March 3

What to do when the answer is no


I’m sure many of us have run into the problem where we ask for an instrumental swallow evaluation and we are told no whether it is nursing, the administrator, or the NP writing the orders. What then?

Let’s go through an example. Let’s say that a new admit to your facility arrived following a stroke. This patient did not have an instrumental swallow evaluation at the hospital because by the time it was appropriate, the patient was discharged to your facility. You complete the clinical swallow examination and administer the Yale 3oz Water Protocol. The patient is not able to pass. So you do what is supported by the evidence and ask for an instrumental examination. Then you are told no. 

What next? You provide evidence and education on why an instrumental swallow study is necessary for treatment. You explain why just putting the patient on thickened liquids is a terrible solution. You explain how getting a FEES would actually make the facility money because it would offer the proof needed for continued treatment. And still, the answer is no. 

So what are the options? 

1. You could just treat without the instrumental. You could guess which exercises may help and guess what would be the safest and most appropriate for the patient. You could just hope that what you are doing is keeping the patient safe. Not a great option…

Or 2. You could say that you can not ethically and effectively provide dysphagia therapy without imaging and so you are forced to discharge the patient. 

Does #2 cause anxiety? You might say, “well we can’t just not treat the patient.” I would ask, how do you know your “treatment” is doing more good than harm? How do you know it is making things better instead of worse? How do you know that the patient even needs treatment? 

What if the doctor never took your blood pressure but put you on a blood pressure medication “just in case?” How would you feel if your orthopedic surgeon decided to do knee surgery without imaging because “You probably need it?” Not great. 

So why do we allow this to happen with our dysphagia patients? Until we stop providing treatment without imaging, we will continue to hear “no.” Let’s change this for our patients. 



Advocacy, Clinical Focus, Dysphagia, FEES, Med SLP, Mobile FEES, SLP, Swallowing, Treatment

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