Hi! I have questions regarding my company's dysphagia waiver. I recently began working in a long term acute care hospital. Here, if a person chooses to go against the safest recommendation of the speech therapist, they must sign a dysphagia waiver. The waiver states that hospital staff will no longer be responsible for any PO intake. If pt is unable to feed themselves, family is responsible for ordering trays from the cafeteria and administering any and all PO intake. This applies to everyone, from a noncompliant patient that is refusing thickened liquids s/p aspiration of thin consistencies during MBSS to dementia patients that are unable to feed themselves, demonstrate s/s of aspiration, but family and/or patient has decided against any type of alternative route. I understand that it is all about liability, but I have never utilized a dysphagia waiver that will not allow hospital employees to feed the patient after the waiver is in place. What types of waivers are you guys!
working , or what's the real legality of this issue? Thank you for any input you can provide!
_______________________________________________
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Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
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)
We previously had a waiver form, but it wasn't so stringent as to require family to order food and feed the patient. Risk management has altered the procedure for us, ensuring that clear documentation is sufficient. Now I am able to liberate diets based on patient request and I just add a note in the MD order form to refer to my documentation in the rehab section of the chart. You would need to document why the prescribed diet is indicated, what foods/liquids the patient is desiring, and that the patient and family have been informed of the risks associated with the decision and that the risks have been explicitly expounded upon.
I would go through the proper channels (Rehab Director, Sr. Management, Risk Management) if you feel that a change needs to be made. Our organization felt that the waiver form was a bit pressurizing, and created guilt and undue anxiety in the patient/families.
Shadd LaGrandeur, M.A., CCC-SLP
Program Coordinator
LRGH Speech Pathology
85 Spring Street
Laconia NH 03246
603.527.2888
-----Original Message-----
From: dysphagia- [mailto:dysphagia-] On Behalf Of Sarah Handley
Sent: Monday, June 06, 2011 4:21 PM
To:
Subject: [Dysphagia] Dysphagia Waiver
Hi! I have questions regarding my company's dysphagia waiver. I recently began working in a long term acute care hospital. Here, if a person chooses to go against the safest recommendation of the speech therapist, they must sign a dysphagia waiver. The waiver states that hospital staff will no longer be responsible for any PO intake. If pt is unable to feed themselves, family is responsible for ordering trays from the cafeteria and administering any and all PO intake. This applies to everyone, from a noncompliant patient that is refusing thickened liquids s/p aspiration of thin consistencies during MBSS to dementia patients that are unable to feed themselves, demonstrate s/s of aspiration, but family and/or patient has decided against any type of alternative route. I understand that it is all about liability, but I have never utilized a dysphagia waiver that will not allow hospital employees to feed the patient after the waiver is in place. What types of waivers are you guys!
working , or what's the real legality of this issue? Thank you for any input you can provide!
_______________________________________________
Dysphagia mail list: Normal and disordered swallowing information
Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
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THIS MESSAGE IS CONFIDENTIAL.
This e-mail message and any attachments are proprietary and confidential information intended only for the use of the recipient(s) named above. If you are not the intended recipient, you may not print,distribute, or copy this message or any attachments. If you have received this communication in error, please notify the sender by return e-mail and delete this message and any attachments from your computer. Any views or opinions expressed are solely those of the author and do not necessarily represent those of LRGHealthcare.
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Hello all
I'm very interested in this, since the hospital I was involved with in the past had their
attorneys look at a waiver. They suggested that although it would be
good to have on file, that legally, the waiver would not eliminate the
hospital's liability for an unfortunate outcome. Have there been other more
recent interpretations?
Cynthia Barnett
M.A.,CCC,SLP, BRS-S
-----Original Message-----
From: LaGrandeur, Shadd <>
To: Sarah Handley <>; <>
Sent: Tue, Jun 7, 2011 7:40 am
Subject: Re: [Dysphagia] Dysphagia Waiver
We previously had a waiver form, but it wasn't so stringent as to require family
o order food and feed the patient. Risk management has altered the procedure
or us, ensuring that clear documentation is sufficient. Now I am able to
iberate diets based on patient request and I just add a note in the MD order
orm to refer to my documentation in the rehab section of the chart. You would
eed to document why the prescribed diet is indicated, what foods/liquids the
atient is desiring, and that the patient and family have been informed of the
isks associated with the decision and that the risks have been explicitly
xpounded upon.
I would go through the proper channels (Rehab Director, Sr. Management, Risk
anagement) if you feel that a change needs to be made. Our organization felt
hat the waiver form was a bit pressurizing, and created guilt and undue anxiety
n the patient/families.
Shadd LaGrandeur, M.A., CCC-SLP
rogram Coordinator
RGH Speech Pathology
5 Spring Street
aconia NH 03246
03.527.2888
-----Original Message-----
rom: dysphagia- [mailto:dysphagia-]
n Behalf Of Sarah Handley
ent: Monday, June 06, 2011 4:21 PM
o:
ubject: [Dysphagia] Dysphagia Waiver
Hi! I have questions regarding my company's dysphagia waiver. I recently began
orking in a long term acute care hospital. Here, if a person chooses to go
gainst the safest recommendation of the speech therapist, they must sign a
ysphagia waiver. The waiver states that hospital staff will no longer be
esponsible for any PO intake. If pt is unable to feed themselves, family is
esponsible for ordering trays from the cafeteria and administering any and all
O intake. This applies to everyone, from a noncompliant patient that is
efusing thickened liquids s/p aspiration of thin consistencies during MBSS to
ementia patients that are unable to feed themselves, demonstrate s/s of
spiration, but family and/or patient has decided against any type of
lternative route. I understand that it is all about liability, but I have never
tilized a dysphagia waiver that will not allow hospital employees to feed the
atient after the waiver is in place. What types of waivers are you guys!
working , or what's the real legality of this issue? Thank you for any input
ou can provide!
______________________________________________
ysphagia mail list: Normal and disordered swallowing information
anage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
isit the new Dysphagia Web Forum: http://dysphagia.com/forum
HIS MESSAGE IS CONFIDENTIAL.
his e-mail message and any attachments are proprietary and confidential
nformation intended only for the use of the recipient(s) named above. If you
re not the intended recipient, you may not print,distribute, or copy this
essage or any attachments. If you have received this communication in error,
lease notify the sender by return e-mail and delete this message and any
ttachments from your computer. Any views or opinions expressed are solely those
f the author and do not necessarily represent those of LRGHealthcare.
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This is a very important topic to discuss. I believe that a dysphagia waiver could actually place a facility at increased risk of liability not necessarily due to poor outcome but may actually may due to violation of the "Patient Self Determination act of 1990". I have included the following abstract.
During a discussion on ethics and the need to have a waiver due to
a patients desire not to agree to recommendations (I prefer not to use the term "noncompliant") having a patient sign a waiver could be seen as an attempt to coerce a particular recommendation upon a patient.
I have also recommended to SLP's that if they are uncomfortable with a patient who does not wish to follow recommendations such as thickened liquids (which its use is a whole nother topic) they should attempt to recommend an SLP who is comfortable.
The Patient Self-Determination Act and public assessment of end-of-life technology.
Heitman E; International Society of Technology Assessment in Health Care. Meeting.
Abstr Int Soc Technol Assess Health Care Meet. 1992; 10.
University of Texas, Health Science Center, Houston 77225.
On December 1, 1991, the federal Patient Self-Determination Act (PSDA) took effect across the United States, requiring health care institutions to ask all adults admitted as inpatients whether they have an advanced directive and to inform them of their right to refuse treatment. Institutions failing to meet the new federal standards risk losing Medicare and Medicaid funds. The law has three primary purposes: 1) to educate the public about state laws governing the refusal, withholding, and withdrawal of treatment at the end of life; 2) to encourage wider use of advanced directives to prevent the uncertainty among doctors and family members that often leads to prolonged treatment of the dying, and in some cases to lengthy court battles; and 3) to reduce the costs of treatment at the end of life by reducing unwanted and unnecessary intervention and the perceived need for defensive medicine. The PSDA and advanced directive statutes assume that lay people want, need, and can appr!
eciate information about medical technologic intervention. It further assumes that health professionals and institutions will respect those decisions. While U.S. experience with informed consent and more recently with advance directives confirms this assumption generally, it also suggests that implementation of the PSDA may fall short of congressional intentions. This paper reviews the history and goals of the PSDA as a response to conflicting views of technological intervention at the end of life, examines the available data on the actual use of advance directives in the United States, and discusses the limitations of the PSDA and state legislation at the end of life.
So I guess I sympathize with you on requiring a waiver and requiring family members to feed their loved one. This, in my opinion, puts undo burden on the patient and family.
Ron Hankins
Ron Hankins, M.,A., CCC-SLP
Speech Language Pathologist
Banner Good Samaritan Medical Center
Neuroscience Clinics
(602) 839-4150
Confidentiality Notice: This e-mail is intended only for the person(s) to whom it is addressed and may contain information that is confidential, proprietary, privileged or otherwise protected from disclosure. If you are not an intended recipient, please (i) do not read, copy or use this communication, or disclose it to others, (ii) notify the sender immediately by replying to the message, and (iii) delete the e-mail from your system. Thank you.
-----Original Message-----
From: dysphagia- [mailto:dysphagia-] On Behalf Of Sarah Handley
Sent: Monday, June 06, 2011 1:21 PM
To:
Subject: [Dysphagia] Dysphagia Waiver
Hi! I have questions regarding my company's dysphagia waiver. I recently began working in a long term acute care hospital. Here, if a person chooses to go against the safest recommendation of the speech therapist, they must sign a dysphagia waiver. The waiver states that hospital staff will no longer be responsible for any PO intake. If pt is unable to feed themselves, family is responsible for ordering trays from the cafeteria and administering any and all PO intake. This applies to everyone, from a noncompliant patient that is refusing thickened liquids s/p aspiration of thin consistencies during MBSS to dementia patients that are unable to feed themselves, demonstrate s/s of aspiration, but family and/or patient has decided against any type of alternative route. I understand that it is all about liability, but I have never utilized a dysphagia waiver that will not allow hospital employees to feed the patient after the waiver is in place. What types of waivers are you guys!
working , or what's the real legality of this issue? Thank you for any input you can provide!
_______________________________________________
Dysphagia mail list: Normal and disordered swallowing information
Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
_______________________________________________
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)
Why can't, as with other patient determination issues like this, the patient's decision be noted in the patient chart by the attending physician and nursing or other appropriate staff? This happens routinely when the patient or surrogate declines procedures or meds invoking his/her autonomy and decision-making rights. We respect his/her decision and note that in the chart. He/she do not need to waive treatment recommendations they can just assert his/her rights I believe.
It is like writing a hospital policy....adding more details and processes often inadvertently result in increased legal and liability exposure.
Bill
Bill Connors
800 Vinial Street, B-408
Pittsburgh, PA 15212
724.494.2534
www.aphasiatoolbox.com
http://aphasiatoolbox.com/calendar/calendar.htm
PRIVILEGED AND CONFIDENTIAL This communication, including attachments, is for the exclusive use of the addressee and may contain proprietary, confidential and/or privileged information. If you are not the intended recipient, any use, copy, disclosure, dissemination or distribution is strictly prohibited. If you are not the intended recipient or received this e-mail in error, please notify the sender immediately by telephone at 724-494-2534 and destroy this communication and all copies.
On Jun 7, 2011, at 10:58 AM, Hankins, Ron wrote:
> This is a very important topic to discuss. I believe that a dysphagia waiver could actually place a facility at increased risk of liability not necessarily due to poor outcome but may actually may due to violation of the "Patient Self Determination act of 1990". I have included the following abstract.
> During a discussion on ethics and the need to have a waiver due to
> a patients desire not to agree to recommendations (I prefer not to use the term "noncompliant") having a patient sign a waiver could be seen as an attempt to coerce a particular recommendation upon a patient.
> I have also recommended to SLP's that if they are uncomfortable with a patient who does not wish to follow recommendations such as thickened liquids (which its use is a whole nother topic) they should attempt to recommend an SLP who is comfortable.
>
>
> The Patient Self-Determination Act and public assessment of end-of-life technology.
>
> Heitman E; International Society of Technology Assessment in Health Care. Meeting.
>
> Abstr Int Soc Technol Assess Health Care Meet. 1992; 10.
> University of Texas, Health Science Center, Houston 77225.
>
> On December 1, 1991, the federal Patient Self-Determination Act (PSDA) took effect across the United States, requiring health care institutions to ask all adults admitted as inpatients whether they have an advanced directive and to inform them of their right to refuse treatment. Institutions failing to meet the new federal standards risk losing Medicare and Medicaid funds. The law has three primary purposes: 1) to educate the public about state laws governing the refusal, withholding, and withdrawal of treatment at the end of life; 2) to encourage wider use of advanced directives to prevent the uncertainty among doctors and family members that often leads to prolonged treatment of the dying, and in some cases to lengthy court battles; and 3) to reduce the costs of treatment at the end of life by reducing unwanted and unnecessary intervention and the perceived need for defensive medicine. The PSDA and advanced directive statutes assume that lay people want, need, and can ap!
pr!
> eciate information about medical technologic intervention. It further assumes that health professionals and institutions will respect those decisions. While U.S. experience with informed consent and more recently with advance directives confirms this assumption generally, it also suggests that implementation of the PSDA may fall short of congressional intentions. This paper reviews the history and goals of the PSDA as a response to conflicting views of technological intervention at the end of life, examines the available data on the actual use of advance directives in the United States, and discusses the limitations of the PSDA and state legislation at the end of life.
> So I guess I sympathize with you on requiring a waiver and requiring family members to feed their loved one. This, in my opinion, puts undo burden on the patient and family.
>
> Ron Hankins
>
>
> Ron Hankins, M.,A., CCC-SLP
>
> Speech Language Pathologist
>
> Banner Good Samaritan Medical Center
>
> Neuroscience Clinics
>
> (602) 839-4150
>
>
>
> Confidentiality Notice: This e-mail is intended only for the person(s) to whom it is addressed and may contain information that is confidential, proprietary, privileged or otherwise protected from disclosure. If you are not an intended recipient, please (i) do not read, copy or use this communication, or disclose it to others, (ii) notify the sender immediately by replying to the message, and (iii) delete the e-mail from your system. Thank you.
>
> -----Original Message-----
> From: dysphagia- [mailto:dysphagia-] On Behalf Of Sarah Handley
> Sent: Monday, June 06, 2011 1:21 PM
> To:
> Subject: [Dysphagia] Dysphagia Waiver
>
>
>
> Hi! I have questions regarding my company's dysphagia waiver. I recently began working in a long term acute care hospital. Here, if a person chooses to go against the safest recommendation of the speech therapist, they must sign a dysphagia waiver. The waiver states that hospital staff will no longer be responsible for any PO intake. If pt is unable to feed themselves, family is responsible for ordering trays from the cafeteria and administering any and all PO intake. This applies to everyone, from a noncompliant patient that is refusing thickened liquids s/p aspiration of thin consistencies during MBSS to dementia patients that are unable to feed themselves, demonstrate s/s of aspiration, but family and/or patient has decided against any type of alternative route. I understand that it is all about liability, but I have never utilized a dysphagia waiver that will not allow hospital employees to feed the patient after the waiver is in place. What types of waivers are you gu!
ys!
>
> working , or what's the real legality of this issue? Thank you for any input you can provide!
>
>
>
>
>
>
>
>
>
>
>
>
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
>
> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
>
> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
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)
Thank you for bringing up this important topic. What a horrible situation
for all concerned. Particular thanks to Ron Hankins for pointing us to the
Patient Self Determination Act.
My colleague Paula Leslie, PhD and I prepared a little paper on the topic of
practicing "undefensively" recently, and Dr. Leslie has spoken on this topic
to various audiences. Conceptually, what you describe is precisely the
attitude we hope to change among health care practitioners. For those of you
who are members of ASHA's SIG 15 Gerontology, please take a look at the
paper and let me know if you have any questions about our thoughts there.
Here is the abstract and citation (sorry, I cannot post copies to the list
as the publication is copyrighted):
How To Practice "Undefensively"
Perspectives on Gerontology 15 54-64 December 2010.
doi:10.1044/gero15.2.54
Abstract
*Speech-language pathologists (SLPs) are increasingly challenged by the
medical complexities our patients present and gripped by the fear of
litigation if patients decline physically under our care. One response to
these pressures may be to practice defensive medical speech-language
pathology. We propose that best practice is ethically achieved by
deliberately using specific external and internal resources to practice
undefensively. We suggest how consideration of these materials and processes
will help SLPs ensure evaluation and clinical decision-making processes are
as effective, evidence-based, and transparent to patients, caregivers,
administrators, and payers as possible.*
On Mon, Jun 6, 2011 at 4:20 PM, Sarah Handley <>wrote:
>
>
> Hi! I have questions regarding my company's dysphagia waiver. I recently
> began working in a long term acute care hospital. Here, if a person chooses
> to go against the safest recommendation of the speech therapist, they must
> sign a dysphagia waiver. The waiver states that hospital staff will no
> longer be responsible for any PO intake. If pt is unable to feed themselves,
> family is responsible for ordering trays from the cafeteria and
> administering any and all PO intake. This applies to everyone, from a
> noncompliant patient that is refusing thickened liquids s/p aspiration of
> thin consistencies during MBSS to dementia patients that are unable to feed
> themselves, demonstrate s/s of aspiration, but family and/or patient has
> decided against any type of alternative route. I understand that it is all
> about liability, but I have never utilized a dysphagia waiver that will not
> allow hospital employees to feed the patient after the waiver is in place.
> What types of waivers are you guys!
> working , or what's the real legality of this issue? Thank you for any
> input you can provide!
>
>
>
>
>
>
>
>
>
>
>
>
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
>
> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
--
Kate Krival, Ph.D. CCC-SLP
Assistant Professor, Speech Pathology
School of Health Sciences
Kent State University
A148 Music & Speech Bldg
Kent, OH 44242
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)
We really do need to be careful with this that is for certain. Many
facilities believe in waivers, even thou they do not holdup in court. I do
not sign them. In addition to not signing the waivers, the kitchen will
continue to serve the recommended diet. The family and friends will bring
in the food/liquid. This is a very touch situation. If something happens
to a loved one, whether a waiver was signed or not, families still accuse
facilities...this is what I have learned. So, I instruct the kitchen staff
to continue diet as written UNLESS the physician decides to change the
order, but I will not change diet unless I deem it to be safe for
residents.
On 6/7/11 11:16 AM, "William Connors" <> wrote:
>Why can't, as with other patient determination issues like this, the
>patient's decision be noted in the patient chart by the attending
>physician and nursing or other appropriate staff? This happens
>routinely when the patient or surrogate declines procedures or meds
>invoking his/her autonomy and decision-making rights. We respect
>his/her decision and note that in the chart. He/she do not need to waive
>treatment recommendations they can just assert his/her rights I believe.
>
>It is like writing a hospital policy....adding more details and processes
>often inadvertently result in increased legal and liability exposure.
>
>
>Bill
>
>Bill Connors
>800 Vinial Street, B-408
>Pittsburgh, PA 15212
>724.494.2534
>www.aphasiatoolbox.com
>http://aphasiatoolbox.com/calendar/calendar.htm
>
>
>PRIVILEGED AND CONFIDENTIAL This communication, including attachments, is
>for the exclusive use of the addressee and may contain proprietary,
>confidential and/or privileged information. If you are not the intended
>recipient, any use, copy, disclosure, dissemination or distribution is
>strictly prohibited. If you are not the intended recipient or received
>this e-mail in error, please notify the sender immediately by telephone
>at 724-494-2534 and destroy this communication and all copies.
>
>
>
>
>
>
>
>
>
>On Jun 7, 2011, at 10:58 AM, Hankins, Ron wrote:
>
>> This is a very important topic to discuss. I believe that a dysphagia
>>waiver could actually place a facility at increased risk of liability
>>not necessarily due to poor outcome but may actually may due to
>>violation of the "Patient Self Determination act of 1990". I have
>>included the following abstract.
>> During a discussion on ethics and the need to have a waiver due to
>> a patients desire not to agree to recommendations (I prefer not to use
>>the term "noncompliant") having a patient sign a waiver could be seen as
>>an attempt to coerce a particular recommendation upon a patient.
>> I have also recommended to SLP's that if they are uncomfortable with a
>>patient who does not wish to follow recommendations such as thickened
>>liquids (which its use is a whole nother topic) they should attempt to
>>recommend an SLP who is comfortable.
>>
>>
>> The Patient Self-Determination Act and public assessment of end-of-life
>>technology.
>>
>> Heitman E; International Society of Technology Assessment in Health
>>Care. Meeting.
>>
>> Abstr Int Soc Technol Assess Health Care Meet. 1992; 10.
>> University of Texas, Health Science Center, Houston 77225.
>>
>> On December 1, 1991, the federal Patient Self-Determination Act (PSDA)
>>took effect across the United States, requiring health care institutions
>>to ask all adults admitted as inpatients whether they have an advanced
>>directive and to inform them of their right to refuse treatment.
>>Institutions failing to meet the new federal standards risk losing
>>Medicare and Medicaid funds. The law has three primary purposes: 1) to
>>educate the public about state laws governing the refusal, withholding,
>>and withdrawal of treatment at the end of life; 2) to encourage wider
>>use of advanced directives to prevent the uncertainty among doctors and
>>family members that often leads to prolonged treatment of the dying, and
>>in some cases to lengthy court battles; and 3) to reduce the costs of
>>treatment at the end of life by reducing unwanted and unnecessary
>>intervention and the perceived need for defensive medicine. The PSDA and
>>advanced directive statutes assume that lay people want, need, and can
>>ap!
> pr!
>> eciate information about medical technologic intervention. It further
>>assumes that health professionals and institutions will respect those
>>decisions. While U.S. experience with informed consent and more recently
>>with advance directives confirms this assumption generally, it also
>>suggests that implementation of the PSDA may fall short of congressional
>>intentions. This paper reviews the history and goals of the PSDA as a
>>response to conflicting views of technological intervention at the end
>>of life, examines the available data on the actual use of advance
>>directives in the United States, and discusses the limitations of the
>>PSDA and state legislation at the end of life.
>> So I guess I sympathize with you on requiring a waiver and requiring
>>family members to feed their loved one. This, in my opinion, puts undo
>>burden on the patient and family.
>>
>> Ron Hankins
>>
>>
>> Ron Hankins, M.,A., CCC-SLP
>>
>> Speech Language Pathologist
>>
>> Banner Good Samaritan Medical Center
>>
>> Neuroscience Clinics
>>
>> (602) 839-4150
>>
>>
>>
>> Confidentiality Notice: This e-mail is intended only for the person(s)
>>to whom it is addressed and may contain information that is
>>confidential, proprietary, privileged or otherwise protected from
>>disclosure. If you are not an intended recipient, please (i) do not
>>read, copy or use this communication, or disclose it to others, (ii)
>>notify the sender immediately by replying to the message, and (iii)
>>delete the e-mail from your system. Thank you.
>>
>> -----Original Message-----
>> From: dysphagia-
>>[mailto:dysphagia-] On Behalf Of Sarah Handley
>> Sent: Monday, June 06, 2011 1:21 PM
>> To:
>> Subject: [Dysphagia] Dysphagia Waiver
>>
>>
>>
>> Hi! I have questions regarding my company's dysphagia waiver. I
>>recently began working in a long term acute care hospital. Here, if a
>>person chooses to go against the safest recommendation of the speech
>>therapist, they must sign a dysphagia waiver. The waiver states that
>>hospital staff will no longer be responsible for any PO intake. If pt is
>>unable to feed themselves, family is responsible for ordering trays from
>>the cafeteria and administering any and all PO intake. This applies to
>>everyone, from a noncompliant patient that is refusing thickened liquids
>>s/p aspiration of thin consistencies during MBSS to dementia patients
>>that are unable to feed themselves, demonstrate s/s of aspiration, but
>>family and/or patient has decided against any type of alternative route.
>>I understand that it is all about liability, but I have never utilized a
>>dysphagia waiver that will not allow hospital employees to feed the
>>patient after the waiver is in place. What types of waivers are you gu!
> ys!
>>
>> working , or what's the real legality of this issue? Thank you for any
>>input you can provide!
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>> _______________________________________________
>> Dysphagia mail list: Normal and disordered swallowing information
>>
>> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>>
>> _______________________________________________
>> Dysphagia mail list: Normal and disordered swallowing information
>>
>> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>>
>
>
>_______________________________________________
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It is a fundamental human right to accept or refuse any suggested medical treatment. Every physician knows this. All that is required, as Bill says is to note the patient/surrogate's preference.
> From:
> Date: Tue, 7 Jun 2011 11:16:43 -0400
> To:
> CC: ;
> Subject: Re: [Dysphagia] Dysphagia Waiver
>
> Why can't, as with other patient determination issues like this, the patient's decision be noted in the patient chart by the attending physician and nursing or other appropriate staff? This happens routinely when the patient or surrogate declines procedures or meds invoking his/her autonomy and decision-making rights. We respect his/her decision and note that in the chart. He/she do not need to waive treatment recommendations they can just assert his/her rights I believe.
>
> It is like writing a hospital policy....adding more details and processes often inadvertently result in increased legal and liability exposure.
>
>
> Bill
>
> Bill Connors
> 800 Vinial Street, B-408
> Pittsburgh, PA 15212
> 724.494.2534
> www.aphasiatoolbox.com
> http://aphasiatoolbox.com/calendar/calendar.htm
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>
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> On Jun 7, 2011, at 10:58 AM, Hankins, Ron wrote:
>
> > This is a very important topic to discuss. I believe that a dysphagia waiver could actually place a facility at increased risk of liability not necessarily due to poor outcome but may actually may due to violation of the "Patient Self Determination act of 1990". I have included the following abstract.
> > During a discussion on ethics and the need to have a waiver due to
> > a patients desire not to agree to recommendations (I prefer not to use the term "noncompliant") having a patient sign a waiver could be seen as an attempt to coerce a particular recommendation upon a patient.
> > I have also recommended to SLP's that if they are uncomfortable with a patient who does not wish to follow recommendations such as thickened liquids (which its use is a whole nother topic) they should attempt to recommend an SLP who is comfortable.
> >
> >
> > The Patient Self-Determination Act and public assessment of end-of-life technology.
> >
> > Heitman E; International Society of Technology Assessment in Health Care. Meeting.
> >
> > Abstr Int Soc Technol Assess Health Care Meet. 1992; 10.
> > University of Texas, Health Science Center, Houston 77225.
> >
> > On December 1, 1991, the federal Patient Self-Determination Act (PSDA) took effect across the United States, requiring health care institutions to ask all adults admitted as inpatients whether they have an advanced directive and to inform them of their right to refuse treatment. Institutions failing to meet the new federal standards risk losing Medicare and Medicaid funds. The law has three primary purposes: 1) to educate the public about state laws governing the refusal, withholding, and withdrawal of treatment at the end of life; 2) to encourage wider use of advanced directives to prevent the uncertainty among doctors and family members that often leads to prolonged treatment of the dying, and in some cases to lengthy court battles; and 3) to reduce the costs of treatment at the end of life by reducing unwanted and unnecessary intervention and the perceived need for defensive medicine. The PSDA and advanced directive statutes assume that lay people want, need, and can !
ap!
> pr!
> > eciate information about medical technologic intervention. It further assumes that health professionals and institutions will respect those decisions. While U.S. experience with informed consent and more recently with advance directives confirms this assumption generally, it also suggests that implementation of the PSDA may fall short of congressional intentions. This paper reviews the history and goals of the PSDA as a response to conflicting views of technological intervention at the end of life, examines the available data on the actual use of advance directives in the United States, and discusses the limitations of the PSDA and state legislation at the end of life.
> > So I guess I sympathize with you on requiring a waiver and requiring family members to feed their loved one. This, in my opinion, puts undo burden on the patient and family.
> >
> > Ron Hankins
> >
> >
> > Ron Hankins, M.,A., CCC-SLP
> >
> > Speech Language Pathologist
> >
> > Banner Good Samaritan Medical Center
> >
> > Neuroscience Clinics
> >
> > (602) 839-4150
> >
> >
> >
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> >
> > -----Original Message-----
> > From: dysphagia- [mailto:dysphagia-] On Behalf Of Sarah Handley
> > Sent: Monday, June 06, 2011 1:21 PM
> > To:
> > Subject: [Dysphagia] Dysphagia Waiver
> >
> >
> >
> > Hi! I have questions regarding my company's dysphagia waiver. I recently began working in a long term acute care hospital. Here, if a person chooses to go against the safest recommendation of the speech therapist, they must sign a dysphagia waiver. The waiver states that hospital staff will no longer be responsible for any PO intake. If pt is unable to feed themselves, family is responsible for ordering trays from the cafeteria and administering any and all PO intake. This applies to everyone, from a noncompliant patient that is refusing thickened liquids s/p aspiration of thin consistencies during MBSS to dementia patients that are unable to feed themselves, demonstrate s/s of aspiration, but family and/or patient has decided against any type of alternative route. I understand that it is all about liability, but I have never utilized a dysphagia waiver that will not allow hospital employees to feed the patient after the waiver is in place. What types of waivers are you !
gu!
> ys!
> >
> > working , or what's the real legality of this issue? Thank you for any input you can provide!
> >
> >
> >
> >
> >
> >
> >
> >
> >
> >
> >
> >
> > _______________________________________________
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I didn't know which thread to chip in to as there were several. All making good points. So I picked my friend Kate's!
In preparation for the Buffalo Day I spent a long time talking to a lawyer for a big health organisation. The important points from a legal perspective are:
- clear and defensible documentation
- outlining a clear and EVIDENCE based rationale
- showing how the patient and family were included in discussions
- and they made an INFORMED decision about their care - which is actually who is important here
Do these not map to exactly what a clinician should think are the important things?
EVIDENCE may be just your clearly documented clinical measurements and outcomes. INFORMED means that a person has considered the cost and benefit of a process and that they understand the consequences - NOT that they chose something off the web claiming a 100% cure or that their doctor told them to do it.
Waivers will not hold up in court and may be viewed as coercement.
Waivers will not protect or stand in the stead of sloppy documentation.
We (clinicians) need to stop worrying about who might sue us (and the figures are in the 0+/-tiny numbers) and hence doing this thing of "defensive medicine" which helps no-one. And deal with the more realistic trouble of educating our institutions (and I include academic institutions) about what the real issues and evidence are about the real costs and benefits of intervention are on a person, their family and their interaction in society. And I know that is tough but start small. Someone complained on the list recently about researchers and others presenting at conferences telling us all the things we can't do or that don't work. So what are we left with - good question. Don't do what you've always done just because you have nothing else fancy. Start with a good rationale, which you document and include evidence of patient inclusion in a process. We can all do that?
Paula
Dr Paula Leslie
CertMRCSLT (UK), CCC-SLP (USA)
Program Director: Doctor of Clinical Science (CScD)
Associate Professor, Communication Science and Disorders
Specialist Advisor (Swallowing Disorders) RCSLT
University of Pittsburgh
4033 Forbes Tower
Pittsburgh, PA 15260
tel: (+1) 412- 383-6748 fax: (+1) 412-383-6555
http://www.shrs.pitt.edu
________________________________________
From: dysphagia- [dysphagia-] On Behalf Of Kate Krival []
Sent: Tuesday, June 07, 2011 11:41 AM
To: Sarah Handley
Cc:
Subject: Re: [Dysphagia] Dysphagia Waiver
Thank you for bringing up this important topic. What a horrible situation
for all concerned. Particular thanks to Ron Hankins for pointing us to the
Patient Self Determination Act.
My colleague Paula Leslie, PhD and I prepared a little paper on the topic of
practicing "undefensively" recently, and Dr. Leslie has spoken on this topic
to various audiences. Conceptually, what you describe is precisely the
attitude we hope to change among health care practitioners. For those of you
who are members of ASHA's SIG 15 Gerontology, please take a look at the
paper and let me know if you have any questions about our thoughts there.
Here is the abstract and citation (sorry, I cannot post copies to the list
as the publication is copyrighted):
How To Practice "Undefensively"
Perspectives on Gerontology 15 54-64 December 2010.
doi:10.1044/gero15.2.54
Abstract
*Speech-language pathologists (SLPs) are increasingly challenged by the
medical complexities our patients present and gripped by the fear of
litigation if patients decline physically under our care. One response to
these pressures may be to practice defensive medical speech-language
pathology. We propose that best practice is ethically achieved by
deliberately using specific external and internal resources to practice
undefensively. We suggest how consideration of these materials and processes
will help SLPs ensure evaluation and clinical decision-making processes are
as effective, evidence-based, and transparent to patients, caregivers,
administrators, and payers as possible.*
On Mon, Jun 6, 2011 at 4:20 PM, Sarah Handley <>wrote:
>
> Hi! I have questions regarding my company's dysphagia waiver. I recently
> began working in a long term acute care hospital. Here, if a person chooses
> to go against the safest recommendation of the speech therapist, they must
> sign a dysphagia waiver. The waiver states that hospital staff will no
> longer be responsible for any PO intake. If pt is unable to feed themselves,
> family is responsible for ordering trays from the cafeteria and
> administering any and all PO intake. This applies to everyone, from a
> noncompliant patient that is refusing thickened liquids s/p aspiration of
> thin consistencies during MBSS to dementia patients that are unable to feed
> themselves, demonstrate s/s of aspiration, but family and/or patient has
> decided against any type of alternative route. I understand that it is all
> about liability, but I have never utilized a dysphagia waiver that will not
> allow hospital employees to feed the patient after the waiver is in place.
> What types of waivers are you guys!
> working , or what's the real legality of this issue? Thank you for any
> input you can provide!
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