“Is This Safe?” Navigating the emotions behind dysphagia management
Does this sound familiar to you…
Your patient is NPO. You've completed the modified barium swallow study, you've developed the perfect, evidence-based plan, and proudly and excitedly share your recommendation to begin PO intake with the patient’s spouse. That’s when they look at you and say, “But is this safe? I don’t want them to be at risk.
In that single moment, your goal totally changes. You are no longer just the SLP recommending a diet. You’re now an educator and a guide. In order to understand how to best navigate this situation, we need to first talk about the weight terms like “safety” and “risk” can have.
Aspiration Risk
The term ‘aspiration risk’ carries an enormous, often disproportionate, emotional weight. It transforms food from a source of pleasure and nourishment into a potential weapon. This is NOT what we want.
We often feel pressured to achieve zero risk and to stop aspiration at all costs. Make them NPO, thicken the liquids, insert a feeding tube… But this is a fool’s errand and a dangerous one at that. This is because of a little secret I’ll let you in on: You can’t bring ANY risk down to zero. And trying to will only INCREASE risk, not decrease it.
Counterintuitive? Maybe, but let’s see how this concept applies to aspiration pneumonia. Let’s eliminate the risk of aspiration at all costs if that’s what’s truly the most important thing. So, the best medical intervention for eliminating the risk of aspiration is making a patient NPO, or eliminating food and liquid entirely. What does this do? It reduces saliva flow, increases the bacterial load concentration, reduces swallow frequency, and increases oropharyngeal atrophy. Psst, this process doesn’t REDUCE the risk of aspiration; in fact, it INCREASES it. Hm, well, that backfired.
You can apply this concept in almost every context. Here are two more examples:
#1 Your patient is at risk of aspirating thin liquids, so you make liquids SO thick they start to stick in the throat, causing residue that eventually pools over into the airway, sticking in the lungs worse than thin liquids ever could.
#2 You try to reduce the risk of choking, so you change everything to puree, which the patient won’t touch with a ten-foot IV pole– eventually causing malnutrition and failure to thrive.
It’s like the person who avoids flying out of state and instead drives, increasing her risk of death by almost 200 times. We’re missing the full picture.
Don’t try to eliminate aspiration at all costs, or anything for that matter. Everyone, even healthy people, aspirates secretions and liquid here and there. It’s a part of life. Therefore, aspiration CANNOT be eliminated, and even if it could be, that wouldn’t be the answer. Risk can never be eliminated entirely. Trying to do so is a phenomenon known as zero risk bias, and we ALL fall victim to it ALL the time (E.g., you pay up the wazoo in insurance for a rental car even though your personal insurance covers 99% of the potential cost).
But this bias is especially relevant in healthcare because of the high stakes of each decision. THIS is why we are questioned about our recommendations. Food and liquid have become a source of fear and no longer a source of nutrition for these patients and their families.
But there is assumed risk in EVERYTHING we do. From driving to the store to getting into the bath. You can’t avoid it. But… You can reduce it.
Shifting from "Diet Police" to "Risk Consultant"
Much of the fear behind PO intake has been escalated in our own hands. We’ve been warning people about the risks of aspirating for years, reiterating that you can even do so silently. Imagine a silent, but deadly invisible assassin gunning right for your throat every time you take a sip of soup (GASP).
It’s time to push back. Our role isn't to enforce rigid, unyielding rules. It's to shift the focus from the impossible pursuit of zero risk to the achievable goal of risk reduction and informed choice. This requires a fundamental change in how we communicate. Three ways we can do this:
Stop Prescribing, Start Consulting: Instead of saying, "Your husband must have thick liquids," shift the language to: "We think a thicker liquid will reduce the risk of aspiration and there are some other things you can help us with to meet his needs” (I.e., implementing safe swallow strategies or a free water protocol). This empowers the caregiver by making them a collaborator, not just a compliance officer.
Highlight the Other Risks: We must remind families that our interventions introduce new risks. Thickened liquids may cause dehydration and reduce quality of life. Strict diet modifications may lead to malnutrition and noncompliance. Even a feeding tube, which often provides the family with comfort, does not eliminate risk and introduces its own complications.
Define the goal: My guess is that the patient and family have goals that go beyond avoiding aspiration. What’s most important to them? Is the goal to prolong life at all costs, or to preserve the joy of eating? Is it simply a sip of coffee in the morning, or is it changing their diet to resume regular foods? When we respect the patient's goals, we can develop a compromise that addresses both safety and quality of life, which is often easier for the family to accept.
Conclusion
Pursuing zero risk is a dangerous bias that often increases harm. Shifting your professional identity from "diet police" to "risk consultant" enables a collaborative approach in which interventions are weighed against the new risks they introduce, such as dehydration from thickened liquids or complications from feeding tubes. Ultimately, effective management requires aligning clinical recommendations with the patient's specific goals, ensuring that the preservation of quality of life and the joy of eating are respected, ALONGSIDE physical safety. You can’t have a life worth living if you don’t have quality of life. So the next time someone asks you, “Is this safe?” Take a step back, see the full picture, and help them make the best decision that fits their wants and needs.
