collaborate to determine treatment goals. This approach not only enhances patient satisfaction but also instills motivation and a sense of ownership over their goals.

When we set goals for therapy, it's essential to ensure that patients are informed about these goals. Without this clarity, patients may not understand what they are working towards. Dysphagia treatment can be challenging, as it involves consciously working on a process that is typically automatic. Patients may find it abstract and difficult to grasp. However, when we actively engage with our patients, help them comprehend the treatment process, and work together to set achievable goals, we often achieve greater patient buy-in and commitment to therapy.

When involving patients in goal-setting, it's crucial to consider the principle of autonomy. This is particularly important when working with older individuals, which is often the case in adult dysphagia therapy. Respecting the decision-making capacities of older patients, including those with cognitive deficits, is essential for as long as possible. While some patients may reach a point where they are unable to make appropriate decisions for themselves, in such cases, deferring to a healthcare proxy may be necessary and appropriate.

Challenges arise when there is a delicate balance between risks and benefits. In the context of dysphagia therapy, virtually any treatment recommended carries both risks and benefits. When working with patients to set goals, it's imperative to consider how the treatment plan will ultimately impact the patient's quality of life.

When involving patients in goal-setting, it's important to outline the process. One effective approach is discussing the results of swallow studies with patients. If possible, reviewing the video of the swallow study with the patient and their caregiver can be highly beneficial. This can be done in the fluoroscopy suite, and it's particularly relevant for clinicians who conduct video fluoroscopy or endoscopic evaluations of swallowing.

Sharing the results and reviewing the video with the patient makes it easier for them to understand their swallowing difficulties. Swallowing is an abstract concept, and many patients have limited knowledge of what a normal swallow should look like. Spending time discussing the video, normal swallow patterns, and the specific aspects of their disordered swallowing helps the patient and caregiver better understand their condition and what kind of recovery can be expected.

Considering the patient's healthcare literacy is an essential aspect of this process. There have been instances where patients have left a discussion about their swallow study, feeling that they understood the results, only to discover later that they didn't retain the information. This highlights the need for effective communication and clarity in our explanations.

To ensure that patients comprehend the information we provide, it's important to use plain language and avoid jargon. After discussing the results and recovery, we must confirm that the patient genuinely understands what has been communicated. Furthermore, when discussing recovery goals, it's critical to inquire about the patient's own objectives. What do they hope to achieve from treatment?

How Do We Discharge Appropriately?

How do we appropriately discharge patients? We often fail to inform our patients clearly about our criteria to decide when treatment should stop. This should be discussed upfront. What are our goals, and how will we determine when these goals are met? Without this clarity, client involvement in decisions about their own care becomes challenging. We must involve our patients and discuss the criteria for discontinuing therapy.

Additionally, we must consider whether it's appropriate to discharge a patient who disagrees with our treatment recommendations. This situation arises frequently, especially regarding non-oral means of nutrition or dietary modifications, such as recommending thickened liquids. If a patient refuses our recommendations, is it grounds for discharge? Not necessarily. If there's any way we can optimize the patient's safety, such as through positioning or feeding strategies, we should do so before considering discharge. Disagreeing with our recommendations alone shouldn't automatically lead to a discharge decision. This decision can be challenging, especially in an inpatient facility, but we must explore how to optimize the patient's safety even when there is disagreement with our recommendations.

Case Study Practice

Case Study 1

These case studies are examples of actual patients I've seen, but these principles can also be applied to your caseloads. The first case study involves a 74-year-old female who underwent a subtotal glossectomy followed by radiation treatment for a sizable T4 squamous cell carcinoma of the lateral tongue. She had a feeding tube placed during treatment, a common occurrence for patients undergoing radiation therapy, as it often becomes challenging for them to eat and drink orally due to pain and discomfort.

She had a PEG tube placed and underwent a post-radiation treatment-modified barium swallow study. This study indicated difficulty with oral transit, which was expected given the glossectomy. However, she compensated well, tilting her head backward to manage the oral phase effectively. Once food and liquid entered the pharynx, she exhibited a functional pharyngeal swallow. The results of her swallow study were quite satisfactory.

Despite this, she was referred to us for therapy because she struggled to discontinue the feeding tube. One of her reasons for continuing to rely on the feeding tube for nutrition and hydration was her concern about choking, as swallowing didn't feel the same as it did before her surgery and radiation. We discussed the reasons for this change in sensation and reviewed the results of the swallow study. Although we had done this immediately after the initial swallow study, we went through the results again during her first therapy session, emphasizing that her pharyngeal swallow was indeed functional.

We worked together to develop compensatory strategies. Her initial goal was to return to her pre-surgery and pre-radiation treatment condition, aiming for her swallowing to be as it was before head and neck cancer treatment. We discussed the significant surgical resection and radiation treatment, acknowledging that things would be different. We needed to help her adjust to this new normal and understand what it might entail.

I saw her for three therapy sessions, primarily addressing oral phase issues and the transition from a feeding tube to a regular diet. After these sessions, she had not made any additional progress and remained dependent on the PEG tube. We had extensive discussions with the patient and her husband. The patient insisted that she would only be satisfied if she could return to a full oral diet with regular textures. If this goal was unattainable, she would continue relying on the feeding tube.  At that point, we discharged her.

Considering our previous discussion, are there specific patient-related factors we can pinpoint for discontinuing treatment? As mentioned, one of the factors was her expectations, as she was determined to return to her pre-treatment quality of life and swallowing experience. When I had a conversation with her about the unrealistic nature of this goal, it became a reason for her to consider discontinuing treatment.

Regarding clinician-related factors for discontinuing treatment, in this case, it became evident that the patient's expectations and my treatment goals were mismatched. Despite my best efforts, I couldn't align her goals with what I could realistically achieve through therapy. The lack of progress toward her desired outcome was another reason that might have led to the decision to discontinue treatment.

Which strategies can we employ to assist patients in establishing realistic treatment goals? It can be quite challenging at times, particularly with patients who have undergone significant surgical resections, to convey what is and isn't realistic goal-setting.

Case Study 2

In the second case study, the patient had previously undergone radiation treatment for T3 squamous cell carcinoma of the supraglottic larynx and was experiencing ongoing dysphagia issues. After participating in 15 sessions of intensive dysphagia therapy, the patient's condition significantly improved, allowing them to be discharged while consuming a regular texture diet with thin liquids. In this case, the primary reason for discontinuing treatment is the patient's perception of success. The patient expressed satisfaction with their progress, feeling that they had achieved their treatment goal, which was to return to a regular diet with thin liquids. Moreover, from the healthcare provider's perspective, the patient had successfully completed the predetermined number of therapy sessions established within the selected treatment program, aligning with the intended treatment goals.

Case Study 3

This is a 53-year-old male with oropharyngeal dysphagia following a recent left hemisphere CVA. A modified barium swallow study was completed, and treatment was recommended. He initially agreed to treatment, attending four dysphagia treatment sessions and receiving daily home exercises.

After six weeks, a follow-up modified barium swallow study showed no functional improvement in swallowing. Should we discharge the patient at this point? It raises the question of whether the patient will benefit from treatment. This situation calls for self-reflection: did we choose the appropriate treatment, including the number of repetitions? What other factors might have contributed to the lack of improvement in swallowing function besides the patient's apparent lack of responsiveness to treatment? Is there an alternative approach or an option to increase the treatment intensity for this patient who hasn't shown significant improvement?

Summary

To conclude, deciding when to discharge a patient from treatment is often difficult for a number of reasons that we've discussed. In this course, I reviewed clinician-driven factors for discharging a patient, patient-driven factors for discharge, and discussed how to go about shared goal-setting.

Questions and Answers

How do we handle a prognosis for rare genetic disorders in young children with alternative nutrition? There is not much information available for these patients.

That is a great question, and I am afraid I don't have a great answer. Consulting with the patient's physician and looking at the literature on what the prognosis might be for that patient may provide some guidance. But without that, some trial therapy could be done to see if there's any improvement. 

If patients don't like their clinician or the schedule doesn't allow for treatment, what other options are available for the patient if therapy is indicated?

If the patient does not like a particular clinician with whom they're working, we can help them find another clinician in their area who might be appropriate. It's perfectly acceptable to say to a patient, "I understand that you don't wanna continue to work with me, so let me see if I can point you in the right direction of somebody who might be appropriate for you to see."

If scheduling is an issue, we want to help them find a location that will work for them.  Many of our patients work during the day so scheduling can be very difficult. Try to find an alternative model, such as teletherapy, that allows more flexibility. 

Is VitalStim an evidence-based practice therapy, or is it more subjective?

That's a really good question. I would say that the jury is still out on the benefits of electrical stimulation treatment, not specific to VitalStim, for swallowing. A number of studies have compared the use of a specific electrical stimulation program, such as VitalStim, to traditional therapy or have included VitalStim plus traditional therapy versus traditional therapy alone. And in those studies, there's really no additive benefit of that specific program has been found. However, when we're talking about electrical stimulation, there are certainly other available programs, so we should be careful not to throw the baby out with the bath water, and perhaps we need to look at adjusting the parameters for patients. So, there might be some clinical utility, but I think there needs to be a lot more research.

Is there a position statement from ASHA for the clinician to reference in their defense of treatment or discharge? Depending on the setting, particularly SNFs, clinicians get pushback from patients, families, as well as doctors and nurses.

Beyond that guidance document I referenced earlier, I don't know that ASHA necessarily has a specific position statement. I think you could look at the ASHA Code of Ethics to get indirect support for why you might choose to discharge a patient or wouldn't continue to see that individual for therapy. ASHA provides us with a lot of guidance. But they do try to steer clear of being dictatorial, so they don't put out a lot of really specific sort of position statements like that.

For case study number one, did the patient want to do pleasure feeds, and if so, was that discussed? Treatment could focus on maximum safety or ease of swallowing if she wanted to consume certain foods for pleasure and or identify the safest, easiest foods to consume.

Yes, the first patient I discussed, the woman with the subtotal glossectomy, I recommended a mechanical texture diet (I am using non-IDDSI language), soft moist textures, because she was functional on her modified barium swallow study. She had a perfectly functional swallow, she could compensate, and she could swallow solid textures. So, at that point, my recommendation was a mismatch with what she felt like she could do. We worked on getting her more comfortable taking the textures that her swallow study showed that she could take safely by mouth.  I had her start a food diary and list foods she was comfortable consuming right now. 

She indicated that she was comfortable with pudding, puree-type textures, and liquids. She wasn't comfortable eating what amounted to a full meal and couldn't maintain her nutritional needs by what she was willing to do. So, in her case, there was a mismatch between what she felt comfortable doing and what I was saying she was capable of doing.

Can people who no longer qualify through insurance be referred to a university training SLP program?

I think it depends on the university SLP training programs. Some programs don't see adults necessarily. But if a university in your area provides services to adults or if there is somebody in the clinic who is comfortable and competent to work with individuals with dysphagia, that's certainly a viable option. Sometimes, university programs have sliding scales in terms of fees so that they can be more affordable for patients. 

References

ASHA. (2004). Admission/discharge criteria in speech-language pathology.

Brindle, N., & Holmes, J. (2004). Capacity and coercion: dilemmas in the discharge of older people with dementia from general hospital settings. Age and Ageing, 34(1), 16-20.

Gillespie, A. I., & Gartner-Schmidt, J. (2018). Voice-specialized speech-language pathologist's criteria for discharge from voice therapy. Journal of Voice, 32(3), 332-339.

Hersh, D., & Cruice, M. (2010). Beginning to teach the end: The importance of including discharge from aphasia therapy in the curriculum. International journal of language & communication disorders, 45(3), 263-274.

Miller, R. M., Miller, R. M., & Groher, M. E. (1990). Medical speech pathology: Aspen Publishing.

Rose, A., Rosewilliam, S., & Soundy, A. (2017). Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Education and Counseling, 100(1), 65-75.

Sharp, H. M., & Bryant, K. N. (2003). Ethical issues in dysphagia: when patients refuse assessment or treatment. Paper presented at the Seminars in Speech and Language.