Clinical Training Recommendations for Speech-Language Pathologists Caring for Patients with Serious Illness

These training recommendations will help speech-language pathologists address the unique needs of patients living with serious illness.

Examples include health professionals working in oncology, cardiology, or primary care.

Assess the Needs and Concerns of Patients

• Recognize the factors that can influence the efficacy and utility of a speech and swallowing evaluation for patients with serious illness (e.g., poorly controlled pain, delirium, cognitive impairment, language barriers), and alert the treating team prior to testing
• Perform a comprehensive assessment of difficulties related to communication, swallowing, and ability to participate in meal times, and assess the impact of these issues on the patient and caregiver’s quality of life and well-being
• Review caregiving needs and resources
• Understand the impact of medications and routes of administration on the patient’s communication and swallowing, and offer suggestions to the patient’s treating team and/or pharmacist
• Provide alternative communication methods as applicable (e.g., need for adaptive equipment, including call buzzers/switches, communication boards, one-way speaking valves, electronic communication systems)
• Know what palliative care is, and when to request a consult

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Identify the patient’s surrogate decision-maker
• Have conversations with patients to understand what matters most to them now that they have a diagnosis of a serious illness, and participate in shared decision-making that is aligned with patients’ values and preferences as related to communication, swallowing impairment, the sensory experience of eating, and preferences about medically administered nutrition and hydration
• Support patient and caregivers to weigh the benefits and significant burdens of using thickening agents for food
• Identify how culture, race, gender, sexual orientation, and context (e.g., social determinants of health) influence patient and family decision-making in the context of a serious illness, and deliver responsive, unbiased care matched to needs and priorities
• When considering referral to hospice, determine whether the swallowing and/or nutritional supports in place can be continued

Manage Pain and Symptoms

• Recognize the impact of common symptoms associated with serious illness on communication and swallowing (e.g., impact of severe pain on ability to participate in treatment sessions), and alert team members about any symptoms, including pain; nausea and vomiting; constipation and diarrhea; dyspnea; fatigue; depression; anxiety; delirium and agitation
• Identify cognitive-linguistic impairment and risk or presence of swallowing disorder
• Assess the feasibility (access and affordability) and tolerability/acceptability of the care plan with the patient (e.g., prescribed use of liquid thickening agents or modified diets)
• Identify patients that would benefit from a specialty palliative care consult for complex or intractable symptoms, or issues related to communication, swallowing function, and social aspects of oral intake, and initiation of medically administered nutrition and hydration; educate patient and family on palliative care, and refer patients or discuss with the care team

Prevent Crises and Plan Ahead

• Collaborate in discharge planning
• Recognize non-physical sources of suffering, and collaborate with colleagues to provide support when needed
• Assess home support system for optimal and safe feeding, as per goals of care, and for alternative communication methods
• Support the patient and family on whether to initiate medically administered nutrition and hydration (weighing the risk of aspiration from oral intake against the experience of eating and drinking, based on patient preferences)

Complete the Learning Pathway, Foundational Skills for All Speech-Language Pathologists, to acquire these skills.

Examples include clinicians working in geriatrics, home-based care, or nursing home settings

Assess the Needs and Concerns of Patients

• Determine patient/member’s level of knowledge about their illness
• Listen actively for emotional, social, psychological, cultural, and spiritual sources of distress related to communication and/or food intake; invite dialog on these issues and alert appropriate team members
• Assess for common factors affecting communication and swallowing, and advocate with the treating team for effective management, including:
  • Social risk factors (presence of caregiver; caregiver burden; racism and other culturally-bound factors that influence care; access to housing, food, and transportation; financial strain, for example, the ability to pay for medications, equipment, or food supplements, thickening agents, and modified foods needed to maintain communication and swallow function, or in the case of non-oral nutrition, home administration of intravenous nutrition)
  • Polypharmacy and its impact on communication and swallowing function
  • Emotional, social, psychological, cultural, and spiritual sources of distress (anxiety, etc.)
  • Physical symptom distress (pain, dyspnea, constipation, diarrhea, etc.)
  • Communication barriers (e.g., vision, hearing, dental issues, nonspeaking status, language, and health literacy)

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Facilitate and participate in conversations with patients and families about what to expect in the future
• Participate in conversations about patients’ goals of care, and advocate on behalf of patients’ values and preferences related to communication, swallowing, eating as a social function, and medically administered nutrition and hydration
• Conduct skilled conversations with patients and families about:
  • Bad news (e.g., results of diagnostic swallow exams, anticipated loss of ability to swallow or communicate through speech)
  • Prognosis (communication and swallowing)
  • Patient/family expectations
  • Financial strain
• Provide education regarding coping with serious illness and its impact on communication and swallowing; self-care; alternatives to maximizing safe oral intake; and benefits and burdens of medically administered nutrition and hydration

Manage Pain and Symptoms

• Anticipate the full spectrum of symptoms related to specific serious illnesses and along the disease trajectory
• Contextualize treatment and/or interventions to incorporate the values, meaning, and priorities of each individual patient to provide person-centered, family-focused, and culturally congruent care

Prevent Crises and Plan Ahead

• Identify community resources that can support patients living with serious illness, and their caregivers (e.g., support groups)
• Identify barriers to meeting patient and family needs and honoring their priorities (oral intake in spite of swallowing disorders or medically administered nutrition and hydration), and discuss the least restrictive alternatives (e.g., provide modified diets)
• Develop a proactive assessment and plan, in the event of choking, a severe aspiration event, or pneumonia

Complete the Learning Pathway, Additional Skills for Speech-Language Pathologists who Focus Primarily on Supporting People with Serious Illness, to acquire these skills.

Thank you to the following clinicians for their review of these recommendations: Marta Kazandjian, MA, CCC-SLP, BCS-S, FASHA