JCPSLP Vol 17 Supplement 1 2015_lores

Text box A. The case

Text box B. Who are the stakeholders impacted on by this case? 1. The hospital as an institution and possibly the local health network more broadly Another hospital within the local area network recently had a coroner’s case concerning a patient choking to death. The coroner’s findings were very clear regarding the need to follow the speech pathologist’s diet modifications and recommendations (when choking due to dysphagia was identified as a risk to patients). Consistent policies across the network are therefore essential. 2. The patients and families who may (or may not) receive care • Patients: Malnutrition is often an issue for hospital inpatients and many patients have very clear food preferences. • Families: Many hospital patients come from multicultural backgrounds for which the provision of food and particular foods is a cultural indicator of “care”. Family members, trusted friends or carers who may hold an enduring power of attorney (medical treatment act) or an advance care directive from the patient are integral to the decision-making processes that will occur in relation to policy and procedures. • Delegated decision-makers: Many dysphagic patients in hospital also have an element of cognitive impairment and therefore enduring power of attorney (medical treatment act) or care directives or delegated decision-makers may be involved. 3. Staff, students and volunteers at the hospital • Consultants often want their patients to “just eat more”. When patients lose weight, they lose muscle tone, stamina and capacity to undertake daily self-care activities. • Nurses who have seen patients choke, sometimes to death, do not want to be forced to feed a patient at risk. Other nurses think patients should be able to eat whatever they like. • Kitchen staff who deliver food and drinks from the kitchen do not want to provide food that could potentially “kill” someone. • Students and new graduates of all disciplines want a clear policy to follow, particularly in sensitive cases. Accurate and detailed policy and procedures inform the staff as to what to do and how to document this. If the hospital/local area health network introduces a “no choke” risk policy, this may impact on disability service providers providing institutional care, local nursing homes, hospices, rehabilitation organisations and individual carers at home. 5. The local community that relies on the hospital/ health network for care Advocates for people with disabilities would stress the importance of autonomy and clients’ rights to the least restrictive intervention possible, particularly in the community. 6. Related agencies such as social services Community members fund health services through taxes. They are invested in health services improving patients’ health status efficiently and effectively, and safely. The office for the public advocate may provide guardianship advice. Solicitors from the public trustees’ office may provide legal advice (particularly given previous coroners’ findings). 4. Other government, non-government and volunteer service providers in the region

reflection on policy formulation and analysis of the potential impact of the policy. The impact of policy While acknowledging policy development may be a small part of many speech pathologists’ roles, the potential impact of a policy or policy change may be broad. Within a hospital context Frolic et al. (2012) suggests policies and policy changes may impact at least six distinct stakeholder groups. Applying Frolic’s groups to a current Australian hospital system these groups may include: 1. the hospital as an institution and possibly the local health network more broadly; 2. the patients and families who may (or may not) receive care; 3. staff, students and volunteers at the hospital; 4. other government, non-government and volunteer service providers in the region; The patient Currently on the medical ward there is a frail, elderly patient of Italian heritage with multiple medical problems who is doing quite poorly. Through clinical assessment and a modified barium swallow study, he has been diagnosed by a speech pathologist as being at risk of choking. The team has recommended a highly modified diet that he finds unappetising and boring. The patient has said he has had enough of life. He has capacity and he wants to eat food that he enjoys. There are also strong cultural and social norms, particularly for his generation, about the healing power of food and his wife is very upset that she can no longer feed him particular foods as she feels this is a role she can play in his healing. The patient and his family want him to be able to eat some of the foods they bring from home that he has loved over the years. The patient and the family are all prepared to take the risk of him choking as they feel his quality of life is suffering; he is unhappy, depressed and losing weight. The rule Currently the unwritten hospital rule is that dysphagic patients who are at risk of choking are not provided with or fed “choke risk” foods by the hospital during their inpatient stay. There has been conflict between staff members and patients and families over this “rule.” It is felt a clear written policy would decrease conflict around this issue and clarify what procedures to follow in the event of any team managing a patient who has been diagnosed as being at risk of choking. The differing perspectives • Some staff support the approach of not providing food to patients who are at risk of choking, in order to not harm (potentially kill) patients. • Some staff believe patients’ autonomy should be respected and patients should be provided with the food they (or their designated decision-makers) request as long as they are informed of the risk. • Some staff are distressed at the thought of providing or feeding a patient with food they might choke on as they have observed a person choking to death.

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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology

www.speechpathologyaustralia.org.au