comfort careEver receive those clinical swallow evaluation orders that secretly have a “Show and Tell” motive? You know the ones I am talking about. The order may read “Clinical Swallow Evaluation (and in small print): Please evaluate for PEG.

Please evaluate for PEG? Do I evaluate for PEGs or do I evaluate for PO? Many times early in my career, I would receive various orders such as these and go through the mental battle. However, over time I learned to take an evaluation with such low expectation and turn it into a positive. I learned creative writing. I learned to play the game.

When I arrived outside the patient’s room, I looked for the RN to inform her that I was here for the evaluation. She chuckled with a sigh,“Good Luck.” I looked at the chart. With each passing medical diagnosis, I sighed. I looked at the labs and each had red double exclamation points highlighting the exceeded range. Chest X-Ray included dreadful terms like “whiteout” and “collapse”. Still looking at the chart, I peaked into the patient’s room, which was half open. I could hear gushes of air coming from the room. The chart confirmed, 100% FIO2 via simple mask. I sighed deeply. I glanced again at the top of the chart and was horrified to see in red caps, FULL CODE. Two choices came to mind:

1) I could write a quick note: “Defer”

2) I could turn this situation into a positive, by playing the game.

I walked into the patient room and several family members inquired about my purpose. Before they could turn me away, I involved them in my modified evaluation of their loved one.  This included a gentle wet towel to the forehead, a simplified oral-mechanism exam in combination with oral care and a little squeezed swab of water with light suction. Next, we had a conversation then I left the room.

What, no more detail about the conversation?

Each clinician will have their own way of framing statements to families in these situations. It is an art and we each get better with experience. However, remember that this was an evaluation for a PEG? Was it really that hard for an MD to make the call on this patient? Did the MD really want me to give him PO trials? Was this a game? Was this a game of “Show and Tell Clinical Swallow Evaluation” for documentation purposes? Perhaps the answer is yes to all these questions. One can be sure that my evaluation was not going to focus on the patient’s severe dysphagia and how he had absent hyolaryngeal elevation, therefore justifying a PEG. The details of the conversation I had with the family were not just mentally noted but were highlighted in my documentation. In fact, the conversation I had, was actually more of a one way conversation. I listened. I listened to several family members state their opinion. I heard them talk about what they thought was the loved one’s wishes. I listened to their ethical dilemma and I neatly and creatively captured it in the following:

Impressions: 93 year old male with end stage metastatic lung cancer with multiple medical comorbidities currently requiring high flow O2 support was seen for a clinical swallow evaluation. This evaluation was limited to a modified exam and limited PO trial due to current respiratory status and decreased level of alertness. Given stated medical prognosis and current Full Code status, patient is deemed unsafe for PO. Multiple family members were present and we discussed rationale for evaluation at this time. Family had multiple questions about risk and benefits of alternative options given patient prognosis.

Recommendations: Uncertain at this time regarding patient and family goals for nutrition. Consider level of comfort care if deemed within medical plan of care and in line with patient wishes.

Creative writing? Well, it may be a little. However, this was a scenario where I turned an automatic “fail” into an open discussion to talk about code status, patient wishes and realistic options. I made sure not to inject my self too much as a decision maker, but rather a facilitator of the discussion. In this case, the patient was removed from full code and taken home on hospice and essentially comfort care.

Remember, I had two choices when I approached this evaluation. Walk away and defer or evaluate the patient for PEG. Well, in this scenario, I evaluated the patient and family for best practice. I evaluated the patient for comfort care. I evaluated the patient to possibly influence code status. This may be a gray area, and I do not recommend it in all situations. However, I found it necessary to provide clinical skill and value to this otherwise unfortunate situation. Did I play the game and evaluate for a PEG? I did, sorta : ) As a result, I see fewer and fewer Clinical Swallow Evaluation orders that include small print.

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