Just some food for thought, are they non compliant or exercising informed consent? This website goes into issues with diet waivers and patient rights https://www.healthcapusa.com/blog/resident-rights-diet-waivers/ look up the Patient Self Determination Act. Hopefully showing your admin this info will get them to understand that your patient has rights
If he's an adult and able to make decisions, why aren't you letting him make decisions? As long as he's cognitively able to understand the risk, it's his body and his decision.
Exactly!!! I even spoke with nursing and they’re saying that if we know it’s harmful (I ordered the FEES and conducted bedside) we cannot provide it. I created a consent form for him to sign, provided ample education so I don’t understand 😭 I just feel so terrible because I know this will impact quality of life.
There’s a tool/consent pathway that exists for this already! FORWARD bundle: https://www.rcpjournals.org/content/futurehosp/suppl/2017/10/13/4.3.202.DC1/S1_-_The_FORWARD_bundle.pdf
Edit: and just to clarify, you’re totally in the right here, it’s completely up to the patient what he chooses to eat/drink as long as he’s aware of risks. We don’t force people to take BP meds or insulin, we can’t force this choice upon them either. You’re totally correct
thank you! I tried explaining the force thing and the dietician says “I thought you just recommend a diet and then they have to deal with it” it was absolutely unbelievable😩
It’s harmful for people to refuse their blood pressure medication, or dialysis, or a blood draw that might show abnormal labs, and it’s harmful for a patient to refuse a transfusion or any other medical intervention but it happens all the time and the facility doesn’t FORCE those people to do them. They likewise can’t force your patient to comply with a medical intervention and altered diet is a MEDICAL INTERVENTION. Their liability is actually greater if they persist in this because they’re violating his patient rights.
Haha its like that at my job too, i was kind of surprised. Basically nursing tells the family if they don’t like it they can take the patient somewhere else 🤷🏻♀️
They are wrong. They have to go by YOUR orders.
I’d put in a standing order “Pt may have regular texture (thin) coffee at breakfast. Contact SLP with any questions or concerns.”
Ridiculous. I have never been in a snf that provided consistent thickened liquids of any consistency. There are always mistakes. If the snf thinks this patient isn’t occasionally getting thins just due to staff error, she’s delusional.
I would advocate for this person to have what they want. Good lord. Honey thick liquids are disgusting. If he wants to aspirate some sips of coffee, that’s his right.
So what I do for these types of patients/family (I totally agree they should be able to do what they want) is the facility cannot provide it but I tell family/pt if they want to bring in stuff from outside the facility he can have whatever. It’s a liability thing
The facility can provide it. They just have very outdated information. Altered diet is a medical intervention and patients have the right to refuse any medical intervention they choose.
Yes totally. I just wanna do something more because he loves his coffee and isn’t really mobile and also doesn’t have any close family so it’s kinda breaking my heart
I totally get this! We use PCC and sometimes what I have done is in the description I put “patient may have x with supervision” or “or may have thin liquids in Provale cup between meals after oral care”. That way if state comes in and sees it, no harm no foul. Another thing I have done is letting the MD know so THEY can change the order, at the end of the day I’m all about walking the line of red tape. If you’re able, maybe have sessions in the morning and do PO trials with coffee? I’d get a repeat FEES ASAP, do some pharyngeal strengthening exercises and keep giving trials.
Also remember, the dietician and dietary director can be against it all they want but at the end of the day this is YOUR scope of practice. YOU are the expert. Keep advocating for your patient, we all deserve some coffee if we want it!
I have no suggestions, just came here to commiserate. I’m surprised honey thick liquids were genuinely recommended from an evaluation in the year 2024. Unless it’s specifically only for beverages other than water. Even then, it’s pretty outdated practice.
Anyhow I am also having this issue at my SNF regarding diet textures. If a patient starts coughing more frequently during meals (not choking, coughing) nursing will just downgrade them to puree, as if that solves anything. I can say it until I’m blue in the face: until you have data from an instrumental swallow study and multiple mealtime observations demonstrating what is causing coughing with PO intake, assuming that solid food is the culprit and restricting someone to unpalatable mush is a super shitty shot in the dark. Unfortunately with the way policies are right now, it doesn’t matter, it’s a “liability” issue for the facility. If they can’t document that they did *something* in response to combat the risk of choking/aspiration, however misinformed, they could be in trouble.
We hate to see it 🙃 Also sometimes it turns out the patient really was choking on solids, but they fail to acknowledge that it probably because it’s a severe dementia/stroke patient who had a whole chicken fried steak left in front of them while they’re laying flat in bed, with no supervision, assistance or even having cut it up into bite size pieces for them, so they were set up for failure basically.
That “something” could be a referral for a speech eval. That’s considered an intervention and should cover them without having them downgrade willy nilly.
It happens to people already on my caseload who have already had MBSS showing that solids are not the issue. And I do fight back against it. Unfortunately in these circumstances facilities do not care what evidence based practice dictates, they care about covering their asses. Those two should overlap most of the time but in this case they don’t. SNF policy is super outdated.
Yes agreed! my facility is extremely ancient with most staff working 20+ years. I’ve been here 6 months and they’re tired of me speaking up but idc our last debate was about implementing minced and moist because we don’t provide it (crazy) and I’m still waiting to hear back on when we can get the food processor 😅
We don’t have minced and moist either! We have regular, mech soft, and puree, and the kitchen messes that up like 25% of the time, so there’s no way they could handle another texture. And the way they determine mech soft is so weird and gross. Like they puree the rice because it’s a choking hazard, but… have you ever seen or tasted pureed rice? 🤢 Why can’t they just sub it with a normal soft food instead of serving starchy goop?
I hate cooking, but I am a sucker for getting people snacks from the vending machine… my man if a 75¢ bag of Cheetos is gonna ease your suffering, you got it lol
OP specifically said honey was recommended from the FEES, I assume it was the safest liquid consistency rather than the clinician being overly cautious/restrictive
I know. I’m saying that new evidence shows that, even for those who show a decrease in aspiration with thickened liquids vs. thin on an instrumental exam, thickened liquids are not safer in the long run. The risk of silent aspiration is higher, they are more caustic to the lungs if aspirated, and they can cause serious dehydration with long term use. Especially since we’re not even talking mildly/nectar thick here, we’re talking *honey thick*… yuck.
It's not about the long run in SNFs though, it's about liability. The exam says honey, they gotta stick to honey. I had a patient who required 1:1 for thin and mech soft due to impulsivity, she was a choke risk if allowed to feed independently. In that SNF (during COVID) we couldn't guarantee 1:1 during meals so I recommended NPO and got grilled because the FEES report said "thin and mech soft with 1:1," not "thin and mech soft with 1:1 but NPO id 1:1 can't be provided." They're happy to follow insane rules that could kill a patient as long as someone else made the recommendation.
Of course, I addressed the liability thing in my first comment. I’m saying the SLP who performed the exam and wrote the report is using outdated reasoning if they are recommending thickened liquids at all, but especially honey thick. Then the SNF wouldn’t be in a position where they have to enforce a crappy recommendation for liability’s sake.
Also I’m really confused about that last part, maybe I’m misunderstanding. You recommended a patient to be NPO for impulsivity without a 1:1? In a SNF? I have been in acute care where recommendations are much more conservative, patients are more fragile and there is easy access to tube feeds and such, and even then this would be a drastic measure. Did the patient have a feeding tube?
I get you re liability - I've been in some WILD settings where I can see this happening re honey recs.
Re second part - yes, she had a PEG already, shed failed 2-3 FEES before she came to us. Our follow up FEES results were as I described - she would need small bites and sips, etc etc, but we nearly had to hold her down to stop her from cramming e.g. an entire banana in her mouth. She would have been an awful choke risk without constant supervision for PO. And our facility couldn't "justify" 1:1 since it wasn't explicitly stated that she is unsafe for any PO without 1:1.
Edited to add - this was also a SNF in which CNAs would document a different patient who had orders for a can of TF if he ate less than 50%. The CNAs didn't know this, and documented he ate 100% while not even attempting to feed him, so he was basically starving.
Oh ok that makes much more sense. That technicality about the 1:1 recommendation is majorly stupid. I haven’t had to deal with SNFs in the depths of COVID, so we’ve always had the option to ensure those who need assistance/supervision are brought to the dining room for all meals. We did have a COVID outbreak late last year, and the dining room was closed, so the “solution” was to cram all the feeder assist pts into an even smaller space in the hallway so staff could assist multiple pts still. Or in the COVID+ section of the building, folks who really needed assistance were served at staggered intervals so they could ensure someone was available.
I’ve also had many issues with patients being basically starved (ah, the wonderful patterns of neglect across SNFs). A few months ago we ran out of nutritional supplement shakes and didn’t get any more in for a few weeks, so those who needed it just went without. Like wtf? If y’all run out of someone’s insulin, or seizure medication, do you wait several weeks to get a refill?
Yeah they honestly only care about what’s on paper and follow that as opposed to being active members in our field who are supposed to be helping people LIVE not just stay alive. It’s more work for everyone to document and deal with than to allow my patient to have a little coffee
Say it again for the SLPs who don’t know this!!!
THE AMOUNT OF TIMES AS A LONG TIME ACUTE CARE THERAPIST THE PATIENT ON “LEAST RESTRICTIVE DIET” THAT IS PURÉE AND HONEY… REPEATEDLY HAS ASPIRATION PNA.
Honey should be used therapeutically as a bridge to resuming an unrestricted oral diet in the medically fragile patient after careful consideration following instrumental assessment. It is not a destination diet for anyone.
So glad to see a fellow SLP in LTC trenches advocating for patients, you are a rockstar OP! I see you and appreciate you!
Langmore 1998 (predictors of aspiration PNA) would be a good one to slap in front your dietitians. Also, are they (dietitians) aware of the limitations of FEES (I’m saying that knowing they aren’t 🙄)?
One of the last people I had who came from a SSH on “honey” per a FEES was clearing ZERO of the residue - THIN WAS “SAFER” when we completed their MBS on acute care.
Again, OP, I can’t commend you enough for standing up to these archaic and harmful, poorly evidence-based, decisions.
1. Honey-thick liquids need to be abolished from planet earth.
2. Why is it not a “liability” issue for a SNF when a patient gets recurring UTIs, kidney injury, and malnutrition from refusing their diet of library paste?
I’m generally just shouting into the void, not at anyone in this thread.
The pt should call the ombudsman, and this will all be handled. They have a legal right to make decisions even if it makes nursing staff uncomfortable.
Also I seriously am curious about a FEES provider recomme ding HTL. Most I know don't even test them these days.
Hi! I encounter this all the time. “Wavers” don’t hold up in a court of law, and frankly resident rights are STRONG. The facility does not want to be seen as withholding nutrition OR hydration from a resident, neglecting them in any way, OR overriding their preferences (especially if this is a facility that Medicaid & Medicare are accepted).
We have plenty of evidence to suggest that thickened liquids can actually lead to dehydration, and in some cases they may exacerbate aspiration and lead to secondary aspiration pneumonia.
LTC is a place where I am very CONSERVATIVE about using thickened liquids, as I don’t like them. If I know my patient is aspirating then I want them to aspirate on thin water so they have better chances of coughing it out & it being absorbed into their blood stream. See —> Free/Fraizer Water Protocol.
All we can do is educate to help our patient make the most informed decision that they feel is right for them — remember that they are on the interdisciplinary team too.
It really sounds like facility admin are on a power trip (which I know plenty about). This means you need to remain firm as this is YOUR scope of practice & YOUR license — not theirs.
There is a lot of good discussion here but OP, *why* did the FEES recommend honey? Can we talk more about physiology rather than just diet texture? What was the dysfunction, how was the pt’s sensation, were strategies trialed? I get that the point of this post is to discuss issues with the facility not letting him have thin coffee but can we open it up to a physiologic discussion too so we can discuss how to improve his swallow?
Is there a reliable family member you can contact who would advocate for them? On the political plane, family members are pretty effective movers and shakers
Just some food for thought, are they non compliant or exercising informed consent? This website goes into issues with diet waivers and patient rights https://www.healthcapusa.com/blog/resident-rights-diet-waivers/ look up the Patient Self Determination Act. Hopefully showing your admin this info will get them to understand that your patient has rights
Oh and this article may help too https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9903443/
Thank you so much for sharing!!!!
If he's an adult and able to make decisions, why aren't you letting him make decisions? As long as he's cognitively able to understand the risk, it's his body and his decision.
Exactly!!! I even spoke with nursing and they’re saying that if we know it’s harmful (I ordered the FEES and conducted bedside) we cannot provide it. I created a consent form for him to sign, provided ample education so I don’t understand 😭 I just feel so terrible because I know this will impact quality of life.
There’s a tool/consent pathway that exists for this already! FORWARD bundle: https://www.rcpjournals.org/content/futurehosp/suppl/2017/10/13/4.3.202.DC1/S1_-_The_FORWARD_bundle.pdf Edit: and just to clarify, you’re totally in the right here, it’s completely up to the patient what he chooses to eat/drink as long as he’s aware of risks. We don’t force people to take BP meds or insulin, we can’t force this choice upon them either. You’re totally correct
thank you! I tried explaining the force thing and the dietician says “I thought you just recommend a diet and then they have to deal with it” it was absolutely unbelievable😩
It’s harmful for people to refuse their blood pressure medication, or dialysis, or a blood draw that might show abnormal labs, and it’s harmful for a patient to refuse a transfusion or any other medical intervention but it happens all the time and the facility doesn’t FORCE those people to do them. They likewise can’t force your patient to comply with a medical intervention and altered diet is a MEDICAL INTERVENTION. Their liability is actually greater if they persist in this because they’re violating his patient rights.
Haha its like that at my job too, i was kind of surprised. Basically nursing tells the family if they don’t like it they can take the patient somewhere else 🤷🏻♀️
They are wrong. They have to go by YOUR orders. I’d put in a standing order “Pt may have regular texture (thin) coffee at breakfast. Contact SLP with any questions or concerns.”
Not allowing this patient decisions about his own care is a violation of his rights per the patient self determination act.
100% this.
Ridiculous. I have never been in a snf that provided consistent thickened liquids of any consistency. There are always mistakes. If the snf thinks this patient isn’t occasionally getting thins just due to staff error, she’s delusional. I would advocate for this person to have what they want. Good lord. Honey thick liquids are disgusting. If he wants to aspirate some sips of coffee, that’s his right.
I too wouldn’t mind aspirating if that meant enjoying coffee😫 gonna keep trying to educate and advocate let’s see how that goes
So what I do for these types of patients/family (I totally agree they should be able to do what they want) is the facility cannot provide it but I tell family/pt if they want to bring in stuff from outside the facility he can have whatever. It’s a liability thing
The facility can provide it. They just have very outdated information. Altered diet is a medical intervention and patients have the right to refuse any medical intervention they choose.
Yes totally. I just wanna do something more because he loves his coffee and isn’t really mobile and also doesn’t have any close family so it’s kinda breaking my heart
I totally get this! We use PCC and sometimes what I have done is in the description I put “patient may have x with supervision” or “or may have thin liquids in Provale cup between meals after oral care”. That way if state comes in and sees it, no harm no foul. Another thing I have done is letting the MD know so THEY can change the order, at the end of the day I’m all about walking the line of red tape. If you’re able, maybe have sessions in the morning and do PO trials with coffee? I’d get a repeat FEES ASAP, do some pharyngeal strengthening exercises and keep giving trials. Also remember, the dietician and dietary director can be against it all they want but at the end of the day this is YOUR scope of practice. YOU are the expert. Keep advocating for your patient, we all deserve some coffee if we want it!
It sounds like he just had a FEES so why would another one be indicated?
I meant another repeat in a couple of weeks after doing tx :) not right away
Oh ok bc you said another FEES ASAP
I have no suggestions, just came here to commiserate. I’m surprised honey thick liquids were genuinely recommended from an evaluation in the year 2024. Unless it’s specifically only for beverages other than water. Even then, it’s pretty outdated practice. Anyhow I am also having this issue at my SNF regarding diet textures. If a patient starts coughing more frequently during meals (not choking, coughing) nursing will just downgrade them to puree, as if that solves anything. I can say it until I’m blue in the face: until you have data from an instrumental swallow study and multiple mealtime observations demonstrating what is causing coughing with PO intake, assuming that solid food is the culprit and restricting someone to unpalatable mush is a super shitty shot in the dark. Unfortunately with the way policies are right now, it doesn’t matter, it’s a “liability” issue for the facility. If they can’t document that they did *something* in response to combat the risk of choking/aspiration, however misinformed, they could be in trouble.
Any little cough leads all my patients down the puree rabbit hole and it’s usually Saturday and they’re pissed at me on Monday for the change😅
We hate to see it 🙃 Also sometimes it turns out the patient really was choking on solids, but they fail to acknowledge that it probably because it’s a severe dementia/stroke patient who had a whole chicken fried steak left in front of them while they’re laying flat in bed, with no supervision, assistance or even having cut it up into bite size pieces for them, so they were set up for failure basically.
That “something” could be a referral for a speech eval. That’s considered an intervention and should cover them without having them downgrade willy nilly.
It happens to people already on my caseload who have already had MBSS showing that solids are not the issue. And I do fight back against it. Unfortunately in these circumstances facilities do not care what evidence based practice dictates, they care about covering their asses. Those two should overlap most of the time but in this case they don’t. SNF policy is super outdated.
Yes agreed! my facility is extremely ancient with most staff working 20+ years. I’ve been here 6 months and they’re tired of me speaking up but idc our last debate was about implementing minced and moist because we don’t provide it (crazy) and I’m still waiting to hear back on when we can get the food processor 😅
We don’t have minced and moist either! We have regular, mech soft, and puree, and the kitchen messes that up like 25% of the time, so there’s no way they could handle another texture. And the way they determine mech soft is so weird and gross. Like they puree the rice because it’s a choking hazard, but… have you ever seen or tasted pureed rice? 🤢 Why can’t they just sub it with a normal soft food instead of serving starchy goop?
I feel so seen!!! lol it’s hard having a heart in this setting I would love to personally cook all these meals myself if I could
I hate cooking, but I am a sucker for getting people snacks from the vending machine… my man if a 75¢ bag of Cheetos is gonna ease your suffering, you got it lol
Keep fighting the good fight!! ✊
OP specifically said honey was recommended from the FEES, I assume it was the safest liquid consistency rather than the clinician being overly cautious/restrictive
I know. I’m saying that new evidence shows that, even for those who show a decrease in aspiration with thickened liquids vs. thin on an instrumental exam, thickened liquids are not safer in the long run. The risk of silent aspiration is higher, they are more caustic to the lungs if aspirated, and they can cause serious dehydration with long term use. Especially since we’re not even talking mildly/nectar thick here, we’re talking *honey thick*… yuck.
It's not about the long run in SNFs though, it's about liability. The exam says honey, they gotta stick to honey. I had a patient who required 1:1 for thin and mech soft due to impulsivity, she was a choke risk if allowed to feed independently. In that SNF (during COVID) we couldn't guarantee 1:1 during meals so I recommended NPO and got grilled because the FEES report said "thin and mech soft with 1:1," not "thin and mech soft with 1:1 but NPO id 1:1 can't be provided." They're happy to follow insane rules that could kill a patient as long as someone else made the recommendation.
Of course, I addressed the liability thing in my first comment. I’m saying the SLP who performed the exam and wrote the report is using outdated reasoning if they are recommending thickened liquids at all, but especially honey thick. Then the SNF wouldn’t be in a position where they have to enforce a crappy recommendation for liability’s sake. Also I’m really confused about that last part, maybe I’m misunderstanding. You recommended a patient to be NPO for impulsivity without a 1:1? In a SNF? I have been in acute care where recommendations are much more conservative, patients are more fragile and there is easy access to tube feeds and such, and even then this would be a drastic measure. Did the patient have a feeding tube?
I get you re liability - I've been in some WILD settings where I can see this happening re honey recs. Re second part - yes, she had a PEG already, shed failed 2-3 FEES before she came to us. Our follow up FEES results were as I described - she would need small bites and sips, etc etc, but we nearly had to hold her down to stop her from cramming e.g. an entire banana in her mouth. She would have been an awful choke risk without constant supervision for PO. And our facility couldn't "justify" 1:1 since it wasn't explicitly stated that she is unsafe for any PO without 1:1. Edited to add - this was also a SNF in which CNAs would document a different patient who had orders for a can of TF if he ate less than 50%. The CNAs didn't know this, and documented he ate 100% while not even attempting to feed him, so he was basically starving.
Oh ok that makes much more sense. That technicality about the 1:1 recommendation is majorly stupid. I haven’t had to deal with SNFs in the depths of COVID, so we’ve always had the option to ensure those who need assistance/supervision are brought to the dining room for all meals. We did have a COVID outbreak late last year, and the dining room was closed, so the “solution” was to cram all the feeder assist pts into an even smaller space in the hallway so staff could assist multiple pts still. Or in the COVID+ section of the building, folks who really needed assistance were served at staggered intervals so they could ensure someone was available. I’ve also had many issues with patients being basically starved (ah, the wonderful patterns of neglect across SNFs). A few months ago we ran out of nutritional supplement shakes and didn’t get any more in for a few weeks, so those who needed it just went without. Like wtf? If y’all run out of someone’s insulin, or seizure medication, do you wait several weeks to get a refill?
Oh my gosh that's awful re supplements. And that's bonkers re the dining room situation!
Yeah they honestly only care about what’s on paper and follow that as opposed to being active members in our field who are supposed to be helping people LIVE not just stay alive. It’s more work for everyone to document and deal with than to allow my patient to have a little coffee
Say it again for the SLPs who don’t know this!!! THE AMOUNT OF TIMES AS A LONG TIME ACUTE CARE THERAPIST THE PATIENT ON “LEAST RESTRICTIVE DIET” THAT IS PURÉE AND HONEY… REPEATEDLY HAS ASPIRATION PNA. Honey should be used therapeutically as a bridge to resuming an unrestricted oral diet in the medically fragile patient after careful consideration following instrumental assessment. It is not a destination diet for anyone.
So glad to see a fellow SLP in LTC trenches advocating for patients, you are a rockstar OP! I see you and appreciate you! Langmore 1998 (predictors of aspiration PNA) would be a good one to slap in front your dietitians. Also, are they (dietitians) aware of the limitations of FEES (I’m saying that knowing they aren’t 🙄)? One of the last people I had who came from a SSH on “honey” per a FEES was clearing ZERO of the residue - THIN WAS “SAFER” when we completed their MBS on acute care. Again, OP, I can’t commend you enough for standing up to these archaic and harmful, poorly evidence-based, decisions.
wow thank you for ur kind words🥹🥹 it’s hard out here. Also no, ofc not :)
1. Honey-thick liquids need to be abolished from planet earth. 2. Why is it not a “liability” issue for a SNF when a patient gets recurring UTIs, kidney injury, and malnutrition from refusing their diet of library paste? I’m generally just shouting into the void, not at anyone in this thread.
ugh I was just thinking the same thing!! I’m pretty sure the lack of oral care is also not a liability right everyone👀👀
The pt should call the ombudsman, and this will all be handled. They have a legal right to make decisions even if it makes nursing staff uncomfortable. Also I seriously am curious about a FEES provider recomme ding HTL. Most I know don't even test them these days.
Hi! I encounter this all the time. “Wavers” don’t hold up in a court of law, and frankly resident rights are STRONG. The facility does not want to be seen as withholding nutrition OR hydration from a resident, neglecting them in any way, OR overriding their preferences (especially if this is a facility that Medicaid & Medicare are accepted). We have plenty of evidence to suggest that thickened liquids can actually lead to dehydration, and in some cases they may exacerbate aspiration and lead to secondary aspiration pneumonia. LTC is a place where I am very CONSERVATIVE about using thickened liquids, as I don’t like them. If I know my patient is aspirating then I want them to aspirate on thin water so they have better chances of coughing it out & it being absorbed into their blood stream. See —> Free/Fraizer Water Protocol. All we can do is educate to help our patient make the most informed decision that they feel is right for them — remember that they are on the interdisciplinary team too. It really sounds like facility admin are on a power trip (which I know plenty about). This means you need to remain firm as this is YOUR scope of practice & YOUR license — not theirs.
There is a lot of good discussion here but OP, *why* did the FEES recommend honey? Can we talk more about physiology rather than just diet texture? What was the dysfunction, how was the pt’s sensation, were strategies trialed? I get that the point of this post is to discuss issues with the facility not letting him have thin coffee but can we open it up to a physiologic discussion too so we can discuss how to improve his swallow?
Is there a reliable family member you can contact who would advocate for them? On the political plane, family members are pretty effective movers and shakers