Reflective log: Challenging dysphagia patient

1. Think of a recent therapy session or event.

I had a patient who was discharged from A and E with significant aphasia and right upper limb hemiplegia after having a LMCA infarct. The patient was supported at home by his family who took time off to be with him. The patient was coughing and showing signs of aspiration on thin fluids. He was also showing signs of aspiration on a soft diet. I recommended that he have thickened fluids and a soft mashed diet and observed him during a mealtime. This patient had a severe expressive and moderate receptive aphasia.           

2. Describe the session/experience

I explained to the patient that he would need thickener in his drinks to make it safe to drink. I used gestures to support his comprehension. The patient became very agitated when he saw me putting thickener in his drinks and refused to drink. He also ordered toast and cornflakes for breakfast with nursing staff. I organised a joint session with the patient’s daughter to explain why he required a modified diet and used written words and pictures to explain my rationale to the patient. The patient communicated that he had had normal food when discharged and was angry to be in hospital and didn’t was thickener. After a few sessions with his daughter the patient would sometimes drink thickened drinks but would regularly get thin tea from domestics.

3. What did this session make you feel?

I felt stressed because the patient was at risk of aspiration. I organised a risk management program with nursing staff and got the patient to agree to a videofluoroscopy in order to have evidence to present to him. I felt uncomfortable recommending modified consistencies that the patient disliked. It took me a while to realise that the patient understood the information I gave him but decided to ignore it. The patient also had memory problems which complicated the process of giving him advice and information. I felt that the patient was not safe to go home and fed this back to the team. The patient resented this information.

4. What would you want to change, and why?

I would find out information about a patients character before giving them information they might resent. I would also organise to give the patient information while their family is present. Later on I gave the patient a diary to support their memory and to use in therapy sessions as a conversation prompt. I would do this earlier and make a visual poster for the patient explaining the rationale for swallowing advice and relating it directly to their symptoms (red in face, coughing on food/ drink). This might support their comprehension and could be used by the MDT to prompt the patient to remember information.

5. What has this session has taught you?

I have learnt that I need to carefully write up risk management plans if a patient refuses advice. I have also learnt that I should provide written or visual advice to a patient. This advice can be used as a prompt by other members of staff and used by patient s as a memory aid. I should also relate advice directly to the patient’s symptoms/ presentation and try to use as much clinical/ observational evidence as I can.

6. What do you need to learn or find out before the next event?

I need to find out what our clinical obligations are when developing a risk management plan.