policy number version number 1.0 csrt...risk feeding policy v1 policy title risk feeding policy...

Risk Feeding Policy v1

Policy Title

Risk Feeding Policy

Policy Number

RM83

Version Number

1.0

Ratified By

Risk and Safety Council

Date Ratified

09/01/2019

Effective From

02/04/2019

Author(s) (name and designation)

Ashleigh Colquitt – Speech and Language Therapist – Acute Hannah Reynolds – Speech and Language Therapist - Community Lucinda Somersett – Speech and Language Therapist – CSRT

Sponsor

Frank McAuley, Clinical Head of Service, Clinical Support and Screening

Expiry Date

01/01/2022

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues


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Version Control

Version

Release

Author/Reviewer

Ratified By/ Authorised By

Date

Changes (Please identify page

no)

1.0 02/04/2019 Speech and Language Therapy

Risk and Safety Council

09/01/2019


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CONTENTS

Section Page 1 Introduction ........................................................................................................................................ 5 2 Context .............................................................................................................................................. 5 3 Aims of policy ..................................................................................................................................... 5 4 Scope ............................................................................................................................................... 6 5 Definitions .......................................................................................................................................... 6

5.1 “Risk Feeding” or “Comfort Feeding”? ................................................................................. 6 6 The Gateshead Risk Feeding Guidelines and the Risk Feeding Policy ............................................... 7

7 Roles and Responsibilities .................................................................................................................. 7

7.1 Speech and Language Therapist ............................................................................................ 7 7.2 The Medical Team ................................................................................................................. 8 7.3 Nursing Staff ......................................................................................................................... 9

7.4 The Nutrition Team ............................................................................................................... 9 7.5 Other Members of the MDT ................................................................................................. 9

8 Reasons for Risk Feeding Decisions ................................................................................................... 10 8.1 Is the patient’s ability to swallow safely likely to return? ..................................................... 10 8.2 What is the reason for the risk feeding decision? ................................................................. 10 8.3 Has a formal decision to risk feed been made previously? ................................................... 12 8.4 Are there any new concerns about the patient’s swallow or capacity? ............................... 12 9 Capacity to Make Risk Feeding Decision ........................................................................................... 12 9.1 Has the patient been provided with information around the risks, benefits etc?................ 13 9.2 Does the patient have capacity to make their own decision around risk feeding? .............. 13 9.3 Could the patient’s capacity to make this decision improve in the short term? .................. 13 9.4 Has the lead clinician met with the LPA/family/IMCA for a best interest discussion? ......... 14 10 Future Management .......................................................................................................................... 14 10.1 Does the patient have an Emergency Health Care Plan (EHCP)? .......................................... 14 10.2 Does the EHCP include management of aspiration-related infections? ............................... 14 11 Outcome of Risk Feeding Decision .................................................................................................... 15 12 Documentation Administration ......................................................................................................... 15

13 Training ............................................................................................................................................... 16 14 Equality and Diversity ......................................................................................................................... 16 15 Monitoring compliance with the policy ............................................................................................. 16 16 Consultation and review ..................................................................................................................... 17 17 Implementation of policy .................................................................................................................. 17


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18 References ........................................................................................................................................ 17 19 Associated documentation ................................................................................................................ 17

20 Appendices ........................................................................................................................................ 17


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Risk Feeding Policy 1 INTRODUCTION

Nutrition is a key priority for healthcare organisations and providing oral intake of food/drink is often an important issue for carers. Managing the risks of oral intake for patients with swallowing problems (dysphagia) is important in terms of safety, but can be a challenging ethical dilemma for healthcare professionals and carers (Hansjee, 2013). Some patients will present with oral or pharyngeal stage dysphagia and can be at risk of choking or aspiration. Other patients can lose interest in food at the end stage of life. Those with end stage dementia may lose the ability to recognise food (Evans & Best, 2015). The risks of malnutrition and dehydration need to be assessed in all patients. Healthcare professionals have a duty to provide appropriate nutrition and hydration for patients in their care (NMC 2015, GMC 2010). This document gives advice and guidance on decision making regarding nutrition and hydration in patients who are at high risk of aspiration (i.e. material entering the respiratory system below the level of the vocal folds) secondary to oropharyngeal dysphagia. Patients who are deemed to have an unsafe swallow and are at risk of aspiration are not always placed Nil By Mouth (NBM). Publications from the Royal College of Physicians and British Society of Gastroenterology (2010) highlight the increasing evidence suggesting that non-oral feeding is not always clinically or psychologically beneficial nor ethically sound for some patients with oropharyngeal dysphagia. In these instances, a decision to eat and/or drink with the accepted risk of aspiration may be more appropriate.

2 CONTEXT

Anecdotal evidence suggests that decisions to feed patients with the accepted risk of aspiration are being made regularly by a range of medical professionals, including doctors and Speech and Language Therapists (SLTs). However, there are often issues with these decisions including:

Decisions not being made in a timely manner

Relevant people not being involved (i.e. family, patient, other members of the MDT)

Decision not being clearly or appropriately documented in medical records. 3 AIMS OF POLICY

The aim of this policy is to provide a clear pathway for risk feeding to guide professionals through the decision making process, whilst also improving:

1. CONSISTENCY - the pathway should be followed for all patients requiring a risk feeding decision

2. DOCUMENTATION - correct use of the Gateshead Risk Feeding Guidelines document (see Appendix 19.1) should provide clear and accessible documentation of the decision

3. COMMUNICATION – the pathway should encourage close working and clear communication between medical professionals, patients, family and carers

4 SCOPE

Any registered member of staff who has a role with a patient for whom a risk feeding decision is considered.


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5 DEFINITIONS

Term Definition

Artificial hydration

The provision of hydration via enteral or parenteral means, for example intra-venous access, sub-cutaneous access, nasogastric tube.

Aspiration Food or drink passes the vocal folds and enters the lungs.

Aspiration pneumonia

A respiratory infection caused by food, drinks, saliva containing bacteria, vomit or enteral feed entering the lungs.

Dysphagia A swallowing disorder, which may occur in the oral, pharyngeal and oesophageal stages of deglutition.

Mental capacity Having the cognitive ability to make one’s own decisions.

NGT A nasogastric tube inserted into the nose, through the pharynx and subsequently the oesophagus through which a liquid feed is pumped into the stomach.

NJ A nasojejunal tube passed through the nose and guided into the small bowel (jejunum) through which a liquid feed is pumped.

LPA Lasting Power of Attorney.

PEG A Percutaneous Endoscopic Gastrostomy inserted through the abdominal wall into the stomach through which a liquid feed is pumped.

PEJ A Percutaneous Endoscopic Jejunostomy inserted through the abdominal wall into the small bowel (jejunum) through which a liquid feed is pumped.

Risk feeding Eating and drinking continues despite the risk of food or drinks entering the lungs.

Swallowing The act of deglutition from placement of food or fluid in the mouth through the oral and pharyngeal stages of the swallow until the material enters the oesophagus through the cricopharyngeal juncture.

5.1 “Risk Feeding” or “Comfort Feeding”

This document only refers to feeding with accepted risk of aspiration using the term “risk feeding”. The term “comfort feeding” has often been used historically. It is commonly associated with patients in the palliative stage of their diagnosis or who are imminently approaching end of life. Oral intake for these patients may be important to maintain quality of life, as food and drinks provide pleasure and enjoyment. However, not all patients at risk of aspiration are palliative or end of life. Examples include, but are not limited to, patients post treatment for head and neck cancer, lateral medullary stroke survivors or patients recovering from traumatic intubation resulting in paresis of the recurrent laryngeal nerve. They experience severe dysphagia, but may otherwise be fit and mobile. The term “risk feeding” is more appropriate than “comfort feeding” in describing these individuals. In addition, oral feeding with the accepted risk of aspiration will result in significant respiratory discomfort for some patients. Issues include severe or prolonged coughing episodes, choking, watering of the eyes, reddening of the face and/or acute shortness of breath. Repeated experience of these symptoms with each mouthful can contribute to distress, fear or anxiety around eating and drinking. For this reason, the term “comfort feeding” is also inappropriate, as it is not comfortable for some. Therefore, professionals involved in the care of patients feeding with the accepted risk of aspiration should use the term “risk feeding” instead of “comfort feeding”.


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6 THE GATESHEAD RISK FEEDING GUIDELINES AND RISK FEEDING POLICY

The following policy is designed to work in conjunction with the Gateshead Risk Feeding Guidelines form (see Appendix 20). In practice, the healthcare professional will use the Gateshead Risk Feeding Guideline form as a flow chart of questions to cover every aspect requiring consideration when making a risk feeding decision. The answers given will then direct the healthcare professional towards the next appropriate question and therefore through a process of decision making appropriate to the patient’s circumstances. Once the form is completed, it should be signed by the responsible professional and stored in the front of the medical records or within electronic records. The Risk Feeding Policy aims to resolve any difficulty a healthcare professional may be having when answering any of the questions on the Gateshead Risk Feeding Guidelines form. Making risk feeding decisions can be difficult, as it involves consideration of medical ethics, the Mental Capacity Act and the opinions of the patient or family members. Clear guidance on such matters is provided within this policy. In addition, the Gateshead Speech and Language Therapy team welcome conversations with healthcare professionals in matters of making risk feeding decisions. They can be contacted via telephone on 0191 445 2599.

7 ROLES AND RESPONSIBILITIES

The multidisciplinary team (MDT) plays a key role in the assessment, management and decision-making process with patients who may require risk feeding. Risk feeding decisions should be decided as an MDT with the consultant or GP having the ultimate responsibility for the patient’s care. If the consultant or GP is not immediately available and in situations where all those involved are in agreement for feeding with the accepted risk of aspiration, it should then be documented by a responsible junior clinician who has been involved in the making of the decision. If delegated, the consultant or GP should be informed at the earliest opportunity. Professionals who most often take key roles in risk feeding decisions are outlined below.

7.1 Speech and Language Therapists

The SLT has an advisory and educating role. They may often be the first professional to indicate that risk feeding is a possibility for a patient following assessment of their swallow, where a high risk of aspiration is identified. SLT are responsible for:

1 Assessing the patient’s swallow function in accordance with professional guidelines set out by the Royal College of Speech and Language Therapy (RCSLT) and the Gateshead Dysphagia Care Standards policy.

2 Evaluating the level of risk of aspiration that the patient is placed at by oral intake.

3 Assessing the benefits/disadvantages of compensatory strategies for reducing the risk of aspiration.


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4 Identifying the need for further assessment, which may include instrumental techniques such as Videofluoroscopic Swallow Study (VFSS) or Fibreoptic Endoscopic Examination of Swallowing (FEES).

5 Offering an opinion based on clinical evidence regarding prognosis for swallow recovery.

6 Communicating these findings to the multi-disciplinary team (MDT).

7 Contributing to discussions with the patient, family and MDT regarding non-oral feeding,

where appropriate.

8 Facilitating more effective discussions between the MDT and patients who have impaired communication skills.

9 Assessing or facilitating communication to aid decisions regarding mental capacity, where

appropriate.

10 Making recommendations for the safest and most comfortable diet and fluid consistencies (if possible) once a decision to risk feed has been made.

7.2 The Medical Team

The medical team should, where appropriate, be involved with:

1 Identifying the need for a risk feeding decision.

2 Assessing mental capacity using the MCA 1 and 2 forms, where appropriate

3 Holding discussions with the patient, family and MDT.

4 Making onward referrals to the wider MDT where necessary (e.g. Nutrition Team).

5 Agreeing the final decision regarding feeding with accepted risk of aspiration.

6 Completing or signing off the Gateshead Risk Feeding Guidelines document.

7 Completion of Emergency Health Care Plans (EHCP) to communicate decisions between acute and community services regarding future management.

The medical team should refer to GMC and RCP guidelines for further details.

7.3 Nursing Staff, Health Care Assistants and Carers

The nursing team, health care assistants and carers should, where appropriate, be involved with:

1. Informing the medical team and SLT of any signs of aspiration in the first instance.

2. Providing the correct diet and fluid recommendations as advised by SLT.

3. Informing SLT of any changes to the patient’s expressed wishes about risk feeding.

4. Informing SLT of any new severe physical discomfort evident during oral intake.


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5. Ensuring the correct nutrition recommendations are verbally handed over when the patient is transferred to another ward or care setting.

The process of feeding patients with the accepted risk of aspiration can often be distressing for nursing staff or carers, as it can result in severe coughing or choking episodes. Staff can also be fearful that feeding may lead to the patient’s death by asphyxiation. No person providing health care wishes to actively cause physical or emotional distress to their patients. However, if a decision to risk feed a patient has been made, nursing staff are encouraged to remember that their actions to feed the patient are in line with the patient’s wishes (where they have mental capacity) or with the decision made by the GP or consultant as part of a best interest decision (where they lack mental capacity). Nursing and care staff may discuss their concerns further with the SLT service at any time.

7.4 The Nutrition Team The Nutrition Team, where appropriate, may be involved with:

1 Identifying whether patients are appropriate for non-oral feeding.

2 Advising patients or family members about the risks and benefits of non-oral feeding.

3 Placement of enteral feeding tubes (e.g. NGTs, NJs, PEGs, PEJs).

7.5 Other Members of the MDT

This may include Dieticians, Specialist Palliative Care Team, Clinical Nurse Specialists (e.g. Parkinson’s disease, palliative care) and pharmacists. They may have a role in:

1. Advising on whether enteral feeding is appropriate.

2. The patient’s expected medical prognosis.

3. Whether pharmaceutical interventions are likely to impact the ability to swallow.

8 REASONS FOR RISK FEEDING DECISIONS 8.1 Is the patient’s ability to swallow safely likely to return after a short period of active treatment?

The prognosis of dysphagia recovery can vary depending on a number of factors centred around the medical diagnosis causing the dysphagia including: i) Pattern of disease progression (i.e. progressive vs stable vs rehabilitative) ii) Disease stage (i.e. acute vs chronic vs end stage) iii) Curability (i.e. reversible vs terminal) iv) Multiple co-morbidities that compound the effect of the main diagnosis

A decision to risk feed would NOT be appropriate in cases where:

i) An acute reversible diagnosis (e.g. LRTI, UTI) has caused generalised decompensation in the patient’s ability to swallow, but it is expected to return to baseline following a period of active medical treatment for a minimum of two weeks


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ii) The diagnosis underlying the onset of dysphagia is unknown and requires further

investigation before an informed prognosis for dysphagia recovery can be made.

In both of these instances, NBM with consideration of non-oral nutrition for a period of up to two weeks would be appropriate. This aims to prevent further episodes of aspiration that, if leading to aspiration pneumonia, could be detrimental to the patient’s medical recovery. A decision to feed with accepted risk of aspiration should be pursued if:

i. The cause of the dysphagia is identified to be chronic or irreversible.

ii. The level of dysphagia has not improved despite a short period of active medical treatment.

8.2 What is the reason for the risk feeding decision?

There are several reasons to pursue a decision to feed with accepted risk of aspiration, the most common of which are:

1. The patient has declined or failed to tolerate non-oral feeding/NBM/modified textures. Patients may decline being NBM, preferring to eat and drink instead. They may also find texture modified diet unpalatable. They may decline such management if they find it uncomfortable, a hindrance to dignity or want to avoid the risks involved with enteral feeding. When a patient has the mental capacity to understand the benefits and risks of such options and declines them all, a risk feeding decision should be pursued, as oral feeding is the only remaining means of nutrition. Patients who lack mental capacity may still express their preferences, either verbally (e.g. “I do not want this”) or non-verbally (e.g. by becoming distressed, pushing staff members away or pulling out NGTs). In these instances, if the risk of distress or injury to the patient outweighs the risks of feeding with a high probability of aspiration, a risk feeding decision should be pursued. However, if the period of time NBM or on modified diet is likely to be short term (i.e. <72 hours) and swallowing is suspected to improve with active treatment, caution should be exercised in pursuing a risk feeding decision. It may not be in the best interest of the patient in the long term if they have a chance of swallow recovery.

2. The risks of PEG/NG procedure outweigh the benefits of non-oral feeding. NG/NJ insertion has several risks and contraindications. These include:

Facial/nasal trauma

Base of skull fractures

Head and neck cancers

Probable reflux of the feed leading to aspiration

An inability to sit at or above 45 degree angle

Patient agitation leading to removal of the NGT when the feed is running PEG/PEJ insertion has several risks and contraindications. These include:


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Acute infection (.e.g. chest infection)

Abnormal positioning of the stomach

Hiatus hernia

Previous gastric surgery

Probable reflux of the feed leading to aspiration

An inability to sit at or above 45 degree angle

Patient agitation leading to removal of the PEG

If the probable risks and contraindications of these procedures outweigh the benefit of non-oral feeding, oral nutrition is the alternative. A risk feeding decision should only be pursued if the risks of non-oral feeding outweigh the risk of feeding with accepted risk of aspiration.

3. To maintain quality of life for the patient who has a poor prognosis. Patients with oropharyngeal dysphagia may have a degenerative condition (e.g. Parkinson’s disease, dementia, COPD) or as a result of an acute neurological event, (e.g. stroke or head injury). In some instances, no further spontaneous recovery or rehabilitation will bring back the ability to swallow safely. Eating and drinking forms a significant part of quality of life. Although a patient’s life may be prolonged by remaining NBM with enteral feeding, this may have little benefit to their quality of life. A decision to risk feed may be preferable in order to maximise quality of life through enjoyment of oral intake. However, it should also be considered that risk feeding can, at times, be extremely uncomfortable for patients if it results in severe and prolonged coughing or choking episodes. The likely level of discomfort when eating and drinking should also be considered within decision making.

8.3 Has a formal decision to feed with the accepted risk of aspiration been made previously?

A decision to risk feed may have previously been made in the acute or community settings. This may be in the form of an Advanced Decision. Therefore, members of the MDT should ask patients or family members for evidence of the Advanced Decision documentations and a copy should be kept in the medical records. Staff members should also check whether such a decision has previously been made as the result of a discussion between a doctor/SLT and the patient or family. This can occur in both the community and acute settings, so efficient communication between services is essential.

8.4 Are there new or different concerns about the patient’s swallow or capacity?

A patient’s swallow or capacity may change from the date of the last risk feeding decision. The patient’s swallow may have improved to the point that they can manage oral intake with no risk of aspiration. The SLT can advise on this. If so, it may be appropriate to cancel the decision to risk feed and record this in the medical notes as advised on the Gateshead Risk Feeding Guidelines document. A patient’s capacity to decide to risk feed may also diminish as their illness progresses. It may be appropriate to consider pursuing a new decision for risk feeding to establish if the original approach to nutrition management is still in their best interests regarding quality of life and medical care. This is done by starting a new Gateshead Risk Feeding document.


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Patients with capacity can also change their decision to risk feed or not at any point. If this is the case, the process of discussion if risk feeding is appropriate should be restarted by completing a new Gateshead Risk Feeding document.

9 CAPACITY TO MAKE RISK FEEDING DECISIONS Patients who understand the risks, benefits and consequences of refusing treatment have the right to decline it. However, for patients who do not possess the mental capacity to understand such issues, a decision to continue treatment will often be made in their best interest. Activities such as taking blood samples, administering medications or mobilising a patient involve varying levels of risks and benefits. However, presenting patients with every possible risk and making a detailed assessment of their mental capacity for every aspect of daily care is impractical and not required. Such activities are clearly in their best interest to meet health and care needs. However, a decision to risk feed a patient is fundamentally different. The above examples of care aim to positively influence the patient’s physical condition, thereby doing more physical good than harm. Conversely, risk feeding increases the chance of a choking or developing potentially fatal aspiration pneumonia, thereby doing more physical harm than good. For this reason, all patients should be helped to make an informed decision on whether they are prepared to accept such a risk. Consideration of the patient’s mental capacity is central to this process.

9.1 Has the patient been provided with the information around the risks, benefits and consequences of feeding with the accepted risk of aspiration vs non-oral feeding?

The patient should be provided with information regarding the risks, benefits and consequences of risk feeding compared to the risks associated with non-oral feeding. Without this information, the patient is unable to make an informed decision regarding care. Information should be presented in simple, easy-to-understand language that a patient without any prior knowledge of such issues could understand. Repetition may be required to ensure the patient is able to remember all aspects of this information. The doctor, GP or SLT are often the professionals that will most commonly present this information to the patient.

9.2 Does the patient have capacity to make their own decision about nutrition and hydration?

All practitioners must adhere to the Mental Capacity Act (2005). It is enshrined in law that everyone must work on the assumption that all adult patients have the capacity to make an informed decision about oral feeding unless there is evidence that their capacity is impaired. If a patient’s ability to process or use language is impaired, they must be provided with all the appropriate support to maximise their ability to participate in the decision-making process. This may include the involvement of SLT if the patient has a communication difficulty (e.g. dysphasia, dysarthria or verbal dyspraxia). Please see the Mental Capacity Act Code of Practice (2007) and GMC Guidelines (2010: 12-24) for additional advice on decision-making with patients who lack capacity.


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The multidisciplinary team must clearly document conclusions made about a patient’s mental capacity in relation to their ability to make informed risk feeding decisions. Mental capacity may need to be assessed on multiple occasions if the patient’s cognitive function fluctuates or is difficult to assess. A second opinion can be requested from other clinicians, the Mental Health Liaison Team or other professionals who are trained in assessing mental capacity.

9.3 Could the patient’s capacity to make this decision improve in the short term? Patients may temporarily lose mental capacity to make decisions around risk feeding as a result of acute delirium. If capacity is suspected to improve in the short term, a risk feeding decision should be postponed for the time it is anticipated to take for their capacity to return. In this instance, NBM with or without non-oral feeding may be appropriate if tolerated. Once the patient’s capacity has returned and their swallow is still identified to be unsafe, the Gateshead Risk Feeding Guideline document should be restarted. If capacity is not likely to improve in the short term, efforts should be made to find out if the patient has made an Advanced Decision outlining their wishes regarding non-oral nutrition or in the event that they are no longer able to swallow safely. If no Advanced Decision exists, a Best Interest Decision needs to be made on their behalf.

9.4 Has the lead clinician met with the LPA for Health and Welfare/family/IMCA for a best interest discussion around nutrition?

Communication with family members or carers is key to the process of a Best Interest Decision in the absence of an Advanced Decision. If a relative has a valid and applicable Lasting Power of Attorney (LPA), that person is able to consent to health and care decisions on behalf of the patient. If there is no LPA, relatives cannot consent on the patient’s behalf, but due regard should be paid to all their views about the patient’s prior beliefs, values and wishes. This information should be used by the MDT to assist in making a decision in the best interest of the patient. If there is significant disagreement between the above parties and health care professionals, an independent second opinion should be sought. Any such discussions should be documented in detail within the medical records. Except in cases where patients have an Advanced Decision, the consultant or GP should ultimately make the decision about risk feeding. The decision must be endorsed by their signature on the Gateshead Risk Feeding Guideline with accompanying documentation demonstrating that the relevant MDT discussions have taken place and adequate information has been shared with the patient or family.

10 FUTURE MANAGEMENT

10.1 Does the patient have an Emergency Health Care Plan (EHCP)? The Emergency Health Care Plan allows health care decisions to be shared between other service providers, along with information about any common or recurring health problems. The EHCP helps the patient receive the most appropriate care for their needs.


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If a risk feeding decision has been made in the community setting, the GP or Community Nurse should consider use of an EHCP. If the decision was made in the acute setting, the discharging medical team should prompt the GP or Community Nurse to consider use of an EHCP reflecting the risk feeding decision.

10.2 Does the EHCP include management of aspiration-related infections? The EHCP can be used to communicate information around management of aspiration-related infections where a risk feeding decision has been made. Where a decision has been made for the patient to risk feed, they have a high probability of developing aspiration pneumonia, which is usually treated via antibiotics. Severe aspiration pneumonia may require hospital admission. Various factors should be considered when including management of aspiration-related infections in an EHCP. These can include:

Current general condition (i.e. frail vs otherwise fit and well)

Timescale of prognosis (i.e. approaching end of life vs non-palliative)

Wishes for future treatment (i.e. withdrawing active treatment to facilitate death vs opting for full active treatment)

Standard of quality of life that may be restored by active treatment (i.e. prolonging a slow, painful decline vs restoring patient to a good functional baseline)

Distress caused by active treatment that may be invasive The patient’s capacity to decide on management of aspiration-related infections should be considered when writing an EHCP. If the patient has capacity or an Advanced Decision, they may decide on future management. However, if they lack capacity or an Advanced Decision, a Best Interest Decision will be required.

11 OUTCOME OF RISK FEEDING DECISION When a decision has been made to pursue risk feeding, consideration should be made as to what the most appropriate modified textures or strategies are. SLT are able to assess patients to advise on the most appropriate oral recommendations. The priority has shifted away from preventing aspiration and moved towards maximising enjoyment gained from oral intake and minimising the risks where appropriate. Each patient has individual difficulties, needs and preferences. Some find modified textures unpalatable. Therefore, providing unmodified textures (i.e. normal diet and fluids) may be more appropriate. Other patients find modified diet or fluid textures beneficial in reducing the severity of coughing/choking episodes compared to normal diet and fluids. Risk feeding can happen alongside non-oral feeding for some patients. For example, a patient may wish to have oral tasters with accepted risk of aspiration alongside their PEG feeding regimen. If so, this should also be detailed within the Gateshead Risk Feeding Guidelines document.

12 DOCUMENT ADMINISTRATION

A decision to feed with accepted risk of aspiration should be clearly documented and visible within paper and electronic medical records at all times.


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A copy of the Gateshead Risk Feeding Guidelines document should be:

i. Kept in the front of the patient’s paper medical records alongside any DNACPR forms or EHCP forms

ii. Added to electronic records, such as Medway Alerts and EMIS notifications iii. Included with the discharge letter from the acute to the community setting iv. Securely faxed, emailed or posted from the community setting to the acute setting in the

event of a hospital admission

Where any conversation has occurred between medical professionals, members of the MDT, patients, family members, carers or LPAs, the details of such conversations should also be documented in the medical records. If a capacity assessment has been completed, copies of the MCA 1 and 2 forms should be kept in the front of the medical records and added to electronic records as appropriate.

13 TRAINING Training is provided by the Speech and Language Therapy team for all grades and professions involved in risk feeding.

The team are involved within the following education programmes:

Dysphagia Awareness Training

Level 1 Dysphagia Screen Training

Level 2 Dysphagia Screening Training

Participation in Care of the Elderly lunchtime meetings

Participation in Housekeepers training quarterly

Adhoc training on one to one basis as requested by staff where possible

14 EQUALITY AND DIVERSITY

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide

services to the public and the way we treat our staff reflects their individual needs and does not

discriminate against individuals or groups on any grounds.

15 MONITORING COMPLIANCE WITH THE POLICY

Standard / process / issue

Assurance

Method By Committee Frequency

Gateshead Risk Feeding Guideline document is completed

Check all documentation related to risk feeding where a decision has been made

Speech and Language Therapy team

Nutrition Steering Group which reports to Safecare Council

Yearly


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Risk Feeding Audit Audit rate of risk feeding decisions, number of Gateshead Risk Feeding Guidelines forms completed and number of patients readmitted with and without clear Risk Feeding and EHCP documentation

Speech and Language Therapy team

Nutrition Steering Group which reports to Safecare Council

Yearly


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16 CONSULTATION AND REVIEW

This policy will be reviewed every two years. Consultation will include consultants, nutrition nurses, as well as multidisciplinary members of the nutrition support team.

17 IMPLEMENTATION OF POLICY

The contents of this policy will be shared with the following:

Nutrition Team

F1 & F2 training sessions

All food and drink work stream leads

Modern Matrons and Ward Managers.

Band 6 clinical leads meetings

Community Services Management Team Meeting

Community Services Quality Governance Meeting

18 REFERENCES

Hansjee D (2013). A safer approach to risk feeding. Bulletin www.rcslt.org.uk, February 2013 pp20-21 Evans L. Best C ( 2015). Managing Malnutrition in patients with dementia. Nursing Standard, Vol 29 No 28 pp 50-57 General Medical Council (2010) Treatment and care towards the end of life: Good practice in decision making. http://www.gmc-uk.org/static/documents/content/Treatment_and_care_towards_the_end_of_life_-_English_1015.pdf# Mental Capacity Act (2005) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf National Institute for Health and Clinical Excellence (2004). Improving supportive and palliative care for adults with cancer. Cancer service guideline CSG4. https://www.nice.org.uk/guidance/csg4 Royal College of Physicians (2010). Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life. Report of a Working Party, Royal College of Physicians. www.rcplondon.ac.uk.

19 ASSOCIATED DOCUMENTATION

Gateshead Dysphagia Care Standards Policy

20 APPENDICES

1 Gateshead Risk Feeding Guidelines

http://www.gmc-uk.org/static/documents/content/Treatment_and_care_towards_the_end_of_life_-_English_1015.pdf



https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf

https://www.nice.org.uk/guidance/csg4

http://www.rcplondon.ac.uk/


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