Ethical Dilemmas Swallowing and Swallowing Disorders Case Article Questions

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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- Downloaded From: http://sig13perspectives.pubs.asha.org/ by a ReadCube User on 08/30/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx 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 Downloaded From: http://sig13perspectives.pubs.asha.org/ by a ReadCube User on 08/30/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx 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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Running head: ETHICAL CASE

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Ethical Case
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May 6, 2019

ETHICAL CASE

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A brief of the Case
The article is on ethical dilemmas and is written under swallowing and swallowing
disorders. The author asks the reader for recommendations on the case of a patient who can be
able to tolerate an oral diet only if certain specific techniques are used and the patient supervised
closely and given assistance, and at the same time there is a problem to the effect the staff who
offer meals during the evening are not able to provide supervision and therefore, one feels that
the patient should have an alternative source of nutrition if they do not have supervision every
time they are having their meals. The paper focuses on Mrs. J a 46-year-old patient who had
been admitted to a rehabilitation hospital due to a short stay for acute ex...


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