Water me, please!

Water me, please!

My husband picked some daisies out of our garden, and I thoughtlessly stuck them in a bone-dry vase that was home to a fake Mary Kay promotional daisy. Two days later the real daisies were slumped over and close to expiring, so I filled the vase with water and they miraculously stood tall again, were even perky. The sight of them reminded me of how water is serious business in my line of work.
Like so many other writers, I have a “day” job. Mine happens to be speech-language pathologist (SLP), more specifically “swallowing specialist,” at a state facility for disabled adults. I’ve watched more people chew and swallow than I care to count, but it’s all worth it when I can get them eating again, or if I can help them stay hydrated with water.
Most people take water for granted, but SLPs who specialize in swallowing do not. Unfortunately, we are a strongly divided bunch of professionals—almost as bitterly divided as politicians who choose left or right, red or blue. As a swallowing specialist, you either recommend water to people who aspirate thin liquid into their lungs, or you don’t. For the record, I’m one of those who recommend water, and I’m happy to say that I’ve never sickened or killed anyone with it.
That’s crazy, you’re saying, everyone drinks water! I agree with you; everyone should drink water, but there are SLPs in the world who literally abolish water pitchers from people’s hospital rooms and ask doctors to write orders for NO THIN LIQUIDS. Instead, people are supposed to drink thickened liquids.
What the heck are thickened liquids? Imagine drinking peach nectar all the time, even when you’re thirsty for a simple glass of water. You ask for water and are given a cup of tasteless glop instead—pure water that’s been polluted with powder or gel thickener. Even worse, maybe you’re unlucky enough to have a pudding-thick liquid order. In that case, your water must be eaten with a spoon.
I’m blogging about this today because I need to vent a little. I just acquired a new patient who was parched beyond belief, thanks to a pudding-thick liquid order he’d been cursed with before he got sent to me.
I also want to educate as many people as possible about this dichotomy in the world of speech pathology, so that as many people as possible can “just say no” to thick liquid.
So here’s what it boils down to: If you, or an elderly loved one (they are the ones who typically fall victim to these orders) are ever so sick that you can’t swallow well anymore, please do not accept a NO THIN LIQUIDS order without questioning it thoroughly. And don’t just take my word for it. Educate yourself on the dysphagia.com listserve. Call Frasier Rehabilitation Center in Louisville, KY, the facility that started the “free water” protocol in 1984 and knocked the first crack in the false belief that a drop of water in the lungs will kill you. Attend a seminar by Tom Franceschini through northernspeech.com. You’ll not only be thoroughly entertained, you’ll learn everything you ever wanted to know about swallowing as it relates to good health.
Water is a nutrient we all need to survive. Protect your right to drink it fiercely and advocate for those who can’t speak for themselves.
I’ll gladly try to answer any questions anyone might have about this water controversy.
Stay hydrated!

Lucy Balch
Author of Love Trumps Logic
Second Wind Publishing


Filed under writing

22 responses to “Water me, please!

  1. This is an interesting controversy. Like most people, I suspect, I had never heard of this malady. Are there any treatments for the condition?

    • lucybalch

      That’s a tough question. It depends on what causes the swallowing problem. If a stroke has caused it then very often “spontaneous recovery” takes care of the problem.
      What research is showing now is that aspiration by itself does not cause sickness. In fact, many “normal”people aspirate small amounts of saliva in their sleep every night. What can finally make a person sick is if their immune system is worn down.
      Then you have the people who have structural defects, like throat cancer victims. Their problem remains with them for life and they have to find ways to compensate. Probably more than you wanted to know …. 🙂

  2. Karen Arnold

    This is eye-opening! It’s sad and horrifying to imagine elderly people being denied water and forced to “drink” pudding-like substances instead. It makes me wonder how many other unquestioned medical protocols are causing needless suffering in those too weak or uninformed to protest.

  3. christinehusom

    I know what you mean. I have observed a number of people in the nursing home with swallowing problems, especially liquids. I’m glad you are working to help them swallow water, especially! Those thickened liquids seem gross and we need to stay hydrated 😉 Daisies are hardy, aren’t they?

  4. Wow! I’d never heard of this. Sounds really gross, and it’s hard to imagine how it can be good for anyone.

  5. Joyce

    I have a resident with a pudding thick order. The MD said he could choke/aspirate on “anything”. For a long time he was on thin liquids and was fine. The SLP placed him on pudding thick telling him “it’s this or a Peg tube”. SCARING him! SO, I am trying to reassure him and explain the NEED for water and fluids so he won’t become dehydrated. I ask though, is there “technically” any free water in a thickened drink?
    Nutrition Services Manager

    • lucybalch

      Hi, Joyce, your post breaks my heart. Some claim that there is hydration in thickened water. Based on experience, I say it isn’t enough, particularly when the elderly person on the thick stuff quits drinking it because it’s unpalatable. And then dehydration sets in, which is a far greater danger than the pneumonia-from-water risk.
      Ask your SLP if she’s ever heard of the research that shows its much more harmful to aspirate thick liquid than thin, since it’s harder to clear the lungs. Pneumonia rates have proven to soar for those people who aspirate thickened liquid, and it sounds like your resident is one of those if the doc says he can aspirate on “anything.” Also ask her to check out the water protocol, if she hasn’t already. Good luck! Lucy Balch, CCC/SLP

  6. Lance

    This was a timely blog for me. My dad has lung cancer and during a particularly low point 5 weeks ago he was in the ER with low oxygen and sleep deprived due to coughing. He had many test and one was a barium swallow test. They determined that he was aspirating water and gave him a feeding tube through the nose. He has been home dealing with that ever since. Today he had an injection into one of his vocal chords to help restore his voice and help in swallowing. The ENT saw no reason for him to continue with feeding tube and sent him to do another Barium Swallow test. He passed and the tube was removed but he was put on “honey thick” liquid. We see this as a huge blessing to be able to get him real food instead of that jevity liquid. My concern now that I got home is how does he stay hydrated? Does the thickened liquid work ok to keep you hydrated? How much liquid does he need to take/eat? .Should we use thickened juice?

    Your post has encouraged me to put a call back in to the doctor to get their perspective. Any thoughts or recommended questions I should ask would be appreciated.

    • lucybalch

      Hi Lance,

      I’m so sorry your dad and all of you are going through this.

      My first question would be: what did the Modified Barium Swallow test actually say? Did it show actual aspiration or only penetration? Sometimes SLPs will recommend thick liquids when there is only the risk of aspiration (the liquid is penetrating the laryngeal additus but not falling through the vocal chords). I disagree with thick liquid recommendations when there is only penetration, particularly when elderly people are involved. Research has shown that just about ALL elderly people have some abnormality in their swallow, but most stay healthy. The swallow ages like the rest of our bodies, but we compensate.

      One major reason that people get dehydrated on thick liquid is because they don’t like it so they don’t drink as much as they should. The risk of dehydration is often higher than the risk of aspiration. As far as how much should be taken in each day, be sure to ask the doctor and dietician who worked with your dad in the hospital. They could tell you how much is needed, or if there are any fluid (amount) restrictions.

      With the Frazier Water Protocol (FWP), only the water is thin. All other liquids remain thickened. The logic behind this is that our bodies are made up of large amounts of water (50-80%, depending on age), and the lungs are well equipped to move any water that gets in them out into the body pool. Acidic drinks (OJ), fatty drinks (milk), drinks with dyes (punch), or carbonated drinks, etc. might not be handled as well, particularly if the immune system is weak.
      There are a few rules with the FWP: since the thin water might be (benignly) aspirated, it should be taken by itself. In other words, you don’t want to wash down a piece of steak or a pill with the water, so only drink the thin water outside of meal times and do not use water to take your medications. Unless you have fluid (amount) restrictions, you can drink as much thin water at other times as you want.
      Also, keep up good oral hygiene. You don’t want to wash oral bacteria into your lungs either.

      As I said in my blog 3 years ago, some SLPs do not use the water protocol. However, I’ve been using it successfully for many years, and I swear by it. It keeps people hydrated and healthy!

      Let me know if you have any other questions. I’m happy to answer them!

      Lucy Balch, CCC/SLP

  7. Karen

    The PT where I work recommended thickened liquids for a nursing home resident however the resident is competent and wants to drink thin liquids only. What do I give to him as his registered nurse?

  8. Lucy Balch

    Hi Karen,
    All nursing homes have their rules, so I don’t want to tell you to go against policy.
    That said, If I were in charge of running the swallowing evaluations and treatments at your nursing home, I’d quickly get the resident you mentioned on the Frazier Water Protocol (FWP).
    Some facilities have waiver forms that competent residents (or authorized representatives for incompetent residents) can sign if they want to go against food or liquid intake recommendations. Does your facility have any such thing? Not all facilities require them, but make sure before you offer thin liquid to your resident. I know it seems silly to have to get approval for basic water, but you don’t want to endanger your job.
    Have you talked to your PT, to ask her if she would consider using the FWP? The biggest argument I’ve heard against it is that oral hygiene in most facilities is so poor. Nevertheless, if your competent resident understands the importance of regular tooth brushing in relation to thin water intake, he will probably turn into an three-times-per day tooth brusher!
    Hope this helps.
    Lucy Balch, CCC/SLP

  9. Bonnie

    My mother who resides in a Nursing Facility was prescribed thickened liquids for a month. She almost died of dehydration. Her sodium and blood sugar stats were thru the roof. For my mother, I felt the real issue was that she needed to sit upright and drink on her own.

    • lucybalch

      You have a very good point about positioning and allowing someone to drink independently. Everyone drinks at a different rate, and sometimes the people assisting with the feeding go faster than desired. They often don’t mean to, but they have tight schedules with many people to assist.

  10. Bonnie

    I noticed that the speech therapist at the hospital tested swallowing using a bit of applesauce. I tried adding a small amount of applesauce as a thickening powder substitute – as a texture/thickener when my mother was too sleepy to drink without aspirating. Is there some reason doing this would be dangerous? I have created a controversy at the nursing home and had to sign a waiver to allow my mother plain water to drink. Would applesauce be dangerous if she aspirated it?

  11. lucybalch

    I understand your desire to move away from the powdered thickener, but I don’t think apple sauce is the best option. If thinned apple sauce was aspirated it could lead to bad results, especially if your mom has a compromised immune system.
    If your facility let you sign a waiver for the applesauce drink, would they let you sign a waiver for the Frasier Water Protocol? Too bad the speech therapist at your facility did not initiate it with your mom. I’d have a discussion with her about it.

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  13. Joy Marsh

    My 93 yo father is in rehab after a fall whilst in the same facility rehabilitating from a broken nose.in the fall his hip was broken. He has emphysema. Prostate cancer. Dementia. Sight impaired.( Legally blind).Now the speech therapist has said he can only have thinkened water and liquids. I had been feeding him when visiting. And found he could drink without problem if I held the cup with him. It takes time which staff do not have. I am afraid he will become dehydrated he refuses the thickened water.and is also only given a small cup. What do I do?

    • lucybalch

      Hi Joy,
      Unfortunately, for the very reason you stated (that “It takes time which staff do not have”), speech therapists very often make the thickened water recommendations. It also takes effort in the form of training and good communication for a nursing home to turn the Frasier Water Protocol into policy. Medicare takes the position that patients should be on the “least restrictive diet possible” so you might think that more nursing homes would make the effort, but they don’t.
      Are you your father’s Authorized Representative? If so, you have a voice. Tell the facility that you want your father to have the thin water (other liquids can remain thickened until your father is better). They may have you sign a waiver form to release them from any liability. Also, there are some adaptive cups that will help staff give your father smaller sips of thin water. Look for the Provale Cup online. It comes in a 5cc (tiny sip) or a 10cc(small sip) size.
      I know it’s scary to go against the machine of nursing home policy, especially when you’re signing a waiver. Maybe making that decision will be easier when I tell you this: I have worked with the Frasier Water Protocol for over ten years. In my experience, it has helped many and hurt none. Best of luck to you!
      Lucy Balch

  14. susan hornugn

    my brother is in a nursing home and is stealing milk and water from other patients rooms. he resides in new jersey and I want to know if a lawyer can help us with getting my brother off thicken liquids. he is very unhappy the way it is now.

    • Hi Susan,
      I’m so sorry your brother is experiencing thirst. In a perfect world, he shouldn’t have to.
      Are you there often? Tell the nursing home that you want to sign a waiver to allow him to drink regular (thin) water with his family and friends. They will probably put up a fuss, but if you are the AR you have a lot of say in the matter. If they agree, make sure you only give him the water when he is NOT eating. That way, he will not wash food particles into his lungs (if he is, in fact, a thin liquid aspirator).
      Does he cough with the water? If not, has he had a Modified Barium Swallow (MBS) to confirm aspiration? Maybe he had a MBS but he had it when he was acutely ill? Often times, people who are acutely ill lose the ability to swallow as well, but once they recover they can go back to eating more normally. If this situation fits your brother, ask his doctor is he can have a repeat MBS study. That might just solve your whole problem.
      I hope this helps!
      Lucy Balch

  15. Donna

    Thank you for taking on this issue. My father’s one comfort right now is water and ice. We signed a waiver (after a big fight) that allows us to give him water and ice, but they will not let us leave the water for him. Is there any way to force the nursing home to allow him access to the water?

    • Donna, if you’ve signed a waiver I would think you could leave water for him. The whole point of the waiver is to remove liability from the nursing home, so why would they object? Have you gone to the director of the facility with this? If you’ve gone all the way to the top in the nursing home, without good results, my next step would probably be consulting a lawyer about it. Not sure anything can be done, but a lawyer should be able to give you a lot more information than I can.
      Be proud of yourselves for fighting for the water! Not all families know to do that…or they fall for the scare tactics that they’re given.
      Good luck!

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