Dysphagia

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Please find below responses to questions Speech Pathology Australia (SPA) members frequently ask about working in the area of dysphagia.

Speech pathologists that have queries regarding the appropriate management of dysphagia should refer to SPA’s Clinical Guideline – Dysphagia 2012 prior to reading the information in this document.

I’m a newly graduated speech pathologist. Can I work in the area of dysphagia?

Yes. Speech Pathology Australia’s (SPA) position is that working in the area of dysphagia is part of a speech pathologist's scope of practice.

All speech pathologists (whether newly graduated or experienced) should, however, always recognise the limits of their competence and not practice beyond these limits as stipulated in principle 3.1.3 of SPA’s Code of Ethics (2010).

Expectations of entry level speech pathologists working in the area of dysphagia are discussed in detail in section 8.1 of SPA’s Dysphagia Clinical Guideline, 2012.

I don’t feel competent to work in the area of dysphagia. What should I do?

You have two options: either you don’t work in this area or you update your knowledge and skills and/or seek supervision from an experienced clinician until you are competent in this area.

Is there a course I can undertake to update my skills?

SPA is not aware of any recognised or endorsed post graduate course/program in Australia concerning dysphagia. SPA has a Dysphagia Independent Study Resource for loan to re-entry members, OSQ applicants and members wishing to update their knowledge in the area of dysphagia. SPA also regularly holds continuing professional development events in this area. For further information go to the SPA CPD Events Library web page or the SPA CPD Branch Events web page.

How do I find and engage a supervisor?

SPA does not have a formal program or register of supervisors for speech pathologists. Individuals wishing to engage a supervisor should contact a speech pathologist who is experienced in this area and make arrangements with them.

What is the difference between dysphagia screening and dysphagia clinical assessment?

This issue is discussed in great detail in SPA’s Clinical Guideline – Dysphagia 2012. The information provided below is a summary of only a few relevant issues.

Screening procedures or tools are designed to identify the risk of dysphagia. They often rely on the presentation of dysphagia symptoms. Screening procedures or tools are not used to measure dysphagia severity, or to guide dysphagia management. Therefore, screening procedures or tools do not replace the clinical assessment of dysphagia by a speech pathologist.

In contrast, the clinical assessment of dysphagia by a speech pathologist involves the integration of information relating to: the client's medical condition and medical complexity; observations of client communication, cognition and behaviour as it relates to swallowing safety; anatomical and physiological assessment of sensory and motor function, and formal feeding/swallowing assessment. The clinical assessment culminates in decisions regarding diagnosis, severity, requirement for further medical investigations, treatment planning, referrals to other health professionals and development of a management plan of food and liquid textures that are safe for that client.

Who can conduct dysphagia screening?

Dysphagia screening should generally only be undertaken by speech pathologists. In some circumstances, it may be appropriate for individuals who have been trained by a speech pathologist to use a validated screening tool to perform dysphagia screening. It should be noted that training and supervision of non-speech pathology staff needs to be regular and repeated to maintain competence and minimise risk. However, if dysphagia screening is performed by a person who is not a speech pathologist, this does not relieve a speech pathologist of their professional duty to properly assess, diagnose and treat a client’s dysphagia condition.

For more information about the delegation of tasks to speech pathology support personnel please refer to SPA’s Parameters of Practice Guideline (2007).

Is there a recognised dysphagia screening tool?

There is no one validated and recognised dysphagia screening tool. For more information about available screening tools, including descriptions of a number of tools, refer to SPA’s Dysphagia Clinical Guideline, 2012.

What happens if a dysphagia screening tool suggests a client may suffer from dysphagia?

If a swallow or dysphagia screen suggests a client may suffer from dysphagia, an appropriate course of action would be for a speech pathologist to perform a clinical assessment and, where necessary, an oral/feeding trial. The speech pathologist should determine whether an instrumental assessment is indicated to support appropriate management. SPA believes the value of a clinical assessment of dysphagia should not be underestimated. It is the platform upon which further clinical decision-making is based.

Who can conduct a clinical assessment of dysphagia?

SPA’s position is that due to the complex nature of the clinical assessment of dysphagia and the specialised training that speech pathologists receive, (it is a core element of speech pathology training in the assessment of clients with swallowing disorders (CBOS, 2011)), a speech pathologist must conduct the clinical assessment of dysphagia.

What other factors need to be considered by speech pathologists or facilities providing dysphagia management?

SPA suggests that the following issues should be considered in dysphagia management.

Risk management

The management of dysphagia by speech pathologists is one of the most complex fields of speech pathology practice often involving the interaction of anatomical and physiological factors. The mismanagement of dysphagia has the potential to cause significant harm, including death (Threats, 2007). Speech pathologists that provide dysphagia management (and clinics or health services which allow the use of non-speech pathology staff to conduct dysphagia screening) are advised to work within a risk management framework where potential risks to the client are evaluated throughout the screening, assessment and management process. The risk management framework should include the following:

  • Methods of identifying risks.
  • Analysis of the impact of identified risks in terms of prevalence and consequences.
  • Development of strategies to minimise the likelihood of the risk events occurring and consequences associated with the risks.
  • Implementation of risk reduction strategies.
  • On-going evaluation of the effectiveness of the risk management plan.

Policies and procedures

The development of quality policies and procedures should be governed by best available evidence.

Speech pathologists and clinics and health services should ensure that policies are in place for the management of foreign body obstruction and the provision of texture modified foods and liquids. Clinicians should be mindful that texture modified foods, including semi-solids may pose a choking risk (Berzlanovich, Fazeny-Dorner, Waldhoer, Fasching & Keil, 2005), as do solid dose medications (e.g. tablets and capsules). A clinic or facility should have policies in place to address these issues.

Training and supervision

Facilities should ensure adequate guidelines are in place for the appropriate training and supervision of staff (especially non speech pathology staff that are being trained to conduct swallow screening). Training and supervision needs to be conducted by a speech pathologist and be regular and repeated to maintain competence and minimise risk. Speech pathologists should be aware that, generally, they are responsible for the actions of their employees.

For more information about the training and supervision of other health professionals please refer to SPA’s Dysphagia Clinical Guideline, 2012.

Provision of appropriate resources and tools

Speech pathologists and facilities providing dysphagia management should ensure there is access to the appropriate resources and tools. This includes access to validated screening tools and clinical assessment tools and equipment and the provision of appropriate texture modified foods and liquids, dysphagia cups etc. Please note texture modified foods and liquids must meet the requirements of the Australian Standards for Texture-Modified Foods and Thickened Fluids (Dieticians Society of Australia, Speech Pathology Australia; Project Officer: Julie A.Y. Cichero,)

Professional Indemnity Insurance

It is the responsibility of each speech pathologist to ensure they have appropriate professional indemnity and public liability insurance cover. Speech pathologists should be aware that there may be instances where their employing body will not necessarily indemnify them for their actions. It is recommended that all practising Speech Pathology Australia members take out their own professional indemnity insurance.

Palliative care

The goals of palliative care are to improve the quality of life of a client who presents with dysphagia as a consequence of a life-limiting illness. Decisions regarding treatment are best made as part of a consultative and collaborative approach in which the best possible management under the circumstances is provided. This may include goals such as comfort and dignity, and eventually the withholding or withdrawing of treatment (Roe & Leslie, 2010; NSW Department of Health, 2005). Of course, decisions regarding treatment and the withdrawal of treatment must be made in accordance with the client’s wishes and applicable laws. For more information about working with palliative care clients with dysphagia please refer to SPA’s Dysphagia Clinical Guideline 2012.

What should I do if facility staff do not follow my recommendations regarding dysphagia management?

Prior to commencing work at a clinic or health service or providing dysphagia management, a speech pathologist should become familiar with that facility’s policies and procedures regarding dysphagia management. If the speech pathologist does not agree with those policies or procedures, or practices in a way that is inconsistent with those policies and procedures, he or she should raise the issue with his or her employer. While an employee speech pathologist will generally have an obligation to comply with his or her employer’s reasonable directions, this is always subject to the exercise of the speech pathologist’s independent professional judgment and ethical and professional duties.

In circumstances where another staff member of a clinic or health services does not agree with or refuses to follow a speech pathologist’s treatment recommendation, the speech pathologist may have to bring this matter to the attention of the relevant facility’s management.

What should I do if a client/family does not follow my recommendations for dysphagia management?

A client who has the capacity to understand the proposed treatment and to provide consent has the right to refuse treatment or to not follow a speech pathologist’s recommendations.

Where a client does not have the capacity to provide consent (for example, a child or a person with a mental impairment) and someone else is responsible for making treatment decisions for them, that person may similarly refuse treatment on behalf of the client. However, if a speech pathologist believes that such refusal of treatment by that person is not in the client’s best interests or may harm the client, it may be appropriate for the speech pathologist to seek legal advice based on the individual circumstances.

In either case, the speech pathologist should:

  • Assess a client’s capacity to understand the proposed treatment and their capacity to provide informed consent and document that assessment in the client’s file.
  • If another person is making a decision on behalf of a client, document in the client’s file the identity of that person and their authority to make such decision – for example, a parent, a guardian, a person appointed under a medical treatment enduring power of attorney, etc.
  • Discuss all options and associated risks, including the risks of not following the speech pathologist’s recommendations, with the client or the person making decisions for the client.
  • Document in detail the discussion, recommendations and outcomes in the client’s file. This should include details regarding the refusal of treatment and the reasons for such refusal.
  • Where appropriate, put the above matters in writing to the client or the person making decisions for the client.
  • If in doubt as to how to proceed, it may be appropriate for the speech pathologist to seek legal advice.

Where do I obtain legal advice from?

Members that have Professional Indemnity insurance with Guild have access to legal advice through Meridian Lawyers or you can contact the Law Society in your State/Territory as they usually provide a directory of lawyers.

What other resources are available to speech pathologist’s working in the area of dysphagia?

SPA’s Position Paper: Fibreoptic Endoscopic Evaluation of Swallowing (2007)

SPA’s Clinical Guidelines: Videofluoroscopic Swallow Study (2013)

Ageing and Aged Care & Private Practice Member Communities

SPA has an Ageing and Aged Care and a Private Practice Member Community where members can post and discuss issues related to working with clients with dysphagia. For more information go to the SPA Member Communities web page.

Non-Association Special Interest Groups

There are also a number of non-Association Dysphagia Special Interest Groups. For more information go to the Special Interest Groups web page.

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Original April 2014

Disclaimer: To the best of the Speech Pathology Association of Australia Limited’s (“the Association”) knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication.