NPO Except Meds: Navigating the Toughest Clinical Calls in Dysphagia Management

Written with help from Ed Bice M.Ed., CCC-SLP and Dr. James L. Coyle, PhD, CCC-SLP, BCS-S, ASHA Fellow

A couple of years ago, I created an Instagram post making a blanket statement about avoiding the “NPO except for medications” recommendation. It would be an understatement to say that this post was not so well-received. The post spread, and I was getting an earful from every direction. Since the post was made for Instagram, a platform that doesn’t exactly value depth, I took a step back to reassess the post and wrote an article to explain what I was trying to get across. But even the article created somewhat of a storm in my inbox.

A couple of years later, I took great pleasure in re-reading the article with a fresh lens, having gained many new clinical experiences and acquired additional clinical knowledge. The earful I received from my well-respected colleagues wasn’t lost on me.

So here’s me being a glutton for punishment and taking another stab at what turns out to be quite the controversial topic. Knowledge is power, and I do NOT take lightly the fact that many people read and use the information I publish. I want to ensure, regardless of the response, that I provide the most accurate and useful information possible. After all, my goal has always been and continues to be to educate people in a way that helps them help their patients… Not next week, not next month, but today.

Hopefully, I’ll accomplish that in my “Take Two”:

Bob

Imagine this: You're consulting on Bob, a 59-year-old with Parkinson's Disease who has been admitted to the hospital with altered mentation. Your clinical swallow evaluation paints a concerning picture: poor responsiveness, generalized weakness, and a failed Yale Swallow Protocol. You've concluded that he's not safe to eat or drink at this time, and you recommend nothing by mouth (NPO). You're planning for a follow-up instrumental study as soon as possible.

But before you can even close your chart, the doctor catches you. "What about his medications?" she asks. "He needs them. Can we at least do NPO except for meds?"

How do you respond in that moment? Did you feel a knot of pressure in your stomach? I know I have. It's a question that pits a patient's immediate medical needs against the core principles of dysphagia care. But let’s unpack the logic behind this seemingly straightforward request.

The Problem with "NPO Except Meds"

First off, "NPO except for meds" is a bit of a contradiction, isn't it? If a patient is NPO, they're supposed to take nothing by mouth. But here they are, taking something. We recommend NPO because we're concerned about safety and efficiency. We believe the patient is aspirating—that food or liquid will end up in the airway—or experiencing pharyngeal residue, where it gets stuck. So, why would we assume that medication, with all its potent chemical compounds, will go to its "intended destination" any more effectively?

Medications are designed for the stomach, a robust environment protected by a thick layer of mucus and bicarbonate. The sensitive tissues of the pharynx, larynx, and lungs, however, are not. Aspiration of a caustic medication can cause severe inflammation, airway stenosis, and can even be life-threatening. So, not only is the patient missing the benefits of their medication, but we could be causing serious harm to their airways and lungs. Oral medications belong in the stomach—nowhere else.

When Rules Get Broken

But maybe you can argue that Bob is a pretty straightforward example of a patient who clearly shouldn’t be eating or drinking, and would not even be capable of keeping meds in his mouth, let alone swallowing them. Nobody in their right mind would feed Bob, and few people are probably debating that.

However, not all patients will present like Bob. Is there a scenario where NPO, except for meds, works and might actually be a viable option? A one-size-fits-all approach never fits when providing care for people with dysphagia. There are too many variables and too many options to break down our practice into “If this then do that” algorithms. Some rules were meant to be broken.

Consider a patient in the ICU who self-extubates, pulls out his nasogastric feeding tube, and is now having a hypertensive event. His blood pressure is off the charts, and the only form of his blood pressure medication available is an oral tablet. This is a high-stakes emergency, and you have to make a quick decision. Forget the rules, forget the algorithms, and realize that if you don’t make a decision now, this patient may die.

In this scenario, we have to triage the problems. A hypertensive event that could lead to a hemorrhage is an immediate and grave danger. The concern of a single pill aspiration event, while serious, is the lesser of two possible catastrophic outcomes. We must prioritize the most urgent threat. This is a situation where the clinical context, rather than the textbook, dictates the right course of action. It's not about making a recommendation for every swallow, but about recognizing when a patient’s life-threatening medical instability must take precedence over potential dysphagia-related issues.

Finding the Middle Ground

The world isn't black and white. What if Bob were more alert, and you only occasionally saw signs of aspiration? What if he couldn't stay awake long enough to eat a full meal but could briefly manage to take an uncrushable medication?

In these grey areas, a robust discussion with the entire interdisciplinary team (IDT) is crucial. The SLP is not alone, nor should we act like we are. A decision made in a silo will never be a good decision. Instead of a blanket NPO recommendation, you might explore some important questions and find a middle ground that incorporates all relevant information, is suitable for the individual patient, and is agreed upon by all IDT members.

Consider these questions to help you navigate these winding, mountain-top roads:

• Can an instrumental study be performed soon? If not, why not?

• What are the patient's individual medical factors, and how might their bodies react to potential aspiration?

• How long can the patient safely go without this specific medication?

• Can the medication be administered via an alternative route, such as an IV or NG tube, and do those concerns outweigh the concerns associated with oral intake?

These conversations highlight that "NPO except for meds" isn't always about aspiration. Sometimes, it's about efficiency or alertness. A cognitively intact patient might choose to assume the possibility of aspiration for a vital medication until a swallow study can be done. Another patient might be weak, unstable, and not quite ready for a full meal but can manage a pill with a small bite of applesauce. The key is that these are conscious, educated, and patient-driven choices, not a mindless default.

Final Takeaways

I’ve learned over the past couple of years that blanket statements don’t have a place in clinical care. While seemingly digestible and easy to go down, they almost always come back up and leave a bad taste in the mouth.

Treat the complexity of dysphagia with the thoughtfulness, comprehensiveness, and collaboration it deserves. And remember, you don't have to face these complex situations alone. A solid IDT is always greater than the sum of its parts. By asking these multi-faceted questions and leading a thoughtful discussion, you’ll provide a loose outline for your IDT when making these tough calls, ensuring the best possible outcome for your patient.

I hope that thinking about and writing about this topic has been as valuable to you as it has been for me.

What is your take on NPO except for medications? When do you use it, and when do you steer clear? Thanks for reading! 

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