A Little Coughing

Things seem to have settled into a routine. Most days Rosemarie is up after breakfast unless she is 'too sleepy' (which usually coincides with staff shortages) and usually dozing (bored) when I arrive. She seems to be sleepy after lunch (but then so am I) and more alert late afternoon / early evening.  We have managed several trips to the garden when it is warm enough, and we talk about the flowers and the pigeons and the fox or I read to her.

But there is always something.

Rosemarie was moved on to a pureed diet with thickened fluids because she was aspirating and this hugely increased the risk of lung infection. The SALT wrote down the guidelines for feeding her and promptly discharged her. The dietician did a 'consultation' over the phone with a nurse who was not familiar with Rosemarie and promptly discharged her.

I have been working with Good Nurse to get these two professionals back to do another assessment. There is some ambiguity about whether she is supposed to be on Stage 2 or Stage 3, and the feeding notes need to be clarified.

I was originally told the pureed food should be the consistency of 'custard' - whatever that means - but the consistency of the food she is provided with varies from what is basically finely chopped mince beef with or sometimes without gravy, and regular mashed potatoes, to a plate full of thick soup. For sweet she is sometimes given a regular yoghurt, sometimes an Extra Thick yoghurt, and sometimes Nutilis Stage 3, which has the consistency of grout. 

The juices, water and tea(!) are thickened with Nutilis Clear, and the instructions are to put the powder in the cup first, then add the liquid (two scoops per 200ml). Any unused preparation should be discarded after two hours.

The result obviously depends on the consistency of the liquid you start with: water is the most...watery, along with tea and thin juice. I supply thicker juices, and the Care Home supplies Ames Complete, which is the consistency of drinking yoghurt. 

So you can wind up with anything from the thickness of double cream to thick jelly (the latter if two heaped scoops have been put into thicker juice and left for three hours or more). 

And the other day a care worker came in with a cup of tea, put a single scoop of thickener in, gave it a quick stir and made Rosemarie drink it from the cup (not with a spoon). When I enquired why she had only put in one scoop she told me it was so Rosemarie would find it easier to drink.

If the consistency is so important it is important that it is....consistent.

And I am not sure now how important it is.

The rule seems to have been allowed to develop that if Rosemarie starts coughing she is aspirating and something is going wrong. This originates from the SALT instructions posted on her wall, that states that if she starts coughing or displays signs of shortness of breath, the doctor should be notified immediately. It makes sense as far as it goes, but doesn't really define what it means by coughing. Obviously if she is distressed and coughing hard, having difficulty breathing, watery eyes, red face....no question. But a couple of quiet coughs, and an attempt to clear her throat of phlegm....?

The guidelines also say she should be as near upright as possible (60 to 90 degrees), fed small portions, and given plenty of time to swallow (the suggestion is that she may take three swallows to clear her mouth of each spoonful).

In a one to one setting, with a microwave handy to reheat the food, and attentive family or friends, this is possible, and she can be fed a variety of consistencies with no or only occasional coughing.

If she is being fed in the lounge it is a different matter. The chair is often tilted right back so her spine is at 45 degrees ('in case she falls out') and if there is no cushion behind her head it will tilt back even more.

The care workers (maximum 4) have nine residents who need feeding, plus the others who need serving. So what are the chances of Rosemarie being fed slowly and in small portions?

I am sure they try. These are not bad people, just overworked. But I have seen Rosemarie presented with the next spoonful while she is still chewing the previous one. This is a recipe for coughing, if not aspiration. 

And once she starts coughing, the temptation is to stop feeding her 'because there is a risk'. Not 'give her a chance to settle down again then take it slowly'. Twice in the past week I have been told that they had to stop giving her lunch because she started coughing. I don't really want to make a direct allegation, but I can see how it is convenient if there is a reason to have one less person to feed...I am sure it would all be subconscious.

I really need to be there when the SALT and dietician visit.