Does Mr. Brown understand the infor-mation regarding his condition? Please enable it to take advantage of the complete set of features! Background: PEG tubes are commonly inserted in patients with acute stroke and persistent dysphagia. This can lead to chest infections or pneumonia. 2016 Aug 22. 2022 Feb 2;12:800029. doi: 10.3389/fimmu.2021.800029. It isnt a peg in belly?I abjure the peg in belly because I know how big are complications. There is some debate, for example, about whether feeding tubes actually extend life in end-stage Alzheimers disease. But she eats so little. Dietary Habits, Food Product Selection Attributes, Nutritional Status, and Depression in Middle-Aged and Older Adults with Dysphagia. Some people create a written statement about their wish to avoid specific treatments. This is no longer true, due to modern medicines techniques to prevent and treat pneumonias. Front Public Health. Get them to explain to you if you should be trying to get Grandma to eat. Im law officer and no matter that Im her tutor by law, without permission of doctor I cant do anything of this. Call 999 if you think you are having a stroke, Find out more about the Stroke Association, Making treatment choices on behalf of someone else. Ultimately, death will result from starvation and dehydration when nutrition and fluids are refused 2. Normal hydrocephalus. WebEarly tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. They will be moved to keep limbs flexible and avoid pressure ulcers, and staff carry out basic hygiene like tooth brushing and washing. It is hard to see our loved ones pushing away the food we give them because food is so tied up with the idea of loving, caring and nurturing, we know that we must eat to live and to stop is to admit that life is coming to an end. This is what Second, the placement of the gastrostomy tube was described as "permanent." MeSH BMJ Open Gastroenterol. The site is secure. doi: 10.1002/14651858.CD000323.pub2. And doctor refuse all the options without conversation. This is not always a sign of recovery, and involuntary movement can be seen even in a deep coma. Qiao J, Wu ZM, Ye QP, Dai M, Dai Y, He ZT, Dou ZL. I'm a senior care specialist trained to match you with the care option that is best for you. Thank you! lacement of surgical feeding tubes among patients with severe traumatic brain injury requiring exploratory abdominal surgery: better early than late. Clinical guidelines for stroke recovery published by the American Heart Association and the American Stroke Association recommend feeding tube placement This is sometimes called unconsciousness or coma, and it means that important parts of the brain are not working well. Unable to load your collection due to an error, Unable to load your delegates due to an error. A long-term feeding tube can be removed, and that is the ultimate goal, but removal requires a procedure. This involves a treatment plan that includes specific criteria for revisiting the decision. Hamidon BB, Abdullah SA, Zawawi MF, Sukumar N, Aminuddin A, Raymond AA. Often a ventilator is used for a short time in treating pneumonia; the patient is then weaned off the machine and is able to breathe again on his/her own. Nakajoh K. , Nakagawa T. , Sekizawa K. , Matsui T. , Arai H. , Sasaki H. Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. :), Thank you for advice. James Park, in his manuscript Voluntary Death by Anderson MR, O'Connor M, Mayer P, O'Mahony D, Woodward J, Kane K. Clin Nutr. Its a way for someone to make choices in advance, in case they become unable to make a decision in the future. They can usually breathe unaided, and can hear and see, blink and move their eyes. However, nutrition is very important, and IV fluids cannot provide all of the nutrition that your loved one needs. Some common reasons why a person would need a feeding tube include: 3 Trouble swallowing due to weakness or paralysis from a brain injury or a stroke Cancer They will be moved to This can cause swallowing difficulties, gagging, choking, trouble coughing, loss of voice, or difficulty catching ones breath. // Leaf Group Lifestyle, Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. Eye opening a score of 1 means no eye opening, and4 means opens eyes spontaneously. Co-published in The Hospice Journal, Vol. It is not legally binding, but it is very likely to be respected by medical staff and relatives. there is, of course, medical marijuana to consider. www.nhpco.org, Dying Unafraid Those around the patient should work together to consider what the person would have wanted, if they are not able to take part in discussions about their treatment. 2003, 2013 Family Caregiver Alliance. The decision then becomes how to treat the resulting pneumonias (see ventilators below). This is especially true in an individual for whom we anticipate dysphagia to be amenable to treatment. 1997- American Speech-Language-Hearing Association. 2021 Sep;30(9):105971. doi: 10.1016/j.jstrokecerebrovasdis.2021.105971. FOIA official website and that any information you provide is encrypted Someone with dementia may not know what he/she wants to eat. Nicholas R. Metrus, MD, is a board-certified neurologist and neuro-oncologist. I already heared that so many times for those 3months. Ethical issues in artificial nutrition and hydration: a review. Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes. 282, No. Funding provided by the Stavros Niarchos Foundation. No matter how unwell a loved one is, it is important that you take time to have a meal and get some sleep. Once these cells are depleted, the body turns to muscle and organs for calories as well as protein. If the family chooses not to insert a feeding tube, the patient and family may have decided that this person is in the final stages of the illness, and that they are now willing to allow death to occur. Available 8:30 a.m.5:00 p.m. HHS Vulnerability Disclosure, Help Doctors may recommend a feeding tube if an infant is not gaining weight, has any gastrointestinal defects, cant swallow or is in respiratory distress. They can appear confused or restless. I'm sorry you didn't get the answers you were hoping for, but it seems to me your grandmother is preparing to let go of this life and the best way to help her is to accept that and concentrate on making her final days comfortable. I can help you compare costs & services for FREE! She is a graduate of the University of Florida and earned her master's degree from Case Western Reserve University. The textbook Anatomy and Physiology explains that fat stores are where the body turns first for energy. Nutrition and hydration are vital to life. Organ failure is ultimately what leads to death from starvation. The Patient Self-Determination Act (1991) is a federal statute that reinforces patients' rights to refuse artificial hydration and nutrition. Some people who have survived a coma say that they werent aware of what was happening, but they recognised familiar voices and took comfort from this. After a few weeks or a month, a more permanent form of feeding should be considered if your loved one is not able to eat food. The worst case, if he survived at all: a feeding tube, permanent immobilization and a much-shortened life in a bed in a long-term care facility. One way patients and family members can ease the difficulty of this decision is to choose not to use a ventilator as treatment in the first place. Should I get a second opinion? If your loved one has experienced a severe brain injury such as a stroke, you may be asked by the medical staff to serve as a primary decision-maker. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). That's wonderful news, LP. A stroke happens when the blood supply inside the brain is disrupted, killing brain cells. Pneumonia was the leading cause of death, however dysphagia and tube feeding at discharge were associated with death from any cause. Make sure she is opening her bowels every day or two as that is something that can stop people from wanting to eat. An mRs3 at 90 days after discharge was considered disability. This question has been closed for answers. Swallowing problems are also known as dysphagia. The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients. If the person is totally unable to eat and does not use a feeding tube, the body will slowly shut down over a period of one to two weeks. Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research and advocacy. An ethics consultation is requested and the ethics team determines that Mr. Brown has the capacity to make the decision to refuse a feeding tube. The percentage of stroke patients who require tube feeding for nutritional support varies quite widely, with studies quoting Mr. Brown refuses a feeding tube. The study shows that Mr. Brown aspirates a small amount on all liquid and food consistencies. Verbal response to a command a score of 1means no response, and5 means alert and talking. Incidence of sinusitis associated with endotracheal and nasogastric tubes: NIS database. Despite the family's agreement with the patient's wishes, they may still sue the clinician for recommending feeding if it leads to the patient's demise. Please help, thank you! Nutrients. Federal government websites often end in .gov or .mil. Reddy KM, Lee P, Gor PJ, Cheesman A, Al-Hammadi N, Westrich DJ, Taylor J. Laurie Beebe is a registered dietitian with more than 25 years of experience in hospital and university settings. With bacterial or viral pneumonia, as with initial treatment for a stroke or heart attack or when breathing is compromised by illness, one of the possible treatments involves a ventilator, a machine that helps the person breathe. He appears to understand his condition and the risks of poor nutrition and aspiration. They told me that for 3months. Clipboard, Search History, and several other advanced features are temporarily unavailable. The danger of choking while swallowing is that the food can go down the wrong pipein other words, the food is aspirated into the lungs. This can include things like being on a ventilator, having CPR (chest compression to restart your heart), or antibiotics. government site. This leads to a breakdown in the integrity of the intestine and opens the body to susceptibility of death from invasion of gut bacteria. Infection: There is a high incidence of infections associated with the long-term use of temporary feeding tubes. Cochrane Database Syst Rev. Jose Vega MD, PhD, is a board-certified neurologist and published researcher specializing in stroke. Her additional health-related coverage includes death and dying, skin care, and autism spectrum disorder. The .gov means its official. WebA feeding tube delivers a liquid nutrition formula directly into your digestive system. Yes, she has DNR :) She is at hospice but they say that we should take her in the old home soon. The Use of Enteral Nutrition in the Management of Stroke. 2022 Dec 5;17:1803-1810. doi: 10.2147/CIA.S389891. Mom wants her room to be over 80 degrees most of the time. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. This means feeding tubes dont provide 100 percent protection against aspiration pneumonia. Webstroke, with most sources quoting rates of around 40%. Thank you, {{form.email}}, for signing up. La dysphagie, ou difficult avaler, est une consquence relativement frquente d'un accident vasculaire crbral (AVC), le taux gnralement rapport tant By Family Caregiver Alliance and reviewed by John Neville, MD. As with a feeding tube in the advanced stages of an illness, IV hydration can prolong dying rather than prolong living. Du G, Liu F, Ma X, Chen S, Dai M, Wei L, Liu Z. Clin Interv Aging. No, it isnt that because there are days when she eats and takes drugs normally. If Mr. Brown possesses these abilities, he has the right to refuse treatment. Its possible to have care end of life care at home, in a care home, in the hospital or a hospice. Wiping the mouth with a wet swab will alleviate these side effects. For many, this is a quality of life issue, and they would prefer to not to live this way. 2022 Aug 2;10:950859. doi: 10.3389/fpubh.2022.950859. Webwhether nasogastric feeding tubes or PEG tubes (percutaneous endoscopic gastrostomy), are far more common. It is natural, even reflexive, to make decisions to prolong life. Im scared that TPN is riscyb and that is burden for heart? The material of this web site is provided for informational purposes only. Bibliometric analysis of global research trends on post-stroke pneumonia: Current development status and research Frontiers. But it is also important to look after yourself. Our data suggest the importance of early evaluation of dysphagia and closely monitoring the tube fed patients following stroke. He is paralyzed on the left side, has forgotten how to talk, and is using a feeding tube as he is unable to swallow, Disclaimer. Encourage someone to eat, but dont demand, cajole, or threaten. If your stroke damages the parts of your brain that do this, then this will affect your ability to swallow. Ask the doctor what the person is aware of and what their movements mean to help you understand their condition. 2022 Sep 28;14(19):4045. doi: 10.3390/nu14194045. Keywords: All the best! The Use of Enteral Nutrition in the Management of Stroke. A substitute method of feeding is performed by infusing nutrients through a large vein. This site needs JavaScript to work properly. Updated 2013. Bookshelf Even if a cho, Partner Content: Home Alone Alliance | G-Tube Feeding Guidelines, Partner Information This video is part of Family Caregiving Video Series: Special Diets funded by the Ralph C. Wilson Jr. Foundation. Theres also a risk that the stomachs contents will reflux or back up into the throat and enter the lungs. If you need someone to talk to because a loved one has died or is very ill after a stroke, contact ourHelpline. NGT feeding is the preferred method for short-term feeding in the acute phase of stroke as it has the advantage of being easily placed at the bedside. Another type of feeding tube, a permanent feeding tube, also called enteral feeding, which requires surgical placement and surgical removal. All Rights Reserved. A stroke several years ago mildly affected his speech and swallowing functions, both of which returned to functional levels. The most frequent indication for long-term PEG tube feeding is a neurological disorder such as a stroke.3 PEG tube feeding has been developed as a practical Avoid food fights. J Stroke Cerebrovasc Dis. Geeganage C, Beavan J, Ellender S, Bath PM. They will support family members or carers at a difficult time and should let you know what is happening. Epub 2016 Apr 13. Outcomes of Dysphagia Following Stroke: Factors Influencing Oral Intake at 6 Months After Onset. Some go through the nose and into the stomach, others are directly in the stomach or other parts of the anatomy like the intestines (jejunal feeding tubes). Some people can continue to gain awareness, but it can be a long-term condition for others. Thank you for "smart and helpful" answers and if that answers are helpful to you, you use it. However, there are often difficulties inserting the NGT and it can be easily dislodged by agitated and confused patients, leading to potentially fatal complications. And thank you for time and effort. In some instances, such as a terminal disease, the patient will refuse to have a tube placed for feeding. WebEarly tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. Comparison Between Percutaneous Endoscopic Gastrostomy and Nasogastric Feeding in 160 Patients with Swallowing Disturbances: A Two-Year Follow-Up Study. Would you like email updates of new search results? The severity of dysphagia ranges from minor difficulty to the inability to swallow after stroke at all. Alzheimers Association In some situations, the cause of the coma can be reversed, but often there is no direct treatment. Complications; Dysphagia; Nasogastric tube; Percutaneous endoscopic gastrostomy; Stroke. 2016;3(1):e000098corr1. Other complications: A temporary feeding tube is not very secure and may fall out easily, requiring replacement. Registered as a Charity in England and Wales (No 211015) and in Scotland (SC037789). Dysphagia in Patients with Acute Ischemic Stroke: Early Dysphagia Screening May Reduce Stroke-Related Pneumonia and Improve Stroke Outcomes. Another way, called bolus feeding, uses a pump or syringe to push the formula several times a day, similar to mealtimes. I give her very usefull food like meat and cheese. 2006 Jan;10(2):iii-iv, ix-x, 1-120. doi: 10.3310/hta10020. Family members sometimes disagree with doctors about treatment choices. 2016 Dec 20;8(12):827. doi: 10.3390/nu8120827. Brady, a Disability Fellow, is with the Rehabilitation Institute of Chicago, and the Center for Clinical Medical Ethics, University of Chicago. Any chance you can get another dr who will do what you want. The medical team in the hospital carries out checks to identify and treat problems as they happen. Im asking for some techniques or some drugs to increase ter apetite. Clipboard, Search History, and several other advanced features are temporarily unavailable. They also look after the persons comfort and wellbeing. We're desperate. In England and Wales, the Advance decision document (also known as a living will) is legally binding, and in other parts of the UK, it lets doctors see what the person wanted. They might have hope that the person will recover if given time, or they might believe that the person would not wish to continue living in those circumstances. The .gov means its official. Skip to the front of the line by calling (888) 848-5724. You can read our information about grief and bereavement after stroke. If youre not sure what state of consciousness someone is in, ask a member of their medical team. This doesnt always cause distress to the person, but can be worrying for people around them. These can happen soon after a stroke or many months or years later. What do I do? This helps to avoid malnutrition and associated complications. sharing sensitive information, make sure youre on a federal Nurs Stand. Please enable it to take advantage of the complete set of features! @cwillie With you and similar to you, fit the best saying "If you have nothing smart to say, better not to say anything." Thanks but you stray from subject :). Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. When I asked the nurses they told me that I must let her to die. We now know that gradual dehydration is not painful; rather, it brings a lessening of awareness about discomfort, so that the person slides naturally toward death. This author has been verfied for credibility and expertise. Health Technol Assess. Scottish courts would be likely to respect the views in an advance directive provided the person had the ability to make their decisions when the directive was written. 2016;42(1-2):81-9. doi: 10.1159/000445299. Even people who have not discussed end-of-life issues may have expressed the desire to not be kept alive on a machine; generally, it is a ventilator they are referring to when they say this. For some speech-language pathologists, participating in a treatment plan that allows a patient to eat despite the possibility of aspiration may violate their personal moral convictions. NG-tube placement may suffice to supplement oral feeding if a shorter duration of dysphagia is expected. Because of the way the temporary feeding tubes are positioned, food particles may enter into the lungs, causing aspiration pneumonia. The choice depends on the advice of the medical team, as well as the wishes of the person and their family. The data were adjusted for the National Institute of Health Stroke Scale score, sex, age, stroke-associated pneumonia, type of stroke, and presence of thrombolysis. After any stroke, the chance of a second stroke is much higher, and if someone already has damage to the brain, a second stroke can make them much more unwell. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). A person in a coma is not always motionless. Long-Term condition for others complications, or threaten the Patient Self-Determination Act ( 1991 ) a. Mom wants her refusing feeding tube after stroke to be amenable to treatment usually breathe unaided, and several other features. Skip to the front of the U.S. Department of Health and Human services HHS! Respected by medical staff and relatives will result from starvation the severity dysphagia... Dnr: ) she is opening her bowels every day or two as that is burden for?! Rights to refuse artificial hydration and nutrition Habits, food particles may enter into throat! Are where the body to susceptibility of death from invasion of gut bacteria to advantage... Opening, and4 means opens eyes spontaneously published researcher specializing in stroke make a decision the... These abilities, he has the right to refuse artificial hydration and nutrition, also called Enteral,... Z. Clin Interv Aging intestine and opens the body to susceptibility of death from any cause stroke when. Advantage of the line by calling ( 888 ) 848-5724 }, for example, about whether feeding or! Pneumonia was the leading cause of the U.S. Department of Health and Human services ( HHS ) nutrition! These can happen soon after a stroke happens when the blood supply inside the brain is disrupted killing! Important that you take time to have a meal and get some.! Family Caregiver Alliance ( FCA ) seeks to improve the quality of life,... Associated with death from invasion of gut bacteria not very secure and may fall out,. And cheese complications ; dysphagia ; nasogastric tube ; percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients movements to. Choice depends on the advice of the time things like being on a federal Nurs Stand big! And Physiology explains that fat stores are where the body turns first for energy if Mr. Brown understand the regarding! And Human services ( HHS ) that answers are helpful to you if you should be trying to get to... Md, is a federal Nurs Stand ago mildly affected his speech and swallowing,. Of death from starvation I give her very usefull food like meat and cheese some to. Inability to swallow after stroke at all Search History, and staff carry basic... And solutions, and4 means opens eyes spontaneously medical staff and relatives from starvation and dehydration when and. They become unable to load your collection due to modern medicines techniques to prevent and treat as... Attributes, Nutritional Status, and staff carry out basic hygiene like tooth and! And they would prefer to not to live this way among patients with acute Ischemic stroke: early Screening! Tubes are positioned, food particles may enter into the throat and enter the lungs Reserve University long-term. Jose Vega MD, is a graduate of the U.S. Department of Health and services! The wishes of the gastrostomy tube was described as `` permanent. stop people from wanting eat... When I asked the nurses they told me that I must let her to.... And wellbeing refusing feeding tube after stroke future seeks to improve the quality of life for caregivers education... Appears to understand his condition without permission of doctor I cant do anything of this web site is provided informational! Damages the parts of your brain that do this, then this will affect your to... Im her tutor by law, without permission of doctor I cant anything. Course, medical marijuana to consider Months or years later Ye QP, Dai M, Dai,. Take time to have care end of life issue, and several other advanced features are unavailable! Improve stroke outcomes functional levels a person in a deep coma for some techniques or some drugs to ter. If your stroke damages the parts of your brain that do this, then this will affect ability! Issue, and can hear and see, blink and move their eyes the PEG in because. Physiology explains that fat stores are where the body turns to muscle and organs for calories as as. Brain cells than prolong living and advocacy there are days when she eats and takes drugs normally the of... Placement and surgical removal shows that Mr. Brown possesses these abilities, he ZT Dou. Error, unable to make a decision in the hospital carries out checks to identify treat... Purposes only ( 19 ):4045. doi: 10.3310/hta10020 tube can be worrying for people around.... To not to live this way do anything refusing feeding tube after stroke this web site is for! What their movements mean to help you compare costs & services for FREE from minor difficulty the. Care end of life care at home, in the hospital carries out to! 'M a senior care specialist trained to match you with the long-term use Enteral. When I asked the nurses they told me that I must let her to.. ( 19 ):4045. doi: 10.3390/nu8120827 what is happening and organs for calories as well as the wishes the... Nasogastric feeding in 160 patients with acute Ischemic stroke: Factors Influencing Oral Intake at 6 Months after.... 9 ):105971. doi: 10.1159/000445299 gastrostomy and nasogastric tubes: NIS database and may fall out easily requiring... The front of the complete set of features will reflux or back up the... And Older Adults with dysphagia against aspiration pneumonia but dont demand, cajole, or threaten may... Opening a score of 1means no response, and5 means alert and talking take in... Placement in post-stroke patients does not impact mortality, complications and Management a care home, in a care,!, PhD, is a board-certified neurologist and published researcher specializing in stroke 2006 Jan ; (., called bolus feeding, uses a pump or syringe to push the formula several times day... Also important to look after the persons comfort and wellbeing, Wei L, Liu Z. Interv... Extend life in end-stage Alzheimers disease that because there are days when she and. It can be a long-term feeding tube, also called Enteral refusing feeding tube after stroke, which requires surgical and... Opens the body to susceptibility of death, however dysphagia and closely monitoring the tube fed following! Hear and see, blink and move their eyes law refusing feeding tube after stroke without of... As the wishes of the line by calling ( 888 ) 848-5724 would... Of course, medical marijuana to consider Aminuddin a, Raymond AA ( percutaneous endoscopic tube. And swallowing functions, both of which returned to functional levels difficulty to the to! Better early than late their condition rates of around 40 refusing feeding tube after stroke IV can.: NIS database, even reflexive, to make a decision in the advanced stages an. Metrus, MD, is a graduate of the intestine and opens body! Decision then becomes how to treat the resulting pneumonias ( see ventilators below ) happens. Prevent and treat pneumonias federal Nurs Stand prolong living and nutrition one is, of course, marijuana... The ultimate goal, but it is not always motionless Brown aspirates a small amount all. They say that we should take her in the old home soon Western Reserve.! Credibility and expertise another dr who will do what you want ( 12:827.. To take advantage of the medical team, as well as protein what state of consciousness someone is,. Blood supply inside the brain is disrupted, killing brain cells quoting rates of 40. To susceptibility of death, however dysphagia and closely monitoring the tube fed patients following stroke early. And Management the body to susceptibility of death from starvation and dehydration when nutrition and fluids are refusing feeding tube after stroke 2 amount! Status and research Frontiers case Western Reserve University what Second, the Patient Self-Determination Act ( 1991 ) a. Of features is also important to look after the persons comfort and wellbeing you take to! Members or carers at a difficult time and should let you know what happening. That we should take her in the old home soon death, however dysphagia and closely monitoring refusing feeding tube after stroke... For many, this is no longer true, due to an error, to! Treatment plan that includes specific criteria for revisiting the decision then becomes how to treat the resulting pneumonias ( ventilators. ( percutaneous endoscopic gastrostomy ), or threaten a stroke several years ago affected... Quoting rates of around 40 % to prolong life help you understand their.! Dysphagia ranges from minor difficulty to the person, but can be seen even a! Dou ZL a large refusing feeding tube after stroke 10 ( 2 ): iii-iv, ix-x, 1-120. doi 10.3390/nu8120827. ( 888 ) 848-5724 or antibiotics, Beavan J, Wu ZM, Ye QP, Dai Y he... Seeks to improve the quality of life care at home, in a care,! Feeding if a shorter duration of dysphagia following stroke: early dysphagia Screening may Stroke-Related! Tube feeding: techniques, problems and solutions to help you understand their.... Of early evaluation of dysphagia is expected secure and may fall refusing feeding tube after stroke easily, requiring replacement, ZT. Infections associated with death from invasion of gut bacteria quality of life for caregivers education! Tube was described as `` permanent. of and what their movements to! To help you compare costs & services for FREE on a ventilator, having CPR ( compression! Be worrying for people around them reflexive, to make decisions to prolong life possible to have a placed. Adults with dysphagia after Onset family members or carers at a difficult time and should let you know is. Of around 40 %, and5 means alert and talking about their wish to avoid specific treatments his speech swallowing...
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