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References Aspray, T., Yarnall, A.,Croxson, S., Chillala, J., & Sinclair, A. (2009). Diabetes . Best Practice Guide. British Geriatrics Society. Australian Commission on Safety and Quality in Health Care. (2011). Patient-centered care: Improving quality and safety through partnerships with patients and consumers . Dy, S. M., & Purnell, T. S. (2012). Key concepts relevant to quality of complex and shared decision-making in health care: a literature review. Social science & medicine , 74 (4), 582–587. Gogarty, H., Robinson, S., Lawson, S., Keane, J., Collins, D., Coughlan, T., & O’Neill, D. (2013). Oropharyngeal dysphagia in end of life care. Irish Journal of Medical Science , 182 , S251-S252. IBM Corporation. (2016). SPSS for Windows , version 24. IBM Corp, Armonk, NY. Lang, A., Sommerville, P., Nightingale, S., & Birns, J. (2017). The FORWARD care bundle: Improving the care of patients feeding at risk. Clinical Nutrition ESPEN , 22 , 135–135. Leder, S., Suiter, D., Agogo, G., & Cooney, L. (2016). An epidemiologic study on ageing and dysphagia in the acute care geriatric-hospitalized population: A replication and continuation study. Dedicated to advancing the art and science of deglutology , 31 (5), 619–625. doi:10.1007/ s00455-016-9714-x Lembeck, M. E., Pameijer, C. R., & Westcott, & A. M. (2016). The role of intravenous fluids and enteral or parenteral nutrition in patients with life-limiting illness. Medical Clinics of North America , 100 (5), 1131–1141. doi:10.1016/j.mcna.2016.04.019 Logemann, J. A. (1998). The evaluation and treatment of swallowing disorders. Current Opinion in Otolaryngology & Head and Neck Surgery , 6 (6), 395–400. Mathew, R., Davies, N., Manthorpe, J., & Iliffe, S. (2016). Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making. BMJ Open , 6 (7) 1–8. doi:10.1136/bmjopen-2015-010416 McCann, R. M., Hall, W. J., & Groth-Juncker, A. (1994). Comfort care for terminally ill patients: The appropriate use of nutrition and hydration. JAMA , 272 (16), 1263–1266. McHutchison, L., Miles, A., Spriggs, D., & Jayathissa, S. (2018). Management of feeding decisions in hospitalised adults with severe oropharyngeal dysphagia. Australasian Journal on Ageing, 37 (4), E120-E126. Miles, A., Watt, T., Wong, W.-Y., McHutchison, L., & Friary, P. (2016). Complex feeding decisions: Perceptions of staff, patients, and their families in the inpatient hospital setting. Gerontology & Geriatric Medicine , 2 , 2333721416665523. doi:10.1177/2333721416665523 Miller, N. (2013). Oropharyngeal dysphagia in an elderly post-operative hip fracture population. Age and Ageing, 42 (6), 679–681. doi:10.1093/ageing/aft081 Miller, N., & Patterson, J. (2014). Dysphagia: implications for older people , 24 (1), 41–57. doi:10.1017/ S095925981300021X Mitchell, S. L., Kiely, D. K., & Lipsitz, L. A. (1997). The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine , 157 (3), 327–332.

clearly documented within the medical record, and the emerging nature of patient care which may have resulted in a change in treatment direction during the admission. However, within the medical model of most hospital settings, there is a strong focus on accuracy, consistency and medico-legal requirements within documentation, thus within this context the utilisation of decision support tools may be of great value. Decision support tools within this context may include naming conventions to describe the nature and type of complex dysphagia decision-making (for example, risk versus comfort feeding), clinical work instructions and decision-making flow charts to guide the professional through the context specific requirements, patient and staff education resources such as pamphlets/brochures, and the completion of face-to-face training such as inservices. The introduction of a standardised decision support tool and complex feeding protocol may assist in increasing these “best interest discussions” and family involvement as identified by a 55% increase in next of kin discussions following the introduction of a complex feeding care bundle (Lang et al., 2017). Similarly, the importance of consistency with regards to definitions and decision-making processes can be seen in the study of the FORWARD bundle, which identified that the introduction of a defined “risk feeding” procedure decreased the mean time an individual was kept nil by mouth unnecessarily in instances of complex feeding (Lang, Sommerville, Nightingale, & Birns, 2017). The current discussion highlighted an alarming gap in provision of interdisciplinary and patient-centred education and decision-making in the area of complex feeding decisions within the hospital context. While these gaps may be context dependant and may be of more concern within the medical/acute setting, the results do raise a number of areas for future consideration and research. Future research in this area should consider a focus on the implementation and evaluation of decision support strategies, education methods and policy which support interdisciplinary, patient- centred decision-making. In addition, the voice of patients in these instances would be of great value in the form of a qualitative research method to highlight areas of decision- making which are important to the patients and family members involved in these ethically complex decisions. Clinicians working in this complex clinical area may wish to consider their own values and beliefs regarding the rights of patients to make informed choices about the direction of their care, the nature and timing of education provided in these instances, the contextual need for consistency in documentation practices, and the consideration of medico- legal factors such as methods of documenting consent. Conclusion Feeding decisions are ethically and clinically complex and thus require a interdisciplinary and person-centred approach to discussion and education, as well as clear, unbiased documentation. The current study demonstrates a lack of consistency and collaboration in this area, highlighting an opportunity for improvement particularly the inclusion of the patient and family as part of the health care team. Acknowledgements Funding for this project was obtained from the Metro South Health Research Support Scheme Small Project Grant funded by the Study, Education and Research Trust Account (SERTA) (PARSS_2018_025)

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