My family is full of therapists, and most of us work in skilled nursing. My sister, an experienced speech language pathologist, called to commiserate about one of her patients who had difficulty swallowing.
She performed a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) and recommended that her patient should continue to be NPO, or unable to take anything by mouth. Not surprisingly, the patient disagreed.
We all know the Patient Bill of Rights. We hand it to everyone admitted, we go over it with them and their families, we live by it. One of the bullets reads:
To receive information necessary for you to give informed consent prior to any procedure or treatment, including a description of the procedure or treatment, any potential risks or benefits, the probable duration of any incapacitation, and any alternatives.
We should know how Person Centered Care works. One of the tenets reads:
Care that’s guided and informed by patients’ goals, preferences and values.
If we are adhering to the rules we live by, and making sure that our clients and residents are safe and get the right care to enhance and preserve their lives, how do we manage the NPO client who wants to eat?
So many residents and families ask physical therapy when they can walk again. Walking is important, but if someone told you you’d never eat again, that seems like a higher priority. It would be for me. We offer swallowing therapy, including exercises and the sometimes-controversial electrical stimulation. NPO is not always forever. But we will frequently see the patient who misses eating. What now?
In PT, the non-weight bearing patient is seen walking to the bathroom without his walker. We advise, educate and then assume that will continue. Adults who have spent 60+ years making their own decisions will continue to make their own decisions.
According to HealthCap Risk Management, there’s no waiver that’s defensible for a facility policy to give an NPO patient food or water. Once the physician orders NPO, it is the responsibility of the facility to ensure that no staff member offers any food or water. But what about the patient’s daughter?
According to F552 CMS tag, “Residents have the right to be informed in advance of the risks/benefits of proposed care and treatment options, as well as alternatives. Residents may choose the options that they prefer.”
However, F684 says “Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices…”
While it’s the resident’s right to eat, from a health and medical standpoint, it’s still our job to ensure that the NPO patient doesn’t. How to compromise?
If the NPO patient’s family brings her food, with fully informed consent both from the family and the patient, it’s my opinion that she should be allowed to eat, under supervision, and with complete and thorough documentation of the patient’s request, what she ate, how much she ate, and the results of her eating.
If the patient orders delivery of food, while still on physician-ordered NPO, it’s my opinion that the patient should be allowed to eat it, under supervision, and with complete and thorough documentation of the patient’s request and the results of her eating. Your resident is an adult and can make those choices. If the patient becomes irate and berates the staff for not providing a tray at meal times, she needs to be educated that her physician has ordered that she not take anything by mouth. Under no circumstances should the physician orders be violated by the SNF staff.
What’s the difference between her family bringing the food and the facility providing it? The NPO order. As clinicians, we have to follow the orders. The patient, however, can do what she pleases, but to ensure safety and watch for signs of aspiration, it needs to happen in an area with staff present. Some facilities have been known to shut off water to NPO patients’ rooms to prevent the instinctive urge to drink water. Alternatively, some facilities practice the Free Water Protocol for their dysphagia patients.
Which is better? Which is barbaric? Which would you prefer?
Our residents, clients and patients are still people, people who have spent their lives eating, looking forward to dessert, and regarding eating with family a celebratory event. We need to consider how to adapt to meet their needs, and make sure our care is “person-centered.”
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.
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