Speech and Language Therapist Dysphagia: Kolb

Concrete experience

I assessed a man in his eighties on a stroke ward with moderate oropharyngeal dysphagia and evidence of aspiration on thin fluids. I recommended thickened fluids and a modified diet. He refused both, clearly and consistently: he had watched his wife on thickened fluids in her last months and would rather take the risk of a chest infection than, in his words, drink glue for whatever time he had left. I checked his understanding of the risks - it was accurate, and his capacity was not in doubt. I initially responded by re-explaining aspiration pneumonia in more detail, and the conversation became strained; he stopped engaging and looked at the window until I left. I returned the next day, apologised for pushing, and instead asked what mattered most to him about eating and drinking. From there we agreed a risk-feeding plan: thin fluids upright with supervision, strategies he was willing to use, and clear documentation of his informed decision, agreed with him, the consultant, the nursing team and his daughter.

Reflective observation

The first conversation failed at the moment I treated his refusal as a comprehension problem. He had not misunderstood my assessment; he had understood it perfectly and weighed it against values I had not asked about. Re-explaining the risks was, from his side of the bed, being told the same thing louder - and the window-staring was not disengagement from his care but from me. What changed everything on day two was a single question about what mattered, which cost nothing clinically and reframed me from opponent to ally. I also noticed my own discomfort was doing hidden work in that first conversation: a patient aspirating on my watch felt like my failure, and some of my persuasion was really about managing my own accountability anxiety rather than his safety.

Abstract conceptualisation

The principle I draw is that a dysphagia recommendation is an offer of information for a decision that belongs to the patient - and that when a capacitous patient declines, my role changes rather than ends: from recommending the safest option to making their chosen option as safe as it can be. Risk in these cases is not a fixed quantity to be accepted or refused but something that can be actively engineered downward around the patient's values. A refusal, properly handled, is the beginning of a different care plan, not the failure of the first one.

Active experimentation

I now open all dysphagia feedback conversations by asking what eating and drinking mean to the person before presenting any recommendation, and in the four such conversations since, two produced modified plans I would previously have read as non-compliance and now recognise as shared decisions. I have drafted a risk-feeding conversation guide for our team based on this structure, which our lead SLT is reviewing, and I presented the anonymised case at our journal club alongside the professional guidance on eating and drinking with acknowledged risk. My documentation has changed too: I record the patient's values and the risk-mitigation plan with the same care I previously reserved for the impairment findings.