Hope for Dysphagia:
Got a Speech-Language Pathologist on Your
Multidisciplinary Dysphagia Team?
By Karen M. Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
This blog is in response to an article published by the Washington Post on February 25, 2018 in the Health & Science Perspective column titled: “Problems swallowing are a big killer, but the treatment can be horrible,” by Drs Douglas Jacobs and Joshua Lang of Brigham and Women’s Hospital in Boston. It seems to leave no hope for dysphagia. This article reminded me of the overly negative writing of a 2016 article by Wang, Charlton, and Kohlwes (of the University of California San Francisco) titled: “The Horrible Taste of Nectar and Honey – Inappropriate Use of Thickened Liquids in Dementia: A Teachable Moment.” See that article discussed here in my response blog from 2016.
Introduction to Hope for Dysphagia:
This inaccurate and harmful article was just what I needed to get my writing juices flowing at 4:30 in the morning (juice pun intended)! The article does such a disservice to people who have difficulty swallowing (dysphagia). The many falsehoods can instill fear and hopelessness in our patients. Speech-Language Pathologists (SLPs), who were not mentioned in the article, work tirelessly every day leading multidisciplinary dysphagia care, providing hope and benefit to people with dysphagia. We aim to return or preserve a person’s quality of life around eating (or to sow the seeds for a life-long enjoyment of eating in an infant). SLPs know that eating may “be what makes life worth living” for some people, as stated by the authors. We see that desire every day, as dysphagia is our profession.
This article was an insult to our profession of Speech-Language Pathology, which has lead the way in dysphagia evaluation and treatment, since Dr Jeri A. Logemann, PhD, CCC-SLP, BCS-S started her research in the late 1970’s. (Read more with this blog honoring our mentor).
My Goal: Correct the Top 10 Errors!
As a board-certified specialist in swallowing and swallowing disorders, I am compelled to respond in detail to transform these errors into teaching opportunities. I have helped with crafting brief response letters with my fellow colleagues at one of the hospitals where I work and with the Dysphagia Research Society, but I felt I needed to do a line-by-line analysis of the errors. I will start each error topic with the authors’ statements in italics, followed by my responses in regular print.
1. “You may have never heard of dysphagia…and the treatment may be worse than the disease itself.”
Dysphagia is not a disease. Dysphagia is a symptom of many different diseases, disorders, structural abnormalities and conditions across the lifespan from premature infants to the elderly. I worry that calling dysphagia a “disease,” may prevent medical teams from searching for the true underlying causes.
2. “Behind your tongue, just a few inches down the back of your throat, lies a dangerous precipice: over one edge it’s a straight shot down your trachea…”
Did we forget the mouth and all that it does to prepare and control the food and liquid? Problems with swallowing start way before the level of the airway. The article over simplifies dysphagia and completely ignores all the phases of the swallow that can be targeted in therapy. Even before the food and liquid enters the mouth, there is a host of sensory information that sets up our system for good motor or movement output. Since the article focuses some of the time on people with Dementia, they should note how the Speech-Language Pathologist (SLP) can offer strategies to address environmental factors, behavioral and cognitive issues, and feeding strategies (along with our occupational therapy colleagues) to make mealtimes more successful.
3. “An estimated 9 million Americans suffer from difficulty swallowing…”
Indeed, as cited by the authors, Dr Bhattacharyya analyzed a 2012 National Health Interview Survey, estimating 9.44 million adults reported a problem. That does not mean that only 9 million adults suffer from dysphagia. The number would be far higher, as many people lack the sensation to feel that food/liquid/pills are stuck in the mouth, throat and/or esophagus (food tube). These people also cannot feel the food, liquid, or even pills going down the wrong way into the airway (trachea). Many different diseases, disorders and other conditions can cause a lack of sensation, including: COPD, Parkinsons, dementia, stroke, radiation after head and neck cancer, and cervical spinal surgeries, to name a few. That is why, if there is any suspicion of dysphagia, a referral to a speech-language pathologist who specializes in dysphagia is warranted immediately for comprehensive testing.
4. “Many of those suffering from dysphagia will end up aspirating, which means that food – along with digestive enzymes and millions of bacteria – veers down the wrong path and into the lungs… If enough food, destructive enzymes and bacteria deviate from the esophagus to the lungs, the results can be deadly…”
Where do I begin?
First, to describe aspiration as “end up aspirating” makes the event sound passive and pointless to even try to prevent it. That is misinformation. Additionally, it is not even solely about aspiration, as there are other negative consequences of dysphagia, such as malnutrition, dehydration and weight loss. This requires appropriate referrals to our colleagues, the registered dietitians (RD). When speech-language pathologists evaluate the swallow, we do not stop at aspiration. We determine WHY the person is aspirating and what we can do actively to prevent it or fix it. We also consider if it is in the goals of care of the patient to try to prevent aspiration at all costs. A cost can be the quality of life of the person with dysphagia. As the authors overly sensationalized, sometimes the treatment becomes too aggressive for patients in the end-stage of their diseases, like dementia. Speech-Language Pathologists provide options from palliative care (where quality of life and enjoyment of eating are the focus) to aggressive care (where aspiration prevention and safety are the main focus). The medical team sits down with the patient and family/caregivers to have what can be a lengthy conversation to review these challenging decision-making processes. Sometimes these thoughtful conversations are unfortunately not completed by the medical team, but they are recommended and maybe even started by the speech-language pathologist. It is not in the scope of practice of the speech-language pathologist to complete these conversations, which determine the ultimate decision-making.
Second, the authors’ statement only focuses on food getting down the wrong way, while the rest of the article suddenly switches to liquids. Food, liquid, pills, saliva, secretions, and the contents of the stomach can all get down the wrong way or be aspirated in the lungs. However, the mechanisms for each item to be aspirated are different.
Thirdly, the authors mentioned that material deviates from the esophagus to the lungs, which only describes ONE mechanism for aspiration. This is where material refluxes up or backflows out of the esophagus and falls into the unprotected airway. (A typical example of this risk would be at night in a dependent patient when lying flat). The authors did not address how people can aspirate during a meal on food particles and liquids, while taking their pills, on a sip of liquid, and/or on saliva and secretions throughout the day. This material falls into the larynx (top of the airway) from the oral cavity or the throat, carrying with it potentially bad bacteria from the oral cavity.
Finally, the authors say: “millions of bacteria,” but the numbers are in the trillions. Every day speech-language pathologists evaluate the oral cavity and provide training to staff on how to improve the oral hygiene. Improved oral care can reduce the risk of getting sick with aspiration pneumonia in our patients who are known to have aspiration. Adequate oral care with brushing teeth and using mouthwash rinses provides hope for dysphagia! However, oral care is often neglected in hospitals, and doctors often do not evaluate the oral cavity sufficiently enough to detect this important root cause of aspiration pneumonia. (For more reading on oral care: https://www.swallowstudy.com/oral-care-aspiration-pneumonia-prevention/)
5. “All that protects us from aspirating is a thin, cartilaginous flap of tissue called the epiglottis. Like all other muscles and tissues in our body, it weakens with aging and illness…”
The epiglottis is not a muscle. It does not have a brain to miraculously flip or not flip to cover our airway. The epiglottis itself cannot weaken with age. This falsehood needs to be put to rest. Too often patients report that their doctors told them that it was simply the epiglottis not working, which can give people a false hope in the simplicity of the fix. We cannot wave a magic wand to just fix the epiglottis?
Any fact checking by the Washington Post would have found numerous research works that review the complexity of swallowing, which is a highly coordinated sensorimotor event that needs to happen within one second. Muscles work in synchronicity to close the vocal cords and lift and close the voice box (larynx). It is the upward and forward lifting of the larynx that starts the passive tilting back of the epiglottis. Effort by the back of the tongue and the throat muscles (pharynx) pushes and squeezes the food and liquid off the back of the tongue and through the throat. The pressure exerted by the tongue base, the throat muscles, as well as the pressure in the ball of the food and liquid itself, flips the epiglottis further and inverts the tip of the epiglottis the rest of the way covering an already closed airway. It is not a perfect seal.
The complexity of the swallow is what is miraculous!
6. “What can doctors do to stop it (aspiration and dysphagia)? Not much.”
This is a horrible thing to tell your patients. Keep in mind, it is NOT in the scope of practice for a general practitioner/internal medicine doctor to fully evaluate and treat dysphagia. So, while the general practitioner may not have much to offer initially, she/he can refer to a speech-language pathologist. Dysphagia is in the scope of practice of the speech-language pathologist, who have a lot of hope for dysphagia to offer.
Why were other disciplines were not mentioned in the article? How do patients know where to go to get help? The swallowing or “deglutition team” may be made up of many disciplines, evaluating and treating the patient in a holistic way: speech-language pathologists, otolaryngologists – ORL or ENTs, gastroenterologists – GI, pulmonologists, radiologists, neurologists, occupational therapists, physical therapists, registered dietitians, respiratory therapists, nurses, and more. Because the speech-language pathologist is an expert in swallowing from the behavioral and pre-oral aspects all the way to the esophagus, he/she is well prepared to perform initial assessments and make appropriate referrals for more testing as needed. The speech-language pathologist’s expertise can help focus the dysphagia evaluation rather than a doctor ordering random tests, making testing more efficient and saving time and money. In the words of Dr Reza Shaker, a famous gastroenterologist and one of the founders of and former president of the Dysphagia Research Society: “we are transdisciplinary deglutologists.” (Read more in my blogs on good dysphagia evaluations guides treatment Part 1 and even more in Part 2).
7. “It begins with sips of water…”
Describing dysphagia assessment as “sips of water” does not even adequately describe the nursing swallow screen, let alone a full dysphagia evaluation (aka, clinical bedside swallowing evaluation). (Please see my blog on Post-stroke dysphagia and risk management that includes a discussion of the swallow screen.) The swallow screen should be seeing if a person can safely swallow 3 ounces of water in a continuous fashion without stopping, as described by Dr Steven Leder and colleagues with the Yale Swallow Protocol. (Please see my blog regarding Leder’s work in this area).
The clinical evaluation performed by a speech-language pathologist is much more involved than sips of water, such as the following purposes:
- Analyze the person’s medical and social history, prior level of functioning, current problems/complaints, including the impact on quality of life;
- Evaluate any cognitive, speech, voice, and/or language problems that may co-occur;
- Perform a full oral evaluation, including: cranial nerves, structural abnormalities, oral/dental hygiene, facial/oral sensation, and facial/oral movement, coordination and strength.
- Test expiratory strength and cough;
- Monitor respiratory pattern and rate to determine if the patient will be at risk for difficulty coordinating breathing and swallowing;
- Provide a full array of food and liquid trials to observe any suspected oral, pharyngeal or esophageal difficulties and overt signs of aspiration or airway compromise.
- Begin the clinician – patient relationship to educate, counsel and treat the person with a person-centered approach, always in line with the person’s goals of care (or that stated by the health care proxy carrying out wishes).
- Begin possible treatment strategies, which could be further assessed for their effectiveness with more extensive swallow testing.
- Realize the limitations of the bedside exam and recommend further testing when needed. The SLP performs a videoswallow study (aka, a Videofluoroscopic Swallow Study/VFSS or a Modified Barium Swallow Study/MBSS ) or an endoscopic swallow study (called a Fiberoptic Endoscopic Evaluation of Swallowing/FEES). Unfortunately, the authors neglected to note the options for FEES testing or other tests that can be performed by the deglutition team (i.e., a Barium Swallow/Upper GI study, endoscopy by ENTs, endoscopy by GI doctors, and manometry studies by ENT and/or GI, just to name a few).
8. “Video swallow studies that quantify the amounts of liquid being aspirated…”
This is one of the most frustrating sentences. If only our evaluation was so simple and quick!
As I noted above, we do not stop an evaluation with aspiration. We figure out why there is a problem and what can be done about it. The instrumental evaluations of swallowing performed by speech-language pathologists include both the VFSS and the FEES, which both have purposes much bigger than just detecting aspiration on liquid.
First of all, we detect safety issues (meaning any secretions, food, liquid, or pills that invade the airway). Then we analyze the efficiency of the swallow (meaning how much of the food and liquid passed cleanly through the mouth, throat and esophagus versus getting stuck along the way). We describe the structural or anatomical problems that could be the source for the difficulty swallowing. We also determine what was wrong with the function or physiology of the swallow to cause the aspiration or residue.
We train the patient during and after the exam, using the video images as biofeedback or for teaching after the exam. We provide a written handout of all the strategies that may help to make meal time successful and enjoyable again. It is common for us to spend well over one hour with a single outpatient VFSS to complete the necessary instruction. We then can continue therapy, as warranted, to address the many rehabilitative approaches and strengthening programs to improve the swallowing coordination, timing and strength.
I want to assure Jacobs & Lang that our evaluations are much more than “evaluating how food passes over the epiglottis,” as they stated in the second to last paragraph.
9. “Treatment of aspiration is to spoil the experience of eating. For a small amount of aspiration, doctors may thicken your liquid drinks.”
“a concoction of unflavored, powdered starch, which can be made to the thickness of either “nectar” or “honey.” (I won’t even repeat the exaggerated descriptions that followed).
“risks of thickening fruit juice to more of a fruit paste.”
“If that is not enough to stop aspiration, doctors make a patient NPO (nothing by mouth)…”
“chin-tucked position found … equivalent in preventing pneumonia.”
“simple chin-tuck maneuver, may be a solution…”
Wait, did I say that number 8 was the most frustrating to me? These statements are worse and more harmful to our patients, encouraging them to see things as black-or-white and with misinformation. This is the era of “fake news,” after all. All too often SLPs hear well-meaning nurses tell people to tuck their chins, without having any testing evidence that it actually works. The chin tuck could cause more aspiration!
We do not thicken liquids only due to a small amount of aspiration. When a person is found to have significant aspiration on the swallow study, this is considered with other holistic information. For example, if the person also has a weakened immune system that may not ward off infection plus a nasty oral cavity that is filled with bad bacteria that could make them sick, we may have to seek careful options to decrease the high aspiration pneumonia risks. One of those options for the dependent patient who may not be able to follow commands for other safe swallow strategies is to try thickened liquids. Patients may be placed on a mildly thick liquid consistency. We certainly do not recommend a “fruit paste,” as was joked about in the current article or an “applesauce consistency,” as was joked about on Twitter. A physician posted a video of himself and his sons dumping corn-starch-based thickener powder into water without measuring and making it way to thick. He shows his sons spitting it out. That is a slap in the face of people who really need thickened liquids.
Thickening liquid should be a temporary compensatory treatment measure, and we realize that it does nothing to rehabilitate or fix the problem. Patients should be re-evaluated when stable and cleared from acute infections, in order to upgrade their food and liquid consistencies.
The authors are likely not informed of the new terminology for thickened liquids and dysphagia diets. Please see www.IDDSI.org for the International Dysphagia Diet Standardisation Initiative’s work to create a new evidence-based framework that includes easily translatable labels for diets and liquid consistencies. The authors mention the old term of “nectar thick,” which according to the new standards is called: “Mildly Thick.” The thicker liquid of “honey thick” now holds the new label of “Moderately Thick.”
Additionally, we recommend gum-based thickeners now, as these may be more palatable, and we hope our institutions’ purchasing will catch up. The older modified food starch or corn-starch-based thickeners can affect the taste of the liquid, feel gritty, can over-thicken in the cup after a few minutes, and can bind with the enzymes in your saliva to thin down in the mouth and cup if contaminated with saliva. If patients do not like the thickened liquids, then they may not drink as much. I have also had patients who actually like the thickened liquids, because they can feel that they are safer for them to swallow. Poor hydration is multifactorial. Staff may also forget to offer enough liquids between meals, as there is no water pitcher at the bedside. People with dysphagia also can be dependent on others to hand-feed them, which may take 30 minutes or more to provide adequate nutrition and hydration in a safe manner. Do staff offer this kind of time?
Displaying treatment options as only thickening liquids versus just a chin tuck shows that the authors have very little understanding of what the speech-language pathologist has in her/his toolbox. My prior writing linked at the beginning of this article has multiple helpful links, including to a webinar I had given in the past on this topic. I stressed that thickening liquids is ONLY ONE TOOL in our toolbox. Additionally, the chin tuck is only one positional compensatory tool, and it must be tested by the speech-language pathologist on an instrumental exam to make sure the chin tuck does not make the aspiration worse. Keep in mind, no doctor or therapist has x-ray vision, and people aspirate silently; therefore, we cannot tell patients sitting in our offices to just chin tuck and all will be fine. See my blog on the chin tuck.
Finally, the authors incorrectly cited the Robbins, et al. (2008) study (https://www.ncbi.nlm.nih.gov/pubmed/18378947) as a 2009 study in one sentence and called the same study a “recent study” in another sentence, when the randomized controlled trial was completed in 2005. They also indicated that it was only with dementia patients, but it was with people with Parkinson’s disease as well. I will not go into the full details of this study or its partner article: Logemann, et al. (2008), so I have provided the Pubmed links: (https://www.ncbi.nlm.nih.gov/pubmed/18230864).
The authors should use caution to not boil down multifactorial issues into just two options, such as either thickened liquids or not eating/drinking anything by mouth. It is up to the medical team to communicate with the speech-language pathologist to learn about the risks but also the many potential treatment options available. Sometimes the options are selecting the least bad one, such as continuing to eat despite the know risks to preserve quality of life in a palliative care approach. Then the team keeps conversations with patients/caregivers open around all options, providing the rationales behind the options. This will help patients/caregivers make sound and informed decisions without coercion or biases from the team. (Please see my blog on The Conversation & the SLP Role in Palliative Care).
10. Let’s tackle the whole NPO issue:
For speech-language pathologists, recommending NPO is the last resort, when all other treatment options have been considered. We do not go around handing out NPO recommendations like speeding tickets! However, at times and for temporary measures, an NPO status may be posed as an option and may be warranted.
It is unfortunate that this decision-making process was portrayed by the authors in such a confusing way. Their statements would hold true had they just stuck with the topic of feeding tubes in people with advanced dementia.
Authors state early in the article: “There are only a few situations where making a patient NPO clearly helps.”
However, the authors contradict themselves later in the article with: “To be clear, there are instances where dysphagia diets, NPO and even feeding tubes make sense. For example, these interventions may be part of the road to recovery from a stroke, surgical procedure, or intensive care unit stay.”
The real problem lies in the statement: “For the majority of the cases, thickened liquids and feeding tubes have questionable benefit at best.”
Let’s pick this apart.
Those broad categories of acceptable diet modification, NPO and feeding tube use could be made even broader and include most of the speech-language pathologist’s caseload in the hospital.
The stroke category could include all acute neurological injuries/lesions/trauma where people are expected to improve over time. These patients are evaluated immediately and placed on the least restrictive diets with multiple recommendations for safer swallow strategies and aspiration precautions. However, this is a large group of people for whom feeding tubes early on may be an viable option to provide nutrition and prevent choking and aspiration pneumonia, while their brain works on recovery. Often people are quite sleepy in the early stages, and eating/drinking by mouth is not a safe or stable method. People can pull tubes out of the nose easily if confused or agitated. Sometimes a more stable feeding tube to the stomach, rather than a tube hanging out of the nose, is needed to get the person off to a rehabilitation center to best participate in all therapies, not just swallowing therapy (e.g., speech therapy, occupational therapy, physical therapy, and respiratory therapy as needed). Patients are then treated aggressively with exercises and therapeutic feeding trials with neuroplasticity principles in mind (i.e., use it or lose it and saliency – which is targeting therapy exercises based on the actual problem found with the person’s swallow structure/function, based on their swallow studies). We are not trying to keep people NPO any longer than is needed for safety.
The category of surgical procedures is also very broad and inclusive. This category should include those who have had cervical spinal surgery, who may initially have poor sensation of their dysphagia deficits. This could include people struggling with head and neck cancer, who have had resections (removal of parts of the mouth and throat) and chemotherapy and radiation therapy. Radiation can have immediate as well as long-term impacts on swallowing.
The broad category of intensive care unit patients is also the majority of some speech-language pathology caseloads. Impacts of critical illness and the subsequent treatments required (e.g., medications, intubations, and invasive procedures) can cause not only delirium but also dysphagia. Temporary diet modifications and/or feeding tubes may help these patients avoid many days of NPO status. Sometimes nutrition is inappropriately forgotten about when the team is focused on all the other aspects of critical care. It takes the registered dietitian to come by and count the exact number of days when the patient had suboptimal or no nutrition. Numbers can be staggering.
Therefore, when the authors go on to say:
“for the majority of the cases, thickened liquids and feeding tubes have questionable benefits at best,” I highly question their numbers to claim a majority. If the authors had just added the words advanced dementia to describe the cases, the statement would have been true.
The authors later noted that “the American Geriatrics Society flatly recommends against placing feeding tubes in patients with advanced dementia.” Yes, we all agree! NPO status and feeding tubes are NOT appropriate for people with advanced dementia. Medicine practice is finally catching up with the research. For years, research has been showing that the placement of feeding tubes in these dependent and bedridden patients with advanced dementia actually causes increased rates of aspiration pneumonia and certainly does not prolong life. Even according to the 2009 Ethical and Religious Directives for Catholic Health Care Services in the United States, artificial nutrition via feeding tubes may offer little “reasonable” hope of benefit to prolong life and may entail “excessive burden” or “discomfort” for patients in the end-stages of diseases. It is okay to decline these extraordinary measures. (See a prior feeding tube blog.)
SLPs can provide a great help to the entire dementia team , which includes the patient/family/caregivers, with a palliative care focus. Diet modifications may be required to prevent actually dying from choking with airway blockage (asphyxiation). Mildly thick liquids may still be needed for some patients to consume liquids more comfortably with less gross aspiration, which can also cause significant discomfort in many people. The SLP can provide strategies to keep the person on a thin liquid with less aspiration or less risk (i.e., improving oral hygiene).
So, yes, as the authors note: “it is time to rethink the way health-care professionals and we as a society address dysphagia.” The way we rethink dysphagia, is for the medical team to use the entire multidisciplinary deglutition team. Have SLPs not been a part of this team because physicians erroneously think that the SLP will just recommend NPO?
Bonus Section on Hope for Dysphagia:
Just can’t stop at 10!
11. Authors use sensationalistic writing with:
“A couple of days without food may be torture, but more than that means starvation.”
“Dinner at a nursing home near you may look like a dystopian fast-food stop: a hallway of humans suffering from dementia with bags of…”
First of all, the medical team needs to stop using the word: “starvation.” This guilt trip is what leads the family members of patients with Dementia to decide on the placement of the feeding tube. They do not want to be accused of starving their loved one to death. The medical team needs to have discussions that include accurate information. People who are at the end of life are often satisfied by just a few bites or sips of water, and do not suffer from the feeling of starvation, according to much hospice and nursing research.
12. My final point, really!
I just had to investigate where this article may have started.
I talked with Kelley Babcock, MS, CCC-SLP, BCS-S, a fellow board-certified specialist in swallowing. She wrote a blog in 2015 in response to the #thickenedliquidchallenge opinions from the team of geriatricians from the University of California at San Francisco (UCSF). This is the same group of geriatricians who were mentioned by Jacobs & Lang in this Washington Post article. Please see Babcock’s informative article here: http://www.geripal.org/2015/03/how-to-succeed-at-the-thickenedliquidchallenge.html
Dr Eric Widera, MD, of UCSF team, recently was on the @thecurbsiders podcast about the “Dementia Dos and Don’ts.” In review of their Dos and Don’ts, it is very disappointing that their recommendation to “construct a multidisciplinary plan of care” does not include a speech-language pathologist on the team. On February 13, 2018, Dr Widera tweeted about the 2016 article that I mentioned at the beginning of this article, which certainly contributed to the negativity around thickened liquids. This all seems to be the likely foundation for the misinformation in this current February 25th article.
I also found a 2015 GeriPal blog that highlights how this out-dated thinking has been threatening effective multidisciplinary care for years. In this blog titled: “Working With Rather than Against Speech & Swallowing Therapists,” Dr Alex Smith shared his fears about ordering a speech-language pathology (SLP) consult:
“I worry that the (SLP) consult will place the patient on an inevitable path toward a PEG tube, without assessment of goals, values, and alternative approaches such as hand feeding.”
Dr Smith seemed surprised that “new speech and swallow recommendations” include an assessment of goals and values related to feeding and nutrition. No, they are not so new. Did old-school SLP thinking contribute to this old myth? Did we flat-out recommend NPO too much in the past without providing rationale and options? SLPs can continually strive to do better. We can all do better for our patients. SLPs provide thoughtful evaluations to highlight the risks, but also to provide options for the team to consider based on the patient’s and family’s goals of care. I often feel like a broken record at the hospital, constantly asking the team to consider the goals of care and a palliative care consult. However, being all part of the same team, we move this complex decision-making process forward!
Provide your patients with hope that evaluations will uncover root causes and treatments can be performed to rehabilitate a more functional swallow, but do not given them false hope that the fix is as simple as a chin tuck or spiffing up that old epiglottis. Multidisciplinary teams need to include the SLP and take the time to have a real sit-down conversations to review options, from palliative care to aggressive measures, with the patient and caregivers or healthcare proxy (when the patient is not able to make complex and informed decisions).