**6. The role of the speech language therapist (SLT)**

**30 day mortality rate (%)**

142 Seminars in Dysphagia

**Sample size (N)**

22% 201 CVA (n=97)

20% 128 CVA (n=34)

22% 112 CVA (n=33)

36% 61 CVA (n=50)

28% 361 CVA (n=120)

15.8% 359 Head and neck cancer (n=97)

10% 77 Neurologic disorders (n=71)

CVA (n=73) Malignancy (n=61) Head injury (n=59) Cerebral palsy (n=38) Congenital anomaly (n=19) Motor neuron disease (n=7)

Dementia (n=5)

Other (n=23)

Other (n=9)

Malignant oesophageal obstruction (n=33) Dementia (n=16) Other neurologic disorders (n=13) Parkinsons (n=12)

Other malignancies (n=5)

Head and neck cancer (n=6)

Non neurologic cerebral hypoxia (n=30) Cranial tumour (n=23) Head and neck cancer (n=19) Motor neuron disease (n=13)

19% 83 CVA (n=83) Norway Ha & Hauge, 2003

Head and neck cancer (n=27) Chronic neurological disorders (n=22) Other (n=30)

18.5% 187 Malignancy (n=187) USA Keung et al., 2012

Head and neck trauma (n=3)

Dementia (n=21) Malignancy (n=9)

Dementia (n=103) Oropharyngeal malignancy

(n=65) Other (n=73)

**Table 1.** International mortality rates 30 days post PEG placement

**Medical condition Country Researchers**

Bosnia Herzegovina Vanis, Saray, Gornjakovic &

Sweden Malmgren et al., 2011

Turkey Ermis et al., 2012

Turkey Gundogan et al., 2014

Britain Longcroft-Wheaton et al., 2009

Israel Abuksis et al., 2004

USA Sanders et al., 2000

Mesihovic, 2012

Evidence exists to support the involvement of an SLT in the assessment and treatment of patients with dysphagia. Langmore et al. (2011) [108] suggested that it is important for an SLT to assess a patient with head and neck cancer and to determine the most optimal approach for each patient to be able to recover swallowing or to compensate for losses due to surgical or chemo-radiation intervention. The role of the SLT in the management of patients with dysphagia who may require enteral nutrition, is not to recommend the route of enteral nutrition, but rather to make a recommendation of whether or not the patient can eat orally and is safe to do so. All discussions and decisions relating to enteral nutrition, whether short or long term, should take place within an inter-professional team including the patient and caregivers.

Considering the multitude of risk factors that exist for poor outcomes post PEG insertion, it follows that a patient should be individually assessed for the presence of any risk factors before being recommended for the procedure [85-87]. A comprehensive assessment by the team needs to consider factors such as: 1) the potential benefits to the individual should they receive a PEG, 2) biochemical parameters, like blood albumin level, 3) multiple comorbidi‐ ties, 4) prognosis, 5) and the presence ofrisk factors that may place a patient atrisk of mortality post procedure, such as being over the age of 60 years and a low BMI [10, 19, 23, 25, 45, 56, 69, 87-89, 90].

Strong emphasis is placed upon a team approach when assessing patients who may be recommended for long term enteral nutrition [85-87]. A rigorous assessment, by a team, for each patient being considered for a PEG ought to be in place. The team needs to ensure that all risk factors which could affect outcome are considered and that an informed decision respects patient autonomy [60, 85-87]. A patient who is considered a high risk for mortality should not be considered a candidate for the procedure as it would be a futile intervention. Better patient selection would improve the outcome of patients who are recommended for and fitted with a PEG [91].
