JCPSLP Vol 20 No 3 November 2018

Ethical conversations

Recipes for successful provision of nutrition and hydration at the end of life Helen Smith and Belinda Kenny

This article explores how ethics can facilitate “recipes” for successful treatment outcomes for people at the end of life. Conversations between a speech-language pathologist, dietitian, and two members of the Speech Pathology Australia Ethics Board delve into how client circumstances, professional philosophies, and ethical approaches may influence recommended treatment options for an individual. Our goal is to highlight the importance of listening to the “other” when decision-making around end of life nutrition and hydration options is necessary. A complex scenario of a client with advanced head and neck cancer is used as a stimulus for this conversation. I n this issue, we will be discussing a case of a client with advanced head and neck cancer. We invited a speech- language pathologist (SLP) and a dietitian to share how they facilitate ethical practice with a client who is facing the end of his life. We will begin with a brief introduction of our participants. Robyn is a senior dietitian with 10 years clinical experience across acute, sub-acute, and community settings. She has worked with clients with various forms and types of advanced cancer, in surgical care and rehabilitation contexts. Previously Robyn has worked as an aged care facility chaplain. Katherine is a senior speech-language pathologist with 15 years clinical experience across a range of clinical caseloads in acute, sub-acute and community settings, including many years working in the oncology team. She is currently undertaking her PhD investigating the role of SLPs in palliative care. The following fictitious case scenario was used to stimulate the discussion between participants. Case scenario Mr Padraig Murphy is a 52-year-old married man. He has two children aged 12 and 18. His eldest child, Donal, has just started year 12. In December last year, Padraig was diagnosed with stage 4 head and neck cancer. His cancer was unable to be surgically managed and he subsequently underwent palliative radio therapy. He desperately wants to

see Donal finish high school. On that basis, he has told the doctors he wants “everything done to prolong his life…” As Padraig’s SLP/dietitian you are asked to assess and manage his dysphagia and malnutrition. The swallowing assessment diagnoses a severe pharyngeal dysphagia. Padraig is only managing mildly thick fluids and small amounts of puree diet safely. He is also having thin fluids and a minced diet comfortably but with clinical signs of aspiration. In the past 6 months since his diagnosis, Padraig has lost 25 kg in weight. He often reports feeling hungry and thirsty. His blood results suggest he is deficient in many micronutrients. After Katherine and Robyn considered the case scenario, we asked them to respond to some questions regarding their management of Padraig Murphy. Questions What ethical issues does this scenario raise for you? From a dietitian’s perspective, Robyn pondered: He’s malnourished. In a head and neck cancer client that doesn’t surprise me, and more importantly, he’s feeling hungry and thirsty, symptoms that can be quite distressing for a person. I ask myself “I wonder what Padraig considers appropriate to manage his inadequate oral intake and weight loss.” With the weight loss would also come loss of strength and muscle wasting. Along similar lines, Katherine considered: “We need to think about the perspective of futile treatment versus what the person themselves wants.” From a speech- language pathology (SLP) perspective, she asked, “Do we need to think then about futile treatment versus individual needs?” Katherine also identified ethical considerations around the client’s medical management, “What would be comfortable for Padraig?” She also raised the importance of communication and how decisions may appear to “trickle down to others” – that is, potential impacts of health care decisions for the client, the family and other health professionals. Both Robyn and Katherine expressed the importance of determining “What Padraig’s goals were”. Robyn reflected on the SLP assessment results with the potential recommendations of thin fluids and minced diet for comfort versus mildly thick fluids and puree for safety. “I start to think about what’s a risk versus what’s a managed risk?” Katherine also spoke of clinical management issues in

Helen Smith (top) and Belinda Kenny

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JCPSLP Volume 20, Number 3 2018

www.speechpathologyaustralia.org.au