How Speech Pathologists Can Enhance Communication with Seriously Ill Patients

Medical speech-language pathologists are regularly consulted for management of disordered swallowing in seriously ill patients. This is certainly a critically important role, because many seriously ill patients do suffer from dysphagia, including individuals post-stroke, with traumatic brain and spinal cord injuries, neurological disorders (e.g., Parkinson’s disease, Alzheimer’s disease, Amyotrophic Lateral Sclerosis), tracheostomy and/or ventilator dependence, and head or neck cancer. In fact, research shows that many patients receiving palliative care struggle with dysphagia. Dysphagia is associated with overall reduced quality of life and general discomfort. The medical speech pathologist understands the impact of dysphagia and associated consequences of aspiration on the overall health of the patient. This can aid the medical team in understanding the risk of oral feeding and how the medical speech pathologist will manage factors to reduce risk.

However, the role of a medical speech pathologist in palliative care goes beyond the facilitation of safe feeding and swallowing. Speech pathologists are also communication experts. We can facilitate and enhance communication between the seriously ill patient and their health care team. We will establish a reliable method of communication that’s appropriate for each patient, based on their specific abilities and needs. As a result, a speech pathologist can be an excellent addition to a palliative care team.

Swallowing, of course, remains a top priority for speech pathologists. We work to develop a feeding plan that optimizes quality of life for our patient, balancing safety concerns with the patient’s wishes. But it’s not an either-or situation. We can focus on addressing challenges in swallowing while also addressing communication deficits.

In fact, I believe it’s important to establish good communication even before conducting a swallowing evaluation. This is a fundamental step, making sure you, your team, and the patient can communicate. Because palliative care is so fundamentally rooted in quality of life, communication is paramount. Without an established avenue of communication, the team is limited in its knowledge of a patient’s wishes and goals of care. In some cases, a seriously ill patient may be completely nonverbal, yet alert and fully cognizant of their goals. When a medical speech pathologist is called to consult on these individuals, perhaps in the intensive care setting, they use their skills to determine whether the patient is cognitively intact—or at least able to understand questions posed to them by their medical team—by determining a reliable response mode. Even nonverbal patients limited to eye movements may be able to answer yes/no questions or spell complex messages to their team with the assistance of a medical speech pathologist.

As an example, I once consulted on a patient who nodded his head in response to every question that he was asked. I suspected that he didn’t actually understand what the team was asking, so I formulated several very specific questions to gauge his actual comprehension. I quickly determined that he had aphasia and didn’t actually understand what we were asking him—hence the constant nodding, no matter what anyone said. I talked to his care team and told them that his ability to make decisions for himself was very limited, even though he was awake and seemed alert. They were surprised, but appreciative of this information because it altered how they approached his care.

It’s not difficult to envision the addition of a speech pathologist to the palliative care team. Often, speech pathologists are already involved in care that could be described as palliative without the official title of palliative care.

We are frequently consulted to see patients in the late stages of advanced dementia when there are limited options for management. Often, these individuals have limited oral (PO) intake and decreased cognition and communication function. Based on what we know about the potentially harmful effect of tube feeding in advanced dementia, my first goal as a medical speech pathologist is not to recommend nothing by mouth (NPO) or a gastrostomy tube. But I can participate in collaborative communication with the family and help the palliative care team as we educate them about what “success” looks like in the advanced stages of dementia. I can help family members or caregivers learn how to provide the best possible care for their loved one to enhance their quality of life, including optimizing safe food intake through careful hand feeding and positioning the patient to reduce the risk of aspiration. And I can help caregivers maximize remaining communication skills by exploring and reinforcing what abilities the patient has retained (e.g., recognition of family members, memories of past events, responses to favorite songs).

Speech pathologists can also encourage people to seek palliative care, because we know the advantages it can provide for patients with many serious medical conditions. I have been working with a patient with amyotrophic lateral sclerosis (ALS). His primary care doctor originally referred him to me after he experienced a few choking episodes, and based on his symptoms, I recommended his doctor pursue a neurological workup. He was diagnosed with ALS and began outpatient speech and swallowing therapy. We had a frank conversation about the likely progression of his disease as it relates to airway protection, swallowing, and communication, and we discussed the benefits of meeting with other palliative care practitioners to create a complete management plan for his symptoms. I think palliative care could benefit both him and his wife, and I believe that I have a vital role as part of his team, in particular, because as a speech pathologist, I understand the unique challenges to his communication and swallowing.

As you explore working with speech pathologists in your practice, I suggest that you embrace these steps:

1. Learn who your medical speech pathologists are, and get to know those who have a particular interest in serious illness. Some medical speech pathologists have received training in serious illness conversation skills and can be a tremendous asset to your team.
2. Involve the medical speech pathologists in your IDT rounds and ask for their input.
3. Request communication tips from speech pathologists when you encounter patients that seem to be distressed and having difficulty expressing themselves.
4. Be specific when consulting medical speech pathologists. Just as you would have to query a general “palliative care to see” order, they will feel the same way. Be explicit about what you want them to do, in terms of communication, swallowing, or both, and how they can support the team.
5. Pick up the phone and discuss the patient as you would with any other consultant. As you become comfortable with each other, you can talk through cases together. Then, in the future, it will become automatic to involve the medical speech pathologist early on in the care of a patient with a serious illness, and challenges to communication and swallowing.

The importance of palliative care in the management of communication and swallowing has received increasing attention in speech pathology programs and practices. As Puntil-Sheltman (2013) commented, “….what happens when the patient has a progressive terminal illness with a possible poor outcome? Speech pathologists can also play a key role in opening the door for patients to be introduced to palliative care.” I look forward to increasing the collaboration between our professions and opening that door for the benefit of our mutual patients.

• CAPC Clinical Training Recommendations for Speech Language Pathologists Caring for Patients with Serious Illness
• Learning Pathways for Speech Language Pathologists

Edited by Melissa Scholl. Clinical review by Andrew Esch, MD, MBA.