Well, when I said she couldn't swallow I meant that she couldn't swallow voluntarily.
"There is no evidence that she could not take enough nourishment to remain alive"
Yes there was. It's called "failing the swallow tests". Where is your evidence that she could swallow enough nourishment to keep her alive? I've asked you three times four times now and you've produced nothing.
"it was inefficient to hand-feed her"
WHAT??? This is the very first time I've read that a feeding tube was used because it was more "efficient". Back up that statement or withdraw it. That's the stupidest thing I've seen posted yet.
"Her parents were willing to feed her."
Yes they were. What's your point?
The evidence is in years of experience with swallowing studies, feeding tubes and end of life decisions. (Note: not everyone who shows aspiration on the barium swallowing test - defined as "failure" in the notes on Terri - undergo the placement of a feeding tube.)
Do a google on swallowing studies. I will, and post the results and a summary, later tonight. (I'm visiting my parents and each time I log on, I tie up their phone line.)
From a Google search on "Barium Swallow Study"
http://pcs.mgh.harvard.edu/heal_lang_art7.htm
Differentiates between barium swallow and modified barium swallow.
http://www.jcge.com/pt/re/jclngastro/abstract.00004836-199703000-00005.htm;jsessionid=CseEZys1RVAXvqDrOehyXuKwXoo8JmW5ULb4GJQtxThfRRZr1RJP!802112076!-949856031!9001!-1
Modified Barium Swallow Does Not Affect How Often PEGs Are Placed After Stroke.
Journal of Clinical Gastroenterology. 24(2):74-78, March 1997.
Akpunonu, Basil E. M.D.; Mutgi, Anand B. M.D.; Roberts, Carolyn M.D.; Khuder, Sadik A. Ph.D.; Federman, Douglas J. M.D.; Lee, Lisa M.D.
Abstract:
Dysphagia frequently follows stroke, but often resolves quickly. Percutaneous endoscopic gastrostomy (PEG) or other feeding tubes are placed to improve nutrition and hydration, and reduce the risk of aspiration pneumonitis. We evaluated the impact of modified barium swallow in determining PEG placements and the influence of specific swallowing abnormalities on PEG placement. The abnormalities assessed were presence of pharyngeal stasis and/or visualization of posterior pharyngeal transfer problems and aspiration of liquid or solids. A total of 302 patients with stroke were admitted to our hospital between 1989 and 1993, but only those with hemorrhagic or nonhemorrhagic stroke by computed tomographic (CT) scans or magnetic resonance imaging (MRI) or autopsy were included in our study. Patients with transient ischemic attacks (TIAs), central nervous system tumors, and traumas were excluded. Barium swallow studies were performed on 69 (23%) of patients; 49 (71%) were abnormal, based on aspiration of barium, pharyngeal stasis, or postpharyngeal transfer dysphagia. PEGs were placed in only 18% of those with abnormal studies. Of the patients with normal barium swallow studies, 25% had a PEG placed. Two hundred thirty-three patients underwent no barium swallow studies, but 11 (4.72%) of these had PEG placed. The rate of PEG placement was not related to any one of the abnormalities noted on the modified barium swallow. Rather, patients who received PEG had significant neurological deficits and increased prevalence of aspiration pneumonitis. The decision to insert PEG was made on clinical grounds and not on abnormal barium studies alone.
(C) Lippincott-Raven Publishers
http://www.gihealth.com/html/education/peg.html
8. How much feeding solution is given? Every patient and situation is different. Some patients can't eat at all and depend completely on the feeding tube for all of their nutrition. They may receive as much as 8 cans a day (2400 calories). Other just need a little help and require less. Ask the patient's doctor or health care provider how much feeding solution to administer and how often.
9. Can the patient still eat and swallow once the PEG feeding tube is inserted? Again every patient and situation is different. Some patients can't swallow at all because of thoat cancer or a stroke. They can not eat normally. But if the patient can still swallow without choking, there is no reason why food can not be taken by mouth in addition to the lquid supplement give through the PEG tube.
http://www.theberries.ns.ca/Archives/Dysphagia.html
DYSPHAGIA PROGRAM
ST. MARTHA'S REGIONAL HOSPITAL
ASSESSMENT THROUGH CLINICAL OBSERVATION AND MODIFIED BARIUM SWALLOW STUDY
Patients with dysphagia following stroke are at high risk for complications of aspiration. In our hospital when a referral for a patient with dysphagia is received, a Dysphagia Team member (Speech-Language Pathologist and/or Dietitian) will review the chart, complete a bedside clinical assessment of the patient's level of alertness, oral motor skill, complete test swallows with a variety of food consistencies and determine if further investigation with a modified barium swallow study is indicated.
Note that observation of presence or absence of the gag reflex is not used as part of the clinical assessment.
TO GAG OR NOT TO GAG
Traditionally, presence or absence of a gag reflex has been used as a clinical indicator in determining the patient's readiness and safety in accepting food orally however.
THE GAG REFLEX
* is not elicited during a normal swallow
* is not protective for the swallow. The protective reflex for swallowing is the cough, which should be triggered when food enters the larynx. The cough reflex is frequently not elicited in dysphagic patients. (See UNRELIABLE COUGH REFLEX below)
* is not elicited when food falls into the pharynx or airway prematurely or in an uncontrolled way
[from Logemann, J., (1985) The Diagnosis and Treatment of Dysphagia. Evanston, Ill.]
Additional evidence in the lack of predictability of the gag reflex in swallowing safety is provided by the following two studies.
Leder, S. Gag Reflex and Dysphagia, "Head & Neck", March 1996.
* 86% of subjects with no gag could safely swallow at least a puree diet
* 13% of normal nondysphagic subjects had no gag reflex
Davies, Kidd, Stone, MacMahon, Pharyngeal Sensation and Gag Reflex in Healthy Subjects, "The Lancet", February, 1995
* 37% of normal subjects had no gag reflex (43% of normal elderly subjects, 26% of young subjects)
* Presence or absence of a gag reflex is not a predictor of swallowing safety.
INFORMATION OBTAINED FROM A MODIFIED BARIUM SWALLOW STUDY
If a modified barium swallow study is recommended, the procedure used is different than a standard barium swallow study. That is, the patient is given small, graduated quantities of various food consistencies (usually thin liquids, thickened liquids, pudding and cookie) while in a sitting position. The MBS gives information on:
1. whether the patient is aspirating,
2. the safest diet, and
3. strategies to improve swallowing safety.
Specific strategies to improve swallowing function are tested and observed during videofluoroscopy. Strategies may include changes in head position, increasing sensory input (through changes in food temperature, pressure on the tongue), variation in food consistency or variation in bolus size.
THE UNRELIABLE COUGH REFLEX
Of the 41 studies completed (May 1996 - May 1997) at St. Martha's Regional Hospital, seventeen studies showed aspiration on videofluoroscopy. Of the seventeen studies, three cases (17.6%) showed visible signs of aspiration, i.e., choking, coughing, during the study. The remaining 14 cases (82.4%) aspirated "silently" during the study. Coughing, the protective reflex for aspiration, was not observed in response to aspiration in the majority of cases. Our findings are higher than those documented by the dysphagia literature which cites silent aspiration at 30-50% of cases.
THE BEST DIET
Consistencies Aspirated during Study
Percentage
Thin Liquid 13/17 76.4%
Thickened Liquid 1/17 5.8%
Pudding 1/17 5.8%
Two consistencies2/17 11.7%
The first oral diet traditionally ordered for new CVA patients is a "clear fluid diet". Our findings, supported by the dysphagia literature, suggest that this diet is the least safe for dysphagic patients. If a patient is suspected of having dysphagia and is placed on an oral diet, the safest choice is a diet consisting of thickened liquids and pureed solids. Medications should be crushed and given with these food consistencies. Aspiration indicators such as a wet cough, gurgly voice after swallowing, respiratory stress and temperature peaks should be monitored when dysphagia is suspected. Further assessment by the Dysphagia Team may be indicated.