man eating in hospital bed
Toronto Rehab’s Specialized Dementia Unit recently changed their food protocol to allow some patients to enjoy a full-texture diet. (Photo: iStock)

When families speak up, we listen.

That's why, in the fall of 2018, when a family member of a patient on Toronto Rehab's Specialized Dementia Unit (SDU) asked that more fresh fruit and vegetables be incorporated back into their loved one's diet, the care team saw it as an opportunity to reassess their protocol of eliminating hard foods from the unit, by automatically downgrading patients who arrive on a full-texture diet, to soft foods.

A soft food diet is comprised of foods that are easy to chew and swallow. It eliminates fresh fruit such as apples or melons, as well as salad, and whole pieces of vegetables and meat, among other foods.  

The protocol had been put in place more than a decade ago to prevent choking, but it was starting to become clear that it was having implications on more than just patient safety – it was impacting their quality of life, by removing the enjoyment that a variety of full-texture foods offer.

After establishing a Quality Improvement Plan (QIP), where UHN staff identify targeted areas for improvement and chart progress towards creating a positive patient experience and delivering high quality healthcare, the protocol has been lifted.

Today, the decision to put a patient on a soft food diet is determined on a case-by-case basis by the speech-language pathologist (SLP) and registered dietitian (RD) and the majority of patients on the unit now enjoy a full-texture diet.

The road to a whole food diet

"The reason the original protocol was put into place was an ethical concept called non-maleficence, meaning we have a duty to do no harm," explains Andria Bianchi, bioethicist at UHN.

On the SDU, where seniors with dementia may be at a higher risk of choking, a soft-food diet seemed like the right call.

"However, ethics is about balancing principles and values," Andria says. "Our duties and obligations to the UHN community are to do no harm, but we must also look at well-being and quality of life."

So Andria, along with Rebecca Brown, RD, Stephanie Barraco, SLP, and Taylor Strande, SLP, formed a multidisciplinary working group with their nursing colleagues, to solve the problem at hand.

"As we started questioning if this is really the best process, it became evident how great a role food plays in a patient's care experience," says Rebecca. 

"We had been restricting foods from our patients that they could safely enjoy and we felt this needed to change."

Formalizing a new food plan

The team's research proved to be fruitful.

They conducted thorough literature reviews across each of their individual disciplines, and involved consultation with numerous long-term care facilities. The ultimate goal was to find any glaring evidence that one diet was more beneficial than the other.

What they did find was that, for the most part, other similar institutions allowed full-texture foods, which offer better nutrition and hydration, and can also support the delivery of medication.

"There's no one-size-fits-all diet texture for patients on the specialized dementia unit; it's not black and white," says Taylor.

Once the team gained clarity on how they wanted to move forward – and gained support from the unit's Quality & Safety Committee, they introduced a new protocol that allows food texture to be determined, based on the individual needs of each patient.

Since February, out of 25 patients admitted on a full texture diet, only five were downgraded to a softer texture diet by the SLP.

Feedback has been resoundingly positive.

"A lot of our patients on the dementia unit can't speak for themselves, they can't communicate their wants and needs directly, so they use more non-verbal ways of speaking," says Taylor. "Since we rolled out this program, one of the ways they are communicating is that they are actually eating the fresh fruits and vegetables now available to them on their trays."

Rebecca says the results have been impactful for TeamUHN members, too.

"Seeing how we can improve someone's quality of life with changes like this is the reason we do what we do," she says.

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