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Rosie

Rosie. Marissa, Courtney, Jodie, Connie, Rachel, Tina. Problem.

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Rosie

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  1. Rosie Marissa, Courtney, Jodie, Connie, Rachel, Tina

  2. Problem • Rosie is an 87 year old woman who’s had multiple CVAs. After each CVA, she has had swallowing problems which have resolved over time. The nursing staff at the Nursing Home where Rosie resides has indicated that following her last CVA, she coughs and chokes on almost every bite. Both the doctor and Rosie’s HMO have denied two requests from Rosie’s SLP and from nursing to do a Bedside Swallowing Evaluation. It appears the doctor has given up hope on Rosie; as a matter of fact, he initially refused to send her to the hospital to rule out another CVA. The family would like the SLP’s input. Nursing has begged the SLP to come observe Rosie in a “nonofficial” capacity to try and make it “easy” for Rosie.

  3. SLP’s Ethical Problem • We were told we were not authorized to do a Bedside Swallow Evaluation and now nursing wants us to do this. • If we do, does this look like we have no respect for the doctor or authority? • What other rules do we break? • On the other hand, if we don’t help, does it appear we have no empathy for patients and the will to do what’s truly right? • Are we just hiding behind policy?

  4. Main Issues to Consider • Multiple CVAs • Doctor refusal • HMO denial of requests • Probable signs of aspiration reported by nursing staff • Family concern

  5. Additional Questions? • How many days post-CVA is she? • Dysphagia=frequent problem a few days post • Consider TPN: Total Parenteral Nutrition through IV until swallowing resolves • What exactly were her swallowing problems in the past? • Did she ever have a MBS? When? What did it show? • How did these problems resolve? • On their own? How fast? • With treatment? What kind?

  6. Additional Questions? • Why have M.D. and HMO denied all requests? • Has the doctor observed Rosie while she’s eating? • What was the doctor’s recommendation for meeting Rosie’s nutritional needs? • Has the current M.D. been involved in Rosie’s past swallowing evaluations and seen her progress? • Has the family observed her cough or choke while eating? • Is Rosie aware of and/or complain about her swallowing difficulties? • Has there been a group meeting (Rosie, SLP, M.D., head nurse, family, dietician) to discuss Rosie’s eating?

  7. Additional Questions? • Nurses say “she seems to cough and choke on almost every bite.” • What types of food/liquids/consistencies? • When? Before, during, after? • How big is a “bite”? What rate does she eat at? • What is Rosie’s current diet? • History of pneumonia? • Vocal quality during/after meals? • Wet, gurgly voice? • Nutrition/hydration status? • Has she lost any weight?

  8. Additional Questions? • Family wants your input… • About what, exactly? • You know her and her family well… • Relationship? Family friends or just a past patient?

  9. Additional Questions? • Is Rosie awake, alert, aware? • can she recognize food, control bite size/rate of intake? Remember to put dentures in? • Does she make her own decisions about her medical care?

  10. Additional Questions? • Ability to follow directions and answer questions? • Receptive and expressive communication skills • Seems to be saying she is thirsty • How? Speech, gestures?

  11. Additional Questions? • Does Rosie feed herself? Is she physically and mentally able to feed herself? Supervision? Positioning? Distractions? • Weakness/hemiparesis? • Can she tolerate any laryngeal exercises or swallow maneuvers?

  12. Ethical Principles • Autonomy • Patients have the right to make choices about their care or appoint a surrogate to help them make decisions if they are cognitively impaired. • Nonmaleficence • “About all, do no harm.” • Beneficence • We are required to provide positive benefits to patients.

  13. Solution 1 • The SLP educates the family about swallowing problems, their legal rights and the SLPs inability to act without doctor’s orders. • Follows autonomy • Put everything in writing and request another team meeting. • Outcome: The doctor and HMO were convinced by the family and ordered an evaluation. • Outcome: The doctor ordered an evaluation, but the HMO denied the request. • Outcome: The doctor and HMO both denied the request. • Outcome: After being educated, the family decides to wait a few days and see if Rosie’s swallowing improves. • Outcome: After being educated, the family decides not to pursue the issue. • Fear of dietary restrictions (e.g. NPO, thickened liquids)

  14. Solution 2 • The family requested a second opinion. • Nonmaleficence: Felt the doctor could be causing harm by refusing to do anything. • Outcome: The second doctor ordered a Bedside Swallowing Evaluation, but the HMO denied it. • Outcome: The second doctor ordered a Beside Swallowing Evaluation and the HMO approved it. • Outcome: The second doctor agrees with the first doctor and denied the request.

  15. Solution 3 • The SLP does nothing and refuses to get involved, stating the doctor and HMO have denied the Bedside Swallowing Evaluation twice. • Outcome: Rosie dies due to: • aspiration pneumonia • asphyxiation • Outcome: The doctor witnessed an episode of choking and ordered an evaluation. • Outcome: Rosie’s swallowing issues resolved on their own after a few days. • Outcome: The family files a lawsuit against the SLP and doctor claiming negligence.

  16. Solution 4 • SLP decides to follow the beneficence principle and observe Rosie while she is eating and offer unofficial suggestions to the nursing staff. • Outcome: The nursing staff implements changes based on suggestions from the SLP and Rosie’s swallowing improves. • Outcome: The nursing staff implements changes based on suggestions from the SLP and Rosie’s swallowing problems worsen. • Outcome: The family files a lawsuit against the SLP and the nursing home for causing more harm. • Outcome: After unofficially observing Rosie, the SLP has grave concerns about her safety. • Outcome: The doctor is upset about the SLP unofficially observing Rosie and questioning his authority. This could lead a breakdown in their professional relationship.

  17. Our Solution • THE BALL IS IN THE FAMILY’S COURT! • We will educate the family about swallowing problems, their legal rights, and the SLP’s inability to act without doctor’s orders. • Rationale: • Ethical principles (autonomy, beneficence, nonmaleficence) • Professionalism • Morals of SLP • Legal issues

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