JCPSLP Vol 21 No 3 2019

context in particular, consistency in documentation needs to be promoted to maintain medico-legal requirements, ensure understanding between interdisciplinary team members, and ensure that patient’s wishes are adhered to at times of discharge or handover of care. Despite the importance of consistent documentation within the medical context, results of our audit suggest that the term “risk feeding” appeared to be most commonly utilised by the SLP with 59.8% of documentation using this term for patients’ choosing to forgo diet/fluid recommendations and/or nil by mouth recommendations. However, there was limited consistency and agreement between the definition documented by the SLP and the medical team. Low rates of documentation regarding “risk feeding” have also been reported in similar studies, with only 50% of reviewed discharge summaries including reference to “risk feeding” as a final feeding decision in a sample of 103 patients (McHutchison et al., 2018). Clinically and operationally, this may reduce understanding between interdisciplinary teams, complicate clinical handover practices, and create confusion between clinical contexts if terms are not used consistently. While the SLP documented that over 68% of patients in this discussion were either “risk feeding” or “comfort feeding”, the processes involved in making this complex decision were variable and often lacked key elements in patient-centred decision-making. Complex feeding decisions were made without a multidisciplinary discussion in over 82% of cases, despite the recognised importance of interdisciplinary collaboration and communication (Miles et al., 2016). Similarly, the current discussion indicates a lack of patient and family inclusion in joint decision-making regarding complex dysphagia decisions, with family education regarding options and alternatives being reported in only around 37% of cases. This is consistent with a recent study of 103 patients with dysphagia, in which only 40% of cases had documented discussions with the patient and family regarding the feeding decision (McHutchison et al., 2018). Greater inclusion of patients and family members is a key future direction in this area, and is in line with a growing focus on person-centred and family- centred-practice and policy, with the patient and family being active members of the health care team (Australian Commission on Safety and Quality in Health Care 2011). In order to promote the patient’s rights to self-determination and autonomous but informed decisions regarding their own care (Aspray et al., 2009), there is a need for strong communication and shared decision-making to ensure the benefits outweigh the risks for the individual (Dy & Purnell, 2012). The results of our discussion paper must be interpreted within the context of clinical practice, in which this study occurred. Retrospective chart auditing was conducted within the acute setting of the two medium-sized hospitals, this setting contextually follows a medical model in which clear documentation, medico-legal considerations and patient safety are considered paramount. A number of factors are likely to influence the consistency of naming conventions, documentation practices and interdisciplinary engagement, including the professional’s education and understanding of complex feeding decisions, the context of specific naming conventions which may be profession specific, the availability of clinical staff and family members to participate in meetings, the likelihood of informal discussions with family members which may not have been

40

37.8

35

30

25

23.2

20

20.7

15

10

9.8

7.3

5

1.2

0

% Percent

Medical team Not commenced Patient/family in consultation with MDT

Patient/family in consultation with medical team Patient/family in consultation

with SP Missing

Figure 1. Decision-making team members

Discussion The outcomes of this exploratory overview of complex feeding decisions provide a number of novel insights and highlight areas for improvement in clinical practice within this complex area. First, although 24% of patients who had a documented complex feeding decision identified were diagnosed with severe or profound dysphagia on admission, there is limited consistency and agreement regarding naming conventions for complex feeding decisions, including variation between health professionals such as the medical team and SLP. Second, despite a high degree of clinical complexity in this area, almost half of the complex feeding decisions in the current study were made without a medical officer discussion, more than 80% occurred without a interdisciplinary team discussion, and more than 60% occurred without relevant education being provided to the patient and family regarding feeding options and alternatives. Given the severity of dysphagia, a large proportion of patients in the current study were placed nil by mouth following initial SLP assessment. Withholding oral intake entirely is a particularly restrictive practice, utilised clinically as a last resort to maintain patient safety (Logemann, 1998; Miles, Watt, Wong, McHutchison, & Friary, 2016) particularly in the acute hospital setting. Recent evidence in the area of dementia, however, supports a preference for careful hand-feeding as an alternative to maintaining nil by mouth status and commencing artificial feeding in these instances (Lembeck et al., 2016; Mathew et al., 2016; McCann et al., 1994; Palecek et al., 2010; Schwartz et al., 2014; Sherman, 2003; Smith, Kindell, Baldwin, Waterman, & Makin, 2009; Vitale et al., 2011). Similarly, restricting oral intake for a competent adult who wishes to continue eating and drinking should not be considered. Thus, it becomes vital to clearly and consistently document the decision to continue oral intake, despite reported risks in these instances, in order to promote patient-centred practice. In the medical

156

JCPSLP Volume 21, Number 3 2019

Journal of Clinical Practice in Speech-Language Pathology