SPEECH & LANGUAGE THERAPY IN PRACTICE
dementia, organic brain disease following a headinjury ten years previously, and depression, whohad been admitted to hospital several times oversix months with chest problems. On each admis-sion he was seen and assessed by the speech andlanguage therapist. The pattern was one of fairlyrapid deterioration and, although initially man-agement had been diet modification and adviceto carers, by the third hospital admission thedementia and related dysphagia had progressedto such a degree that no consistency of food ordrink was considered without risk. He had no nextof kin, and very limited ability to understand ormake decisions for himself. He was constantly indistress and crying out on the ward and wouldoften pick up empty cups and put them to hismouth as if drinking.
The speech and language therapist was aware ondiagnosing a severe progressive dysphagia thatany decision on feeding would have implicationsfor the patient’s quality of life and ongoing care.Feeding orally carried a high risk of a life threat-ening pneumonia, and not feeding would leavethe patient deprived of nutrition and the pleasureof eating. Naso-gastric and PEG feeding wouldalso carry risks including poor patient toleranceand surgical hazards and complications. The initialrecommendation by the speech and languagetherapist was that the issues involved in this caseshould be discussed at team level. This wentahead and the patient was kept nil by mouth onintravenous fluids in the meantime. Short termnaso-gastric feeding was not possible due to agi-tation. The consultant, nursing staff, physiothera-pist, occupational therapist, house officers andspeech and language therapist were all present atthe meeting. Although legally the consultant hasthe final say in cases where the patient is unableto make choices, the case was discussed at lengthand all were in agreement that our patient shouldbe allowed to eat for his own pleasure and quali-ty of life. PEG feeding was dismissed as a viableoption. It was felt that, given his poor prognosisand the risks involved with a PEG, it was inappro-priate to deprive him of the only thing he hadbeen seen to enjoy. The decision was made tominimise the risk of aspiration by allowing hischest to improve over a weekend, and attemptingto ensure aggressive oral care.He was fed small amounts of oral intake fourdays later. Staff observed that he appeared toenjoy this. He developed aspiration pneumonia aday later, was kept comfortable on the ward withno more intravenous fluids, and died not longafterwards.A contrasting case involved a 28 year old femaleadmitted to the neurosurgical unit having sus-tained a severe head injury in a road traffic acci-dent. She was a known intravenous drug userand premorbidly significantly underweight.Difficulties weaning from the ventilator resultedin a tracheostomy. When first seen by a speechFigure 1 - Four principles of medical ethics
The principle of autonomy is about having respect for an individual’s ability to makedecisions and choices regarding their medical care or treatment. Topics addressedaround this were: Can we be sure that individuals are capable of understanding thenature of their condition? Can they make informed decisions about methods offeeding? Is the person able to express a view or have a view expressed (very pertinent inthe case of dysphasic clients)? Do certain behaviours (for example, pulling out a naso-gastric tube or turning away from a spoon) express a desire / need? How can we besure that previously held views, which may have been expressed to friends or family,have not changed? How can we know that the wishes of the family are in line withwhat their relative would have wanted? Can a person’s views be influenced by mentalhealth factors such as depression and, if so, would those views change after treatment?
This principle means acting in the best interests of the patient, that is, ‘doing good’. Itcovers feeding, and the basic human need for nutrition. Delegates discussed thebenefits of PEG and naso-gastric feeding as an aid to rehabilitation in stroke. Issuessurrounding dependence for feeding were also raised, and the need for awareness ofcarers as to what is ‘good’ or ‘harmful’ for an individual - for example, inappropriatediet consistency. For some patients, eating and drinking is not always in their bestinterests. However, in many cases, it can be argued that it may also be in the bestinterests of an individual not to prolong a life of suffering.
Surrounding this principle of doing no harm to another person were the questions ofwithholding feeding and malnutrition. The appropriateness of PEG feeding for patientswith end stage dementia was discussed in detail. There are many issues surrounding theethics of allowing people to go on eating and drinking with the knowledge that it maybe doing them harm. Documentation is important in these cases, stating the risks andbenefits according to evidence based clinical judgement. However, in many patientswith dementia, bedside assessment is not sufficient to diagnose accurately the nature ofa problem. Videofluoroscopy may not always be easily accessible or appropriate, andmany at the conference felt it should only be done if those involved are prepared toalter the management of a patient, by instigating non-oral feeding if aspiration isconfirmed. Could PEG feeding improve the quality of life of the patient, or would itactually cause harm, depression or increased suffering? Is a person to be denied thepleasure of eating and drinking because it may lead to their death?
The principle of treating equals equally and unequals unequally according to theirrelevant difference is all about treating people fairly. If two patients in adjoining bedshave similar impairment and disability, but very different cultural or religious beliefsystems, the principle of justice dictates that it may be appropriate to manage thesepatients in different ways. We each carry with us our own personal belief systems. It isoften impossible not to convey these in some way as we go about our work. Our voicesmay belie the content of our language. How much of our own personal belief is itappropriate to convey to a patient or their family? Is it at all possible to remaincompletely objective?