SALT 2
This is a long overdue post and I have quite a lot to catch up on.
I have been waiting to meet the Speech And Language Therapist for some time. I spoke to her on the phone after the first time she saw Rosemarie (I was not present) but since then the Clonazepam has been stopped and I thought this may have made her swallowing easier. I had asked for another referral (and stressed I wanted to be there) but had been told that the waiting list was 28 weeks. Good Nurse, before she went on maternity leave, was trying to get a SALT from the Rapid Response Team to do an assessment, but whenever I chased either of these options up I got no feedback.
Then on Sept 21st I got a call from the Care Home at 9.30 advising me that the SALT was visiting at 12.30. That day. Three hours' notice. Lucky I wasn't working.
Of course 12.30 is lunchtime, and a good time to observe Rosemarie eating. I am not normally there to give her lunch so she has it in the lounge. I moved her to her room to feed her because it was more private (for the assessment) and had the microwave (hot food).
The SALT duly arrived and turned out to be the person I had talked with on the phone all those months ago. She had been coming to the Home to see another resident and had seen Rosemarie's name on the list and decided to squeeze her in.
I was feeding Rosemarie when she arrived and for a few minutes she just sat and watched, getting up from time to time and listening through her stethoscope to Rosemarie's throat as she was eating. I had a very strong feeling that I was being assessed just as much as Rosemarie.
I am always very cautious feeding Rosemarie but I wanted to represent the full range of techniques the Home uses to feed her. This provoked some slightly alarmed comments from the SALT and we had a very useful discussion about her problems and how to address them.
The 'three swallows' rule still applies and the SALT explained in detail the mechanics of swallowing food and showed me how to recognise the stages. It is apparent that the whole process is problematic for Rosemarie and although sometimes she does swallow easily and in one or two attempts it is the exception not the rule.
It made me worried that the speed at which the carers feed her is perilously close to force feeding and I asked the SALT to write all this down in Rosemarie's notes so it was part of her care plan.
She also pointed out behaviour that she characterised as Rosemarie indicating that she didn't want any more food. This included turning her head away from the spoon, keeping her teeth closed and tilting her head back. When I write it like that it seems pretty unambiguous, but it is not that simple. Sometimes, I think, she does not register me telling her that food is coming and she responds to the spoon as a foreign object touching her lips. When I repeat that I am giving her hot food she opens her mouth and accepts it. Of course, it could be that she feels full or tired and doesn't want to eat, but this decision does not persist and she is easily 'tricked' into eating by trying again a few seconds later. I also think that sometimes she is trying to indicate that the food is unappetising or too cold: heating it up in the microwave makes it more palatable.
The SALT pointed out that Rosemarie gets very tired and the process of eating is much more arduous for her because less of it is automatic. She also may be filled up by the thickened liquids she is given regularly.
I said to the SALT that if we stopped feeding her the first time she refused a spoonful she would starve to death in short order. Her response was that any type of forced feeding increased the risk of aspiration. If Rosemarie really didn't want to eat her food it was not in her best interests to force her, so it all becomes about interpreting the signals.
Which raises another more chilling possibility.
Rosemarie's communication options are incredibly limited. If she decided deep inside that she had just about had enough of all this and wanted it to end, about the only communication option available to her is to refuse food.
This is all so complicated.
I have been waiting to meet the Speech And Language Therapist for some time. I spoke to her on the phone after the first time she saw Rosemarie (I was not present) but since then the Clonazepam has been stopped and I thought this may have made her swallowing easier. I had asked for another referral (and stressed I wanted to be there) but had been told that the waiting list was 28 weeks. Good Nurse, before she went on maternity leave, was trying to get a SALT from the Rapid Response Team to do an assessment, but whenever I chased either of these options up I got no feedback.
Then on Sept 21st I got a call from the Care Home at 9.30 advising me that the SALT was visiting at 12.30. That day. Three hours' notice. Lucky I wasn't working.
Of course 12.30 is lunchtime, and a good time to observe Rosemarie eating. I am not normally there to give her lunch so she has it in the lounge. I moved her to her room to feed her because it was more private (for the assessment) and had the microwave (hot food).
The SALT duly arrived and turned out to be the person I had talked with on the phone all those months ago. She had been coming to the Home to see another resident and had seen Rosemarie's name on the list and decided to squeeze her in.
I was feeding Rosemarie when she arrived and for a few minutes she just sat and watched, getting up from time to time and listening through her stethoscope to Rosemarie's throat as she was eating. I had a very strong feeling that I was being assessed just as much as Rosemarie.
I am always very cautious feeding Rosemarie but I wanted to represent the full range of techniques the Home uses to feed her. This provoked some slightly alarmed comments from the SALT and we had a very useful discussion about her problems and how to address them.
The 'three swallows' rule still applies and the SALT explained in detail the mechanics of swallowing food and showed me how to recognise the stages. It is apparent that the whole process is problematic for Rosemarie and although sometimes she does swallow easily and in one or two attempts it is the exception not the rule.
It made me worried that the speed at which the carers feed her is perilously close to force feeding and I asked the SALT to write all this down in Rosemarie's notes so it was part of her care plan.
She also pointed out behaviour that she characterised as Rosemarie indicating that she didn't want any more food. This included turning her head away from the spoon, keeping her teeth closed and tilting her head back. When I write it like that it seems pretty unambiguous, but it is not that simple. Sometimes, I think, she does not register me telling her that food is coming and she responds to the spoon as a foreign object touching her lips. When I repeat that I am giving her hot food she opens her mouth and accepts it. Of course, it could be that she feels full or tired and doesn't want to eat, but this decision does not persist and she is easily 'tricked' into eating by trying again a few seconds later. I also think that sometimes she is trying to indicate that the food is unappetising or too cold: heating it up in the microwave makes it more palatable.
The SALT pointed out that Rosemarie gets very tired and the process of eating is much more arduous for her because less of it is automatic. She also may be filled up by the thickened liquids she is given regularly.
I said to the SALT that if we stopped feeding her the first time she refused a spoonful she would starve to death in short order. Her response was that any type of forced feeding increased the risk of aspiration. If Rosemarie really didn't want to eat her food it was not in her best interests to force her, so it all becomes about interpreting the signals.
Which raises another more chilling possibility.
Rosemarie's communication options are incredibly limited. If she decided deep inside that she had just about had enough of all this and wanted it to end, about the only communication option available to her is to refuse food.
This is all so complicated.
posted by Other Kosh at 10:46 am
1 Comments:
Jeez.
So, so difficult.
Big, big hugs
Mxx
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