Understanding the FreeWater Protocol
The FreeWater Protocol (FWP), also sometimes called the Frazier Water Protocol after its origin at Frazier Rehabilitation Hospital, is a set of guidelines that allow certain patients with dysphagia (difficulty swallowing) to have access to plain, unthickened water. This is typically permitted even if they require thickened liquids for all other beverages. The underlying principle is that the lungs can safely absorb a small amount of water if accidentally aspirated, provided strict safety conditions are met, primarily focusing on maintaining excellent oral hygiene. Aspiration of small amounts of water is considered a benign event due to its near-neutral pH and rapid absorption by the lung mucosa. In contrast, aspirating thicker, less sterile fluids or food poses a far greater risk of developing aspiration pneumonia.
The Unrestricted Amount of Water
The most important detail regarding the quantity of water is that intake is unrestricted, as long as the patient adheres to the protocol's rules. There is no specific cup count or milliliter limit. The patient is allowed to drink as much water as they desire, driven by their natural thirst. This autonomy is a significant improvement for patients, as many find thickened fluids unsatisfying for quenching thirst. This approach directly addresses the issue of dehydration often associated with thickened liquid diets, which can result from patient non-compliance or dissatisfaction with the provided fluid. By allowing free access to water, the protocol empowers patients and promotes better overall hydration.
The Strict Rules of the Protocol
While the amount of water is not capped, the timing and conditions of consumption are very specific and must be followed precisely to minimize risk. The specific guidelines vary by institution but generally include the following elements:
- Oral Care is Mandatory: The oral cavity must be cleaned thoroughly using a toothbrush and toothpaste, or oral swabs, before the first meal of the day and after every meal or snack before drinking water. This reduces the amount of bacteria in the mouth, which is the primary risk factor for aspiration pneumonia.
- Timing Restrictions: Water is only permitted between meals. It is strictly prohibited during meals, and patients must wait at least 30 minutes after completing a meal or snack to have water. This waiting period allows any food residue to clear from the pharynx via spontaneous swallowing and gravity.
- No Medications with Water: Medications must be taken with thickened liquids or in a semi-solid food like applesauce or pudding. Pills or thin liquid medications should never be taken with unthickened water under the protocol.
- Sit Upright: Patients must be positioned upright, at a 90-degree angle, while drinking water and should remain upright for a period afterward to aid swallowing and digestion.
- Use Compensatory Strategies: If prescribed by the speech-language pathologist (SLP), patients must continue to use safe swallowing strategies, such as a chin tuck or head turn, while drinking water.
- Supervision: Especially for patients with cognitive deficits or impulsivity, adequate supervision may be necessary to ensure compliance with all rules.
Comparing the FreeWater Protocol vs. Thickened Liquids
| Feature | FreeWater Protocol | Traditional Thickened Liquids |
|---|---|---|
| Quantity of Water | Unrestricted plain water access, based on thirst. | No thin water permitted; limited intake of thickened fluids. |
| Timing | Only between meals; requires oral care before. | Must be consumed with meals and snacks. |
| Oral Hygiene | Rigorous oral care is a mandatory safety measure. | Oral care is important but not a core requirement tied to every fluid intake. |
| Patient Satisfaction | High; most patients report increased satisfaction and a quenched thirst. | Often low; many patients dislike the taste and texture. |
| Hydration Status | Improved due to increased fluid intake and higher compliance. | Often poor due to low fluid consumption and non-compliance. |
| Risk Perception | Perceived risk of aspiration by some clinicians, but research suggests benign outcomes for water aspiration in select patients. | Reduced risk of aspiration but increased risk of dehydration and lower quality of life. |
Patient Eligibility and Medical Considerations
The FreeWater Protocol is not a universal solution and is only appropriate for carefully selected patients. A speech-language pathologist (SLP) must conduct a thorough swallowing evaluation to determine a patient's suitability. Factors considered include:
- Alertness and Cognitive Status: Patients must be awake, alert, and able to follow directions consistently. Individuals with severe cognitive impairment or impulsivity are generally not candidates.
- Mobility: The patient should be able to get out of bed consistently and maintain an upright posture for drinking.
- Respiratory and Medical Stability: Patients with acute pulmonary disorders, a history of recurrent aspiration pneumonia, or poor respiratory status are typically excluded.
- Oral Health: Excellent oral hygiene is critical. Patients with conditions like thrush or significant dental decay must be treated before being considered for the protocol.
Conclusion
The FreeWater Protocol offers a compassionate and effective way for eligible patients with dysphagia to consume unrestricted amounts of plain water, significantly boosting their hydration and quality of life. The core of the protocol is not about limiting intake, but about adhering to a strict set of safety guidelines that include diligent oral hygiene and timed consumption. By working closely with a speech-language pathologist, patients and caregivers can ensure these rules are followed, transforming the experience of managing dysphagia from one of frustration and potential dehydration to one of improved satisfaction and well-being. Ultimately, the amount of water a patient can drink is limited only by their thirst and their commitment to following the rules of the protocol.
For more clinical context, refer to the American Speech-Language-Hearing Association's resource on the Frazier Free Water Protocol.
Understanding the FreeWater Protocol
Patient Eligibility and Medical Considerations
The FreeWater Protocol is not a universal solution and is only appropriate for carefully selected patients. A speech-language pathologist (SLP) must conduct a thorough swallowing evaluation to determine a patient's suitability. Factors considered include:
- Alertness and Cognitive Status: Patients must be awake, alert, and able to follow directions consistently. Individuals with severe cognitive impairment or impulsivity are generally not candidates.
- Mobility: The patient should be able to get out of bed consistently and maintain an upright posture for drinking.
- Respiratory and Medical Stability: Patients with acute pulmonary disorders, a history of recurrent aspiration pneumonia, or poor respiratory status are typically excluded.
- Oral Health: Excellent oral hygiene is critical. Patients with conditions like thrush or significant dental decay must be treated before being considered for the protocol.
Conclusion
Ultimately, the amount of water a patient can drink on the FreeWater Protocol is limited only by their thirst and their commitment to following the rules. It is not about restricting fluid, but about creating a safe window for consumption. This approach significantly improves quality of life and hydration status for eligible individuals, making it a valuable tool in dysphagia management. When implemented correctly under the supervision of a healthcare team, particularly an SLP, the FWP represents a patient-centered approach that prioritizes both safety and satisfaction.
For more clinical context, refer to the American Speech-Language-Hearing Association's resource on the Frazier Free Water Protocol.
