Thickened Liquid Challenge Helps Providers Understand Patient Experience

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Taking the Thickened liquid challenge - Eric Widera

Dr. Eric Widera, associate professor of clinical medicine in the Division of Geriatrics at UCSF and director of hospice and palliative care at SFVAMC, takes the "Thickened Liquid Challenge.”

A patient-centered outlook to long-term care is a key pillar of quality improvement.

The Thickened Liquid Challenge is among the latest initiatives promoting awareness of the patient experience. The six-part blog series, featured on GeriPal, was founded in 2009 by Dr. Alexander Smith, a clinician at the San Francisco VA Medical Center (SFVAMC) and an associate professor in the Division of Geriatrics at the University of California, San Francisco (UCSF), and Dr. Eric Widera, associate professor of clinical medicine in the Division of Geriatrics at UCSF and director of hospice and palliative care at SFVAMC. The purpose of their blog is to encourage open discussion of topics involving palliative and geriatric care.

The Challenge stemmed from Widera’s and Smith’s interest in the patient perspective. Previously, they had posted personal accounts of tasting medications to experience what it was like for patients who took the medicine. They decided to do the same with the thickened liquids that are commonly administered to people with swallowing problems.

Like any other intervention in health care, you should be thinking about the benefits, the risks, and how you can come up with a shared decision that is consistent with [the patient’s] goals and values.”

According to Widera, one in 12 nursing home residents are placed on a diet that includes thickened liquids to prevent fluid from entering their airway and causing pneumonia. The liquid thickener is typically corn starch-based, creating a honey- or nectar-like consistency for ordinary beverages like tea, soda or juice. When Widera and Smith tried it for themselves, they were startled and intrigued.

We were shocked at how hard it was to drink,” Widera said. So we decided to set a challenge where we would try to survive 24 hours just drinking thickened liquids.”

It proved difficult; of eight colleagues who tried the challenge, none could continue beyond 12 hours. They experienced extreme thirst, decreased appetite, dry mouth and dehydration.

That was an eye-opening moment for us,” Widera said. We were giving something to people that potentially had a lot of side effects – effects we were able to experience by trying it for only 12 hours.”

This prompted them to question whether the practice’s benefits outweigh the risks. Widera says there is little evidence that the practice prevents aspiration pneumonia or death in individuals with progressive neurological diseases like dementia, but there is strong evidence pointing to an increased risk of dehydration and diminished quality of life. 

Inspired to start a conversation, the team launched a social media campaign challenging readers to put themselves in patients’ shoes. They called on participants to drink only honey-thick liquids for a designated period of time. Using the hashtag #thickenedliquidchallenge, participants shared videos of themselves attempting to drink a thickened beverage and nominated others to follow suit. Alternatively, they could donate to a geriatrics or palliative care charity. 

The Challenge received strong response from caregivers nationwide, including doctors, medical students, social workers and institutions like the American Geriatrics Society, the University of Chicago and the American Academy of Hospice and Palliative MedicineQualis Health, the QIN-QIO for Idaho and Washington, was even up for the challenge. The organization recently posted a video of Quality Improvement Consultant Aimee Ford, RN, MS, drinking the honey-thick liquids for 12 hours.

The goal, said Widera, was to get people thinking critically about an accepted practice and to motivate them to approach care with a patient-focused mindset. He endorses working with the patient and family to determine whether the treatment is appropriate and to evaluate alternatives.

It should not be an automatic thing for anyone with a swallowing problem,” Widera said. Like any other intervention in health care, you should be thinking about the benefits, the risks, and how you can come up with a shared decision that is consistent with [the patient’s] goals and values.”