Physicians’ behavior regarding non-acceptance of oral restriction (<i>nil per os</i>) by dysphagic patient with risk of laryngotracheal aspiration

Alvarenga, Frederico de Lima; Haddad, Leonardo; Silva, Daniel Marcus San da; Alvarenga, Eliézia Helena de Lima

doi:10.31744/einstein_journal/2020AO4952

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Original Article • Einstein (São Paulo) 18 • 2020 • https://doi.org/10.31744/einstein_journal/2020AO4952 copy

Physicians’ behavior regarding non-acceptance of oral restriction (nil per os) by dysphagic patient with risk of laryngotracheal aspiration

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To define physician´s behavior in the face of a mentally capable elderly dysphagic patients at risk of pulmonary aspiration, who do not accept oral restriction.

Methods:

Observational, cross-sectional study, presenting a clinical case of an independent elderly with clinical complaints of dysphagia and laryngotracheal aspiration by flexible endoscopic evaluation of swallowing who rejected the proposal to restrict oral diet. A questionnaire about the patient's decision-making process was used to assess whether the physician was sympathetic and justify their answer, and if they are aware of hierarchy of ethical principles (recognition of the person´s value, autonomy, beneficence, nonmaleficence and justice), in the decision-making process, and which was the main principle that guided their decision.

Results:

One hundred participants were classified by time since graduation as Group I (less than 10 years) and Group II (more than 10 years). Of them, 60% agreed with the patient's decision, with no difference between the groups. The main reason was autonomy of patients, in both groups. Among those who were not sympathetic, the main argument was beneficence and nonmaleficence, considering the risk between benefit and harm. As to awareness about the hierarchy of principles, we did not find differences between the groups. Autonomy was the principle that guided those who were sympathetic with the patient's decision, and justice among those who didnot agree.

Conclusion:

Physicians were sympathetic with the patient's decision regarding autonomy, despite the balance between risks of beneficence and nonmaleficence, including death. We propose to formalize a non-compliance term.

Keyword:
Deglutition disorders; Bioethics; Dysphagia; Aged; Personal autonomy

Variable		Total	Time since graduation		OR	95%CI		p value
		Total	Up to 10 years	More than 10 years		95%CI
		(n=100)	(n=58)	(n=42)		Inferior	Superior
Sympathetic								0.192^* * χ2 test;
	No	31 (31)	15 (25.9)	16 (38.1)
	Yes	69 (69)	43 (74.1)	26 (61.9)	0.57	0.24	1.34
Argument^† † 3 people from the group with up to 10 years since graduation did not respond;
	Autonomy	35 (36.1)	23 (41.8)	12 (28.6)	0.56	0.24	1.31	0.178^* * χ2 test;
	Autonomy versus do good versus avoid evil	33 (34.0)	14 (25.5)	19 (45.2)	2.42	1.03	5.71	0.042^* * χ2 test;
	Do good and avoid evil	26 (26.8)	16 (29.1)	10 (23.8)	0.76	0.30	1.91	0.561^* * χ2 test;
	Autonomy and dignity	3 (3.1)	2 (3.6)	1 (2.4)	0.65	0.06	7.38	>0.999^‡ ‡ Fisher's exact test.

Variable		Total	Time since graduation		OR	95%CI		p value
		Total	Up to 10 years	More than 10 years		95%CI
		(n=100)	(n=58)	(n=42)		Inferior	Superior
Awareness of hierarchy								0.764^* * χ2 test;
	No	47 (47)	28 (48.3)	19 (45.2)
	Yes	53 (53)	30 (51.7)	23 (54.8)	1.13	0.51	2.51
Hierarchy^† † one person of the group with more than 10 years since graduation did not hierarchize;
	Autonomy	43 (43.4)	26 (44.8)	17 (41.5)	0.87	0.39	1.96	0.739^* * χ2 test;
	Dignity	9 (9.1)	6 (10.3)	3 (7.3)	0.68	0.16	2.91	0.732^‡ ‡ Fisher's exact test.
	Beneficence	32 (32.3)	23 (39.7)	9 (22)	0.43	0.17	1.06	0.064^* * χ2 test;
	Justice	15 (15.2)	3 (5.2)	12 (29.3)	7.59	1.98	29.05	0.001^* * χ2 test;

		Group I						Group II
Variable		Not sympathetic	Sympathetic	OR	95%CI		p value	Not sympathetic	Sympathetic	OR	95%CI		p value
Variable		(n=15)	(n=43)	OR	Inferior	Superior	p value	(n=16)	(n=26)	OR	Inferior	Superior	p value
Main principle in decision
	Autonomy	6 (40.0)	20 (46.5)	1.30	0.40	4.31	0.662^* * χ2 test;	2 (12.5)	15 (60.0)	10.50	1.95	56.56	0.003^* * χ2 test;
	Dignity	1 (6.7)	5 (11.6)	1.84	0.20	17.18	>0.999^† † Fisher's exact test.	1 (6.2)	2 (8.0)	1.30	0.11	15.69	>0.999^† † Fisher's exact test.
	Beneficence	6 (40.0)	17 (39.5)	0.98	0.30	3.26	0.975^* * χ2 test;	4 (25.0)	5 (20.0)	0.75	0.17	3.35	0.717^† † Fisher's exact test.
	Justice	2 (13.3)	1 (2.3)	0.16	0.01	1.85	0.161^† † Fisher's exact test.	9 (56.2)	3 (12.0)	0.11	0.02	0.50	0.004^† † Fisher's exact test.

		Group ENT I						Group ENT II
Variable		Not sympathetic	Sympathetic	OR	95%CI		p value	Not sympathetic	Sympathetic	OR	95%CI		p value
Variable		(n=10)	(n=26)	OR	Inferior	Superior	p value	(n=10)	(n=11)	OR	Inferior	Superior	p value
Main principal in the decision
	Autonomy	3 (30)	14 (53.8)	2.72^† † there are no cases to estimate.	0.57	12.91	0.274^* * Fisher's exact test;	1 (10)	7 (63.6)	15.75	1.42	174.25	0.024^* * Fisher's exact test;
	Dignity	0 (0)	3 (11.5)				0.545^* * Fisher's exact test;	2 (20)	1 (9.1)	0.40	0.03	5.25	0.586^* * Fisher's exact test;
	Beneficence	6 (60)	9 (34.6)	0.35^† † there are no cases to estimate.	0.08	1.58	0.260^* * Fisher's exact test;	3 (30)	2 (18.2)	0.52	0.07	4.00	0.635^* * Fisher's exact test;
	Justice	1 (10)	0 (0)				0.278^* * Fisher's exact test;	4 (40)	1 (9.1)	0.15	0.01	1.68	0.149^* * Fisher's exact test;

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[1] Corresponding author: Frederico de Lima Alvarenga, Ambulatório de Disfagia da Universidade Federal de São Paulo Rua Pedro de Toledo, 947, Zip code: 04039-032 – São Paulo, SP, Brazil, Phone: (55 11) 98245-2177, E-mail: frederico.a.lima@hotmail.com