NPO and patient autonomy

[nikolaite]

Not sure where to post this...the SLP subforum seems to be dead. Part of my job is to scrutinize med records for admissions to research studies. I came across one in a thrombectomy study group that was plain bizarre.

The pt was designated NPO pending procedure upon admission to PCU from ER. Some time after procedure was set to occur, nursing designated pt NPO after reported failed swallow study, no details. Much later family informed nursing that pt was given water when he requested; nursing did not record educating pt or family on NPO. Nursing recorded conducting bedside swallow screen. Pt failed third round; nursing recorded informing family of strict NPO. Hospital policy on NPO in med record denoted allowance for the pt and family to countermand the NPO prior to modified barium swallow. After approx 30 hrs in hospital, pt threatened to AMA if the staff would not feed him. Nursing recorded that there would be a 48 hour more delay for barium study and that they were under orders to give no food or water. Cross covering doc saw pt, but also recorded that the pt would have to wait two days before the barium study before he could be cleared to eat or drink. Pt left AMA.

Have you ever heard of anything like that? It’s new to me. What was the likely reason behind the 48 hour wait on the modified barium swallow study? Should patient autonomy be respected, especially in light of hospital policy?

---

Members don't see this ad.

 

[Crayola227]

Not sure where to post this...the SLP subforum seems to be dead. Part of my job is to scrutinize med records for admissions to research studies. I came across one in a thrombectomy study group that was plain bizarre.

The pt was designated NPO pending procedure upon admission to PCU from ER. Some time after procedure was set to occur, nursing designated pt NPO after reported failed swallow study, no details. Much later family informed nursing that pt was given water when he requested; nursing did not record educating pt or family on NPO. Nursing recorded conducting bedside swallow screen. Pt failed third round; nursing recorded informing family of strict NPO. Hospital policy on NPO in med record denoted allowance for the pt and family to countermand the NPO prior to modified barium swallow. After approx 30 hrs in hospital, pt threatened to AMA if the staff would not feed him. Nursing recorded that there would be a 48 hour more delay for barium study and that they were under orders to give no food or water. Cross covering doc saw pt, but also recorded that the pt would have to wait two days before the barium study before he could be cleared to eat or drink. Pt left AMA.

Have you ever heard of anything like that? It’s new to me. What was the likely reason behind the 48 hour wait on the modified barium swallow study? Should patient autonomy be respected, especially in light of hospital policy?

Wow there's a lot to unpack here. I will point out that patient autonomy was absolutely respected in this case though. Respecting patient autonomy doesn't mean you have to give them food or water to choke on or tell them it's safe to eat or drink. And no one stopped the patient from leaving AMA.

I always point out to patients that ultimately we don't "make them do" anything. But they come to us with a problem and ask for solutions. They don't have to take those solutions, but that's what we have to offer. If they want to walk out of the hospital right now, they certainly can and I can't stop them. If I'm seem like I'm trying to stop them, it's because I can imagine what will happen if they don't take my advice and I honestly don't think it's anything they would want to have happen.

OTOH, when they *literally* can't check themselves out AMA without assistance, they point this out and it hurts my little speech. But in that case, I point out that maybe the fact you can't even take yourself out of this bed or you'd have to crawl beyond the hospital doors where you would likely collapse, is a sign you need to be here. And that's not my fault, that's your body. Which is what I'm trying to help with.

It's essential everyone reorient themselves to this reality now and again. The power dynamic, loss of control due to illness, and the fact that the typical order of things is patient/family looking to you to call the shots, can make people easily lose sight of *why* they called you in and they have felt forced to do as you say.

People also get funny about what they think you are compelled to do in your role as a healthcare provider. It isn't to do whatever they think makes them feel better, that isn't synonymous with actually addressing issues for the long term and do no harm. So getting people to understand is all part of the therapeutic alliance.

In a similar situation it has come down to saying, well, OK, maybe you'd rather die than be NPO. But then we can't bring you in, feed you, give you pneumonia, and then try to cure the pneumonia while feeding you. Well, we can but I digress, the reality is they can usually understand why this is what you're trying to avoid, the logic usually computes well enough. Palliative is often where goals of care need to be hashed out. In some situations maybe hospice needs to be considered.

 

[nikolaite]

Thanks for the reply. I was really wondering about the barium swallow lag. I have never heard about a pt being considered a high aspiration risk not getting SLP consult and barium swallow within hours of designation. My experience was that within 24 hours of admission, an NPO pt either had a PEG or NG tube placed, or some other notes in the chart saying why this wasn’t possible. Nursing noted the family asked for NG tube to keep the pt from AMA. CC doc also noted request. No notes as to why this could not be done.

I am not suggesting a high asp pt be given a regular hospital meal.

 

[Crayola227]

Thanks for the reply. I was really wondering about the barium swallow lag. I have never heard about a pt being considered a high aspiration risk not getting SLP consult and barium swallow within hours of designation. My experience was that within 24 hours of admission, an NPO pt either had a PEG or NG tube placed, or some other notes in the chart saying why this wasn’t possible. Nursing noted the family asked for NG tube to keep the pt from AMA. CC doc also noted request. No notes as to why this could not be done.

I am not suggesting a high asp pt be given a regular hospital meal.

A few things here. Yes, I have seen it take that long. I have no real great idea why the delay, I imagine like anything like that, if it isn't life threatening with delay then there can be a delay in a hospital service depending on coverage and patient load.

The thing is, no patient on IV fluids is going to die from being NPO for two days pending the barium swallow. The other thing is, I highly doubt that the swallow study was going to drastically change management and afterwards the patient was going to get to eat. I mean, it does as far as they probably needed to get it done before they would be able to justify placing a PEG tube or something like that. But I rarely see a patient fail a bedside swallow, get a barium swallow, and then return to any amount of meaningful PO intake, depending on the whole picture and how much their swallowing is really tied to some very acute issue they are being hospitalized for and can get better as they are treated.

Lastly, is that for patients already accustomed to eating, an NG tube or PEG feedings doesn't actually do much for the subjective sense of hunger and desire to eat. Nutritionally it can make a big difference, even by a matter of days. First thing I learned about these kind of feedings. Because I too because of patient distress felt antsy about needing to place these things so a patient would feel better. But it does not work like that oddly enough.

It sucks to feel like you've got days of NPO and days of a wait to feel like your care is advancing, but there's no disrespect to patient autonomy here, and no medical reason why being 2 days NPO waiting for a swallow study is anything much more than uncomfortable. And having placed an NG or PEG or something earlier wouldn't do much for a patient missing PO except possibly be a psychological comfort. There's a nutritional argument to be made in all this. But sometimes things in the hospital take the time they take.

 

[nikolaite]

Thank you for answering. To clarify: when I asked my question about patient autonomy, I considering anti-dumping laws. I wasn't trying to suggest that letting a compos mentis patient AMA is not respecting his autonomy.

Consider, for example, that this patient was not brought to the ER voluntarily, had emergency med condition, was not admitted to the PCU voluntarily, was altered LOC for much of his stay, was admitted and worked on without family knowledge or consent, had not reached stable vitals, etc.. I know this is added info over my original post, but in that example, can a doc even allow a patient to leave legally? Does the patient have autonomy? Is it actually a respect of autonomy to let him leave?

I hear you about the subjective side of hunger. I pulled the followups on this patient, and found that he was evaluated shortly after AMA by outpatient SLP. SLP designated him high asp risk and recommended strict NPO, but patient never received barium swallow. I'm elaborating because I find this an interesting bizarre case. Oddly enough, patient reported to his neuro he had been eating and drinking. Outpatient neuro followup pointed out that severe swallow deficit in PCU was likely due to the approx 16 mg lorazepam he'd been dosed with over the 6 hours he spent in the ER prior to PCU admit. No aspiration pneumonia in his record over a year. Also interesting to find that ER did not send MAR with patient to PCU. I'm guessing the PCU team didn't know about the lorazepam, since it appears nowhere in his PCU MAR as a reference.

 

[NotAProgDirector]

The most common reason for a 48 hour delay for an MBS where I work? Friday. If ordered on a Friday and doesn't get done, we don't do them on the weekend. So it waits until Monday.

You've now added more details which make things more complicated. You ask if the patient has "autonomy". What you actually are talking about is "capacity". Does this patient understand the consequences of their decisions - that's what we need to know. Patients are allowed to make bad decisions They are allowed to make stupid decisions. As long as you are certain that they understand the issues, and the consequences of those actions.

In this case, its possible the patient might be better served by the team being flexible. Nursing evaluated the patient and feels they are high risk to aspirate. Perhaps this is their baseline. Perhaps it's something new. The docs should assess the situation. NPO and an MBS are the "best" plan. But what if this is chronic? And they "fail" their MBS. Are we going to put a PEG in and tell them they can't eat for the rest of their life? Or are we going to let them eat and see what happens?

If the patient had capacity, I'd consider allowing them to eat some limited options as long as they understood the risks. Find a diet that's lower risk to aspirate (mechanical soft -- pureed diets are horrible). Make sure he's sitting up when drinking. Negotiate a solution with limited PO intake. Letting him leave AMA, if he's still recovering from the procedure, seems like a big loss. If the only thing keeping him in the hospital is the swallow issue, and he says he's never getting a PEG, then why bother with all this? in fact, probably better to allow him to eat in the hospital so you can observe. High risk to aspirate doesn't mean he will actually aspirate.

Patients leaving AMA doesn't let docs off the hook. Them signing a form does absolutely nothing. In fact, it may increase litigation since the patient gets all angry. Solving problems like this is hard -- you end up negotiating with the patient AND the nurses. Nursing will start talking about policies and what not, you need to be the voice of reason.

There are limits, of course. Patient behavior / decisions that put hospital employees or other patients at risk are not tolerated. Racist / sexist / hate type speech is also not tolerated, although is much harder to enforce.

 

[nikolaite]

The most common reason for a 48 hour delay for an MBS where I work? Friday. If ordered on a Friday and doesn't get done, we don't do them on the weekend. So it waits until Monday.

You've now added more details which make things more complicated. You ask if the patient has "autonomy". What you actually are talking about is "capacity". Does this patient understand the consequences of their decisions - that's what we need to know. Patients are allowed to make bad decisions They are allowed to make stupid decisions. As long as you are certain that they understand the issues, and the consequences of those actions.

In this case, its possible the patient might be better served by the team being flexible. Nursing evaluated the patient and feels they are high risk to aspirate. Perhaps this is their baseline. Perhaps it's something new. The docs should assess the situation. NPO and an MBS are the "best" plan. But what if this is chronic? And they "fail" their MBS. Are we going to put a PEG in and tell them they can't eat for the rest of their life? Or are we going to let them eat and see what happens?

If the patient had capacity, I'd consider allowing them to eat some limited options as long as they understood the risks. Find a diet that's lower risk to aspirate (mechanical soft -- pureed diets are horrible). Make sure he's sitting up when drinking. Negotiate a solution with limited PO intake. Letting him leave AMA, if he's still recovering from the procedure, seems like a big loss. If the only thing keeping him in the hospital is the swallow issue, and he says he's never getting a PEG, then why bother with all this? in fact, probably better to allow him to eat in the hospital so you can observe. High risk to aspirate doesn't mean he will actually aspirate.

Patients leaving AMA doesn't let docs off the hook. Them signing a form does absolutely nothing. In fact, it may increase litigation since the patient gets all angry. Solving problems like this is hard -- you end up negotiating with the patient AND the nurses. Nursing will start talking about policies and what not, you need to be the voice of reason.

There are limits, of course. Patient behavior / decisions that put hospital employees or other patients at risk are not tolerated. Racist / sexist / hate type speech is also not tolerated, although is much harder to enforce.

Thank you for the response and insights. There wasn’t anything recorded in this pt record about disruptive behaviour or hate type speech. I can’t discern any animosity at all between pt, docs and nurses from the record...just the threat that the pt would leave if he didn’t get fed. When the referring specialist sent me this patient’s case it came with what would amount to 200 printed pages of nursing flow sheets, so when I was bored I read the whole thing. The day nurse had two flow sheet entries dealing with assisting the patient to eat and drink should the family countermand NPO before barium swallow. I LOL-ed at one which was part of the pt assessment that occurred maybe like an hour after the patient was recorded to have left.

Sorry for going all TMI on you folks; I spend the day alone reading and can’t really commiserate with anyone on the weird stuff I come across.

 

[Crayola227]

Simply reading cases like these aren't always the best for learning about complex issues that are greatly impacted by interpersonal dynamics. Ultimately it's because you're missing the whole story. This is why medicine has to be taught by actually being a part of patient care live as it happens.

Without knowing more about conversations taking place between the providers and family on rounds, it's very difficult to Monday morning quarterback these. Even when a discussion is well documented, when you are part of the case but then read the documentation you can always see where some of the picture isn't captured.

 

[nikolaite]

Thank you folks so much for replying. I really appreciate your time.