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<\/a>![\"\"](\"https:\/\/blogs.bmj.com\/spcare\/files\/2022\/11\/Alan.jpg\")
<\/a><\/p>\n\u201cI don\u2019t want thickener!\u201d, \u201cI want to eat it, not down my RIG\u201d or most commonly \u201cI want my roast dinner and all the trimmings, not smooshed!\u201d Sound familiar?<\/p>\n
There has been an ongoing debate in our hospice. What was once easily swallowed has become harder to get your mouth around. \u00a0A \u2018risk feeding\u2019 MDT form has been created for our patients. The form outlines and quantifies (as much as able) the risk and then ask the patient (or in their lack of capacity the family) to sign. Especially if the patient is not compliant with recommendations and wishes to have a bacon butty.<\/p>\n
Is this a compassionate way of allowing patients to have their wishes while simultaneously protecting the staff should anything go wrong?<\/p>\n
Let\u2019s dig right into this juicy medium rare steak of a topic.<\/p>\n
The assessment of the patient, the grading of the requirement, is commonly done by the excellent speech and language specialists, aptly named \u2018SaLT\u2019 adding to the zest and flavour of their role, or maybe a preservative of life?<\/p>\n
The often touted MDT decision, however, when the patient disagrees with the recommendation, is often less \u2018MDT\u2019 as more \u2018doctor you can override my recommendations\u2019, a technician of risk stratification. A condiment in the decision making process.<\/p>\n
And I understand their reluctance, the responsibility shouldn\u2019t hold with one aspect of the MDT. I repeat, it shouldn\u2019t hold with one aspect of the MDT.<\/p>\n
So a meal was cooked, chewed and consumed by the whole MDT whilst discussing what solution was best, and surprised by our own ingenuity, a novel idea was contrived, (another) form was made. This magical piece of paper protecting both the pillars of governance and best practice. Alas, this created more questions than answers.<\/p>\n
Such as what is the definition of \u2018at risk feeding\u2019? Like how to heat milk, no-one knows. Are we not all at risk of choking? Where is the line of choking acceptability? Even if someone drinks hot coffee slush puppies are they not still at risk to some degree? If so do we enforce it with the same vigour?<\/p>\n However, the most contentious debate centred around the signature. Should we have a patient or family (if patient has no capacity) sign to allow \u2018risk feeding\u2019? – whatever that is?<\/p>\n Frankly, this is nuts (and nuts are a choking hazard). This inadvertently puts pressure on the patient and family. Indeed, if the patient is very compliant, such as Mrs Betty Agreeable, who thanks me again and again irrespective of the inordinate amount of horrible procedures we have done to her, she will always agree, never daring to be non-compliant with the nice healthcare staff. She fears the potential, thus never more will she get her desired roast Turkey at Christmas.\u00a0 If they do sign, thus taking all responsibility, and unfortunately they do choke, it wholly lies on themselves or their family, leaving guilt and regret in the wake \u2013 \u2018I should have taken that advice\u2019.<\/p>\n As healthcare professionals if we do this, it feels as if we are \u2018washing our hands\u2019 of any responsibility, on your head be it.<\/p>\n This issue of getting the patient to \u2018sign\u2019 has already been suggested for other documentation, such as \u2018risk of falls\u2019 and \u2018risk of pressure sores\u2019. Therefore we have to think very carefully. Where does patient consent versus medical responsibility begin and end?<\/p>\n So what should we do? <\/strong><\/p>\n According to the \u2018Equality and Human Rights Commission\u2019: 1<\/sup><\/p>\n \u201c- that the right to adequate food should \u2018not be interpreted in a narrow or restrictive sense which equates it with a minimum package of calories, proteins and other specific nutrients\u2019, but implies it should be:<\/em><\/p>\n Our \u2018Human Rights\u2019 do not mention modality of food, i.e. via RIG or PEG or even thickened, but, it is a \u2018Right of adequate food and water\u2019.<\/p>\n What about signatures?<\/strong><\/p>\n A legal definition of a signature always pertains to forming contracts. The legality website defines it as such: 2<\/sup><\/p>\n \u00a0<\/em>\u201cA signature conveys:<\/em><\/p>\n Okay, but what about our immediate practice in medicine of obtaining consent prior to surgery. The GMC outlines in \u2018Decision making and Consent\u2019 3<\/sup> document in the section \u2018taking a proportionate approach\u2019. This outlines most interventions do not need a signature and verbal consent is adequate.<\/p>\n Indeed, obtaining a signature prior to a procedure or surgery is understanding the risks of medicine doing something to you, that something the doctor doesn\u2019t have to offer if inappropriate. As per our Human Rights however, we can NEVER refuse to give food and water.<\/p>\n I worry that in creating a signature and thus contract regarding food and water, we abandon our patients in an unsupported risk averse way. This is neither compassionate nor co-operative.<\/p>\n Do we have a solution?<\/strong><\/p>\n Nope. Below are some appendices of us attempting to outline our thoughts. But we are left with a unsavoury taste in our mouths and a whole bunch of questions.<\/p>\n Given swallowing difficulties are part of normal dying are we over-medicalising dying? Is this a legalistic influx into healthcare? But what legal protection is there for staff if a patient chokes after expressing their wishes to suck humbugs and the family complains? Does feeding via RIG\/PEG neglect the need for an oral route and we can refuse to give oral food? Or does the Human Rights intervene? Indeed, is it ethical to refuse food in any circumstances? What about in the dementia patients? What are the consequences for other similar risk areas, falls, pressure sores etc. Do they need signatures? Indeed, why don\u2019t we get the patient to sign DNACPR forms? What about time as a factor, lower risk with high consequences over a longer period compared to a shorter time period and lower risk? Indeed, all aspects of managing uncertainty. And thus who, or what team takes overall direction on this? The assessors are the most close understanders of the risk, but how to make it a cohesive MDT decision?<\/p>\n What is certain is this issue is no gag.<\/p>\n<\/a>
\nMatt cooking dangerously, taking whisks.<\/em><\/p>\n\n
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Appendix 1<\/strong><\/h6>\n
HOW DO WE MANAGE PATIENTS WHO HAVE CAPACITY AND WHO CHOOSE NOT TO FOLLOW HEALTH PROFESSIONAL ADVICE
\n<\/strong><\/a><\/h6>\nAppendix 2<\/strong><\/h6>\n