Background     Speech pathologists can facilitate communication among members of the medical team, and between the team and the patient/family, to make treatment decisions that honor patient wishes.  Speech pathology services for symptom control to enable the individual to maintain activities of daily living and basic functional skills are reimbursable under the Medicare Hospice Benefit (see Fast Facts #82, 87, 90). Swallowing studies are used to evaluate a patient’s ability to safely ingest oral food and oral secretions, yet the role of swallowing studies to facilitate optimal care near the end of life is not clear.   This Fast Fact will review the indications and contraindications for a swallowing study and the role of the speech pathologist.  

Potential Indications for a swallowing evaluation (Bedside or Instrumental)

• Acute stroke or other neurological condition affecting oral motor function (see Fast Facts #201, 300).
• Tracheostomy or recent endotracheal extubation.
• Changes to oropharyngeal anatomy secondary to tumor, surgery, trauma, etc.
• Observed difficulty swallowing food or liquid.
• Recurrent upper respiratory infections or pneumonias.
• Reduced oral food intake; unexplained weight loss or fever.

Contra-indications for swallowing evaluation (Instrumental only)

• Imminent death—death expected within 2 weeks (See Fast Fact #3).
• Death expected within weeks from any progressive terminal illness.
• Reduced level of arousal (e.g. coma/obtundation).

Types of swallowing studies

• Bedside dysphagia evaluation involves an in-depth feeding/swallowing history, oral peripheral examination, and trial swallows of various food consistencies.  Bedside evaluation cannot rule out silent aspiration.
• Instrumental swallowing evaluation is performed via modified barium swallow (videofluoroscopy), fiber-endoscopic evaluation of swallowing (FEES), or fiber-endoscopic evaluation of swallowing with sensory testing (FEEST). All of these instrumental assessments require the patient to be alert, cooperative, and able to follow simple commands. 

Speech Pathologist Role     The decision to perform a swallowing evaluation should be made based on the overall goals of care and expected prognosis.  Consultation with your speech pathologist prior to ordering an evaluation can help clarify how you will use any new information to improve patient comfort and satisfaction.  If performed, the speech pathologist will evaluate the patient’s swallowing and recommend feeding strategies which may include:

• Appropriate food consistencies.
• Positioning of the head and neck.
• Timing of meals
• Promoting family involvement.

Using the Speech Pathologist’s Assessment    Decisions regarding feeding management should not be made based solely upon the speech pathologist’s assessment of swallowing dysfunction, which may be a sign of the final stage of life in many terminal conditions.  In addition, feeding tube placement decisions in this population should not be based on the likelihood of aspiration.  In patients with advanced dementia and other terminal conditions, feeding tubes have not been found to reduce the incidence of aspiration and can significantly impair the dying patient’s quality of life (see Fast Facts #10, 84).

References:

1. Finucane TE, Christmas C, Travis K.  Tube feeding in patients with advanced dementia.  1999; 282:1365-1369.
2. Levy A, Dominguez-Gasson L, Brown E, Frederick C.  Technology at End of Life Questioned.  The ASHA Leader. 2004; July 20: pages 1, 14.
3. Ahronheim JC. Nutrition and hydration in the terminal patient.  Clinics in Geriatrics. 1996: 12(2):379-391.
4. Monteleoni C, Clark E.  Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study.  BMJ. 2004; 329:491-494.
5. Pollens R. Role of the speech-language pathologist in palliative hospice care. J Palliat Med. 2004; 7(5):694-702.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in December 2004. Version re-copy-edited in April 2009; revised again July 2015 by Mary Rhodes MD.