A few months ago I was creating a handout on the Free Water Protocol. I wanted to make sure I understood the present research, so I read four articles about the Free Water Protocol. The handout I created had to include the associated risks with adopting the Free Water Protocol.

As expected the research and opinions went both ways. Some people are for Free Water Protocol and others were against. In particular I read two articles printed in 2006 for the Perspectives on Swallowing and Swallowing Disorders. James L. Coyle wrote an article against the use of Free Water Protocol, while Susan E. Langmore wrote an article in support. Both Coyle and Langmore are respected researchers within the field of dysphagia.This blog post is a journey through how I formed my opinion on whether I will recommend Free Water Protocol.

First, a little background on my experience. I work with the geriatric population in long-term care and skilled nursing facilities. Most of my patients have progressive neurological diseases and multiple co-morbidities. I have some experience working with adults in the ICU and inpatient neurorehabilitation, but that is not my focus.

Here are some things I considered while making my decision:


There is limited direct evidence supporting Free Water Protocol. Coyle states that “It is not appropriate for healthcare professionals to employ methods that are not scientifically based. SLPs are ethically obligated to use evidence-based methods of clinical decision making.” Langmore discusses indirect evidence as a support for Free Water Protocol. The indirect evidence she mentions includes:

  • Thickened liquids are not liked by patients, resulting in avoidance.
  • Feeding tubes are associated with pneumonia.
  • Thickened liquids are more harmful than thin liquids when aspirated.
  • Water is relatively benign when aspirated in small quantities.

I agree with both of them. If I found evidence stating that Free Water Protocol was harmful to specific patient populations, I wouldn’t recommend it. But the indirect evidence Langmore mentions is persuasive.

The truth is we just don’t have enough evidence. We don’t have evidence against it. I’m not ready to rule it out for individual patients when my clinical decision-making combines evidence, my experience, and patient wishes. I agree with Coyle and Langmore who both indicate it is not wise to institute it as a facility policy. I believe it needs to be a case-by-case decision, especially since we are in need of more direct evidence.

Quality of Life

Who wants a nice cold glass of nectar thick apple juice with their breakfast? How about room temperature nectar thick liquids? I’m not surprised that many of my patients don’t like thickened liquids. They aren’t as refreshing as thin liquids.

More often than not, when patients don’t want thickened liquids, they “cheat”. They snag thin liquids – coffee, orange juice, milk, etc. – whatever is at the ready. With the Free Water Protocol patients would be able to have the refreshment of a glass of cold water, which research indicates carries less risk in terms of aspiration compared to other beverages. And with Free Water Protocol we can focus on improving oral hygiene to reduce the amount of bacteria being potentially aspirated. (I wrote a recent post about oral hygiene and aspiration pneumonia over at the Eden Alternative blog; http://www.edenalt.org/help-elders-avoid-aspiration-pneumonia-grab-a-toothbrush.)

There is no denying I’m a foodie. I have my own dietary restrictions, which prohibit me from enjoying some foods in my shared culture. I want to help my patients enjoy life’s simple pleasures, such as eating and drinking (safely). Food isn’t just nourishment; it’s part of our social interactions and our culture.


For some patients, if they don’t “cheat” and drink thin liquids they just won’t drink at all. Thickened liquids aren’t as hydrating and it’s more difficult for patients to drink 8 glasses a day. Dehydration causes multiple negative changes in body, including cognitive decline.

I recently saw a patient who was incredibly malnourished and dehydrated. The bedside swallow evaluation indicated he was not safe with thin liquid consumption; however, due to his medical status and severe dehydration the family opted for thin liquids. In that case, we didn’t even limit it to water. Coca-cola, apple juice, anything goes. Pushing fluids was the priority. As the SLP, I educated family members on how to help him drink as safe as possible with thin liquids.

But I can see Coyle’s perspective too. He states, “If we cause dehydration or renal failure by prescribing thick liquids because we think we are preventing aspiration, what have we gained? We need to strike a balance when deciding whether a patient is a good candidate for unlimited water or its alternatives.”


I also consider how quickly intervention will upgrade my patient to thin liquids and if they are post acute onset of stroke, TBI, or other condition where I expect fairly rapid improvement. As blunt as it may seem, I agree with Coyle when he says, “Speech-language pathology evolved as a rehabilitative profession, one whose practice requires the patient’s active participation to restore effective communication. There has never been a speech pill. Why have we so quickly forgotten about active intervention?”

A texture or consistency recommendation won’t fix dysphagia. And there aren’t magic powers of an SLP watching a person eat either. Active intervention is necessary in order to make improvements. The Free Water Protocol isn’t an intervention or a treatment. It won’t fix dysphagia. So I think about what we can do to improve a patient’s dysphagia.


I remember when I used to complete bedside swallow evaluations, determine someone was unsafe with thin liquids, and then throw out their thin liquids and replace them with nectar or honey liquids. I don’t do that anymore. Education comes first. If the patient is able to participate in their care, I educate the patient (and family too). If not, I educate the family. I see my job as giving patients and families all the tools to make the best decision for them.

When they opt to decline recommendations for thickened liquids, I tell them about the Free Water Protocol. I tell them, “It’s not foolproof. There are still some risks, but it will help.” While the evidence for the Free Water Protocol isn’t plentiful, it’s a lot better than signing a diet waiver or AMA and doing nothing else. And even with Free Water Protocol I extensively document my education and their response/wishes.

Looking at two dysphagia researchers opinions on Free Water Protocol and my own clinical experiences, we all seem to agree. It’s a case-by-case decision, and we need more research.


Coyle, J.L. (2011). Water, water everywhere, but why? Argument against free water protocols. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 20:109-115

Langmore, S.E. (2011). Why I like the free water protocol. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 20:116-120

Links of Interest

  1. Find Rachel on Facebook, Twitter
  2. www.graymattertherapy.com