Over-treatment in Dysphagia: Why Less is More
Meet Ellen, a 91-year-old with late-stage Alzheimer’s disease who was recently admitted for aspiration pneumonia. Ellen has been NPO for three days, has pulled her nasogastric feeding tube out twice, and is actively fighting the nurses over the placement of her IV. Her family, desperate for direction, signed off on the most recent recommendation: a percutaneous endoscopic gastrostomy (PEG) tube for long-term feeding.
Why? Because the previous SLP identified nine different deficits on the instrumental study, resulting in five distinct, complex compensatory strategies and a modified diet of pureed solids and moderately thick liquids that Ellen won’t look at, let alone eat. Her husband couldn't manage the sheer volume of precautions at home, compliance fell, her appetite fell even faster, and here they are in the hospital with you, their new SLP. The clinical kitchen sink was thrown at her, and the patient drowned in the complexity.
Now, you’re here to help clean things up, if there’s still time. You’re standing at her bedside, looking at a patient who is losing her will to cooperate, and a husband who is burnt out from trying to manage an impossibly complicated plan. At this point, you realize the critical, life-altering question isn't, "What else can we do?" but rather, "What is the one, essential thing that matters most right now?"
Breaking Through the Noise
As SLPs, our dedication to comprehensive care often leads us down a path of "more is better": More testing, more restrictions, more recommendations. We pile on modified diets, thickened liquids, and complex protocols and multi-step directions, driven by a desire to mitigate every possible risk. But what if this exhaustive approach is actually diluting our impact, exhausting our patients and colleagues, and obscuring the simple, yet critical changes that truly make a difference in people's lives?
Do we target every single potential issue, or do we focus on the major ones where we can make the most significant difference? Do we respond by throwing every possible intervention at them to see what sticks, or do we use the approaches with the best track records and the most effective carryover?
What if the secret to achieving extraordinary outcomes and maximizing our influence lies not in doing more, but in doing less?
What is Essentialism?
I was inspired to write this article after reading Greg McKeown's book on the philosophy of essentialism. Focusing on the things that matter and cutting back on the things that don’t. Instead of asking, "What else can I do?" I’ve started asking, "What is the one thing that matters most right now?"
Becoming an Essentialist SLP means cutting through the chaos to focus on the vital few elements that deliver profound, lasting results for our patients. This deep dive challenges the sacred cows of our field (yes, I’m looking at you, thickened liquids!) to prioritize what truly matters.
My goal as a clinician is to stop chasing every potential problem and start winning the battles that truly count. Ready to clear the noise and focus on what's essential in dysphagia? Let’s get into it…
The Essentialist Approach
When we first see a patient, there is often an overwhelming amount of information being presented to us. I recall when I first started, the skilled nursing facility I worked in was still using paper charting. The sheer weight of the hospital records the patient would come in with upon admission would literally weigh on me. If you were to look for me, you'd find a desk buried under stacks of paper, with only my unruly hair peeking out if I hadn't managed to comb it that morning.
How do we focus on what’s essential? Let’s focus on the most crucial elements to obtain the right information that will help us move forward in the context of Ellen’s case, as introduced above.
A Follow-up Instrumental Swallowing Evaluation: Let’s get to the core of the problem without making assumptions. Identify the specific deficits that are having the most impact on the patient’s safety and efficiency so that we can target them with one or two interventions.
Patient-Centered Care: Understanding the patient and their family’s preferences, needs, and quality-of-life priorities is essential and may help avoid complications down the road. Do they enjoy mealtimes? Why or why not? How did they eat before their recent decline? Can we mimic that environment and those food items? Are they willing to accept a modified diet at least for a little while? What type of food and liquid brings them the most joy?
Interdisciplinary Team Collaboration: Working closely with the patient, their family, and the medical team ensures everyone is on the same page and working towards the same goals. The last thing we want is to explain our recommendations for maintaining PO intake at 10 a.m. only to discover the doctor came in at 10:30 to discuss plans for a feeding tube.
Eliminating the Nonessential
Sometimes, less is truly more. What are some things that we can leave off the table, at least initially, to consider alternatives that may better suit the patient’s needs?
Challenge the "Thick Fix": The SLP’s number one dysphagia intervention is to modify diets and thicken liquids. But pureed food and thickened liquids are by no means a panacea. The research has not crowned them as the best intervention (or even a very effective one), so why are we treating them as if they are? They come with a slew of potential side effects, too, including dehydration, pulmonary compromise, medication interactions, and decreased quality of life.
Rethinking Feeding Tubes: Feeding tubes do not eliminate the risk of aspiration pneumonia (you can’t eliminate saliva!) and can significantly impact quality of life, even introducing complications (e.g., dislodgement, reflux, and infection).
While essential in some cases, these interventions may not be necessary for patients who accept a degree of aspiration risk. Instead, the focus can shift to improving quality of life, learning compensatory strategies, exercising breathing and swallowing muscles, and maintaining adequate hydration and nutrition. These interventions are not Band-Aids that temporarily hide the problem, but rather are well-constructed, evidence-based treatments that address the core of what’s needed for the patient to improve.
Prioritizing the Essential
Having identified areas to de-prioritize, what strategies should we prioritize to maximize our positive impact within the field?
The most effective way to have the greatest impact is to identify patients who need our services the most. After this, we determine the most effective ways to evaluate their condition. Lastly, we determine how we can best assist them. This process can be broken down into three questions:
1. Is this patient in a high-risk category (e.g., high risk of dysphagia, aspiration, infection, weight loss, or dehydration)?
2. What can we do to determine the specific level of risk for this individual patient (i.e., what testing do we have available to determine the specific deficits)?
3. What interventions can be used that will reduce that risk in the most significant way?
Of course, there aren’t blanket answers to these questions, nor is there a guideline for answering them. Every person is unique: different in anatomy, physiology, and biology, with distinct wants and needs. We need to respect that and do the work required to find a unique solution for each patient. Don’t ask, “What’s the best approach?” Instead, ask, “What’s the best approach for this patient?” And be able to answer why it’s the best approach.
But what would an essentialist say about some of the approaches and insights that are most useful to SLPs when developing a plan of care? Three things:
Understand the underlying cause: Dysphagia is a symptom, not a condition in itself. Investigating and addressing the underlying cause is essential for effective management.
Preserve quality of life: Most people don’t eat to “refuel the engines.” For many, food doesn’t just give life; it is life. Keeping that in mind, meals should be enjoyable and social experiences that our patients look forward to. Not something to dread. Within this framework, prioritizing the patient's preferences and dignity is essential.
Maintaining overall health: Avoid narrow, short-sighted thinking (e.g., stopping aspiration at all costs) and instead think about the best solution to make this patient healthier in the long run. This might involve straying away from strict diets and precautions and instead making compromises with the patient to determine what they are (or are not) willing to do and how we can make a tentative plan of care more palatable (pun definitely intended).
WIN
Lou Holtz, the famous Notre Dame football coach, is attributed with coining the acronym WIN, which stands for “What’s important now?” You can’t always avoid losing, but you can always WIN and figure out what the most crucial goal is for your patient at the moment. Upon entering the patient’s room, what if we asked ourselves, “What’s important now?” Instead of juggling the dozens of things we have to document and the other countless tasks on our to-do list, we could ask ourselves, “What’s the most important thing that we can do right now to help the patient?” Cutting through the thick bog of the day-to-day chaos of being an SLP can be liberating and can help us truly make a difference in the lives of the patients we serve. And the answer will be different every time, of course. It could be…
Education on a proven-effective strategy will allow them to enjoy their favorite food.
Training on an exercise that will strengthen the patient’s ability to protect their airway so they aren’t constantly coughing during the meal.
Education on a free water protocol so the patient can enjoy some cold water for the first time in weeks.
Utilizing a lingual strengthening program to improve bolus clearance and avoid the discomfort of significant residue building up during a meal.
Whatever it is, it should be something meaningful to the patient and align with what they are trying to achieve. Not an arbitrary goal clicked off from a drop-down menu, created by an executive who never even worked in your setting.
Along these same lines, every day I ask myself: “How can I make this person’s day a little bit better?” It reminds me that there are many things I can do, sometimes completely unrelated to the reason I am there in the first place. These can range from helping schedule a swallow study to helping understand the results. They can also be as simple as getting the patient a blanket or pillow to make them slightly more comfortable. Think, “What’s important now?” and set you and your patient up for a genuine WIN.
The Essentialist SLP
So, what happened to Ellen? When you met with her, you dismissed the nine complex deficits and focused on the one essential thing: her joy. She lit up only when her husband mentioned chocolate ice cream. You urged the team to hold off on the PEG placement given its contraindications in patients with late-stage dementia, and used the follow-up instrumental study to find the safest way to deliver that joy. You focused on upright positioning and pacing (the vital few elements) and recommended a pureed diet with fortified ice cream at every meal. We also trained her husband on incorporating a modified free water protocol to help with hydration and to avoid the use of thickened liquids (since she wasn’t drinking them anyway). We prioritized quality of life and compliance over the endless, unmanageable precautions. And it worked. By cutting through the chaos, you restored her dignity and gave her family the simple, single thing that mattered most in her life.
By adopting an essentialist mindset, SLPs can become more effective and efficient in their dysphagia management. This involves:
Focusing on the vital few: Identify the most critical interventions and eliminate the ones that haven’t been useful.
Prioritizing patient-centered care: Make decisions based on the patient's individual preferences and values. A recommendation is useless if the patient doesn’t follow it. Beauty is in the eye of the beholder. And it turns out half of the patients don’t think our dysphagia recommendations are too pretty.
Collaborating effectively: Work closely with the care team to ensure a holistic approach that not only addresses the swallow and the dysphagia, but ensures the whole patient continues to thrive. Until the pharynx itself develops a brain and a sense of self, our jobs remain to treat the patient, not the swallow.
How might you apply essentialism to dysphagia management? Share your insights and experiences in the comments below!
