Clinically Speaking

Giving a Crucial Voice to Non-Verbal Clients

When I arrived in the ICU hospital room, I found Lili, my best friend of 33 years, with a vent tube in place that precluded her from speaking.

This did not mean she wasn’t able to communicate.

Lili lost her battle with cancer in September 2010, but steadfast in her life as a teacher and camp director, she continued to teach us until the end.

With eyes wide open, giving a thumbs-up, she signaled her determination. With her finger pointing to the tube in her throat, she clearly stated she had important things to say to her husband and children, to me and to the teachers at her school.

“When are they removing the tube?” she wrote, using the paint program on my iPad. “I have a meeting at the school at 11 o’clock.”

As doctors and nurses began the “merry-go-round” of coming in and out of her room, the questions began.

“How is she feeling today? Does she need more medicine?”

And thus we answered over and over, “I don’t know. You will have to ask her.”

As evaluations continued, one remained lacking: what type of communication system would be used to ensure Lili continued to have a “voice” in her own care. As a PT who has worked with persons with disabilities for 19 years, it was difficult for me to accept the lack of awareness and assumptions being made about her ability to think and communicate.

Can You Hear Me Now?

Everyone wants to be heard; it’s human nature. Regardless of the patient’s diagnosis or the type of professional treating that client — PT, OT, speech or RTS/ATP — direct communication with the patient is the most powerful tool in assessing and addressing a patient’s needs. Anyone working with the patient should address the individual as if they could communicate, whether it be to encourage facial expressions, mouthing words, eye blinks, thumbs-up/down or a more sophisticated communication method.

But I have had patients come to my clinic for a wheelchair evaluation with a communication mount on the wheelchair frame… and no sign of the device. The common response from the family: “We didn’t know we needed to bring that for the wheelchair evaluation.”

Without that device, it was extremely difficult to hear from that patient regarding what their goals were and their feedback on the equipment being trialed.

With some patients, by virtue of their diagnoses, we do not know the cognitive status or their communication ability. But we still owe it to the patient to remove the ladder of inference and clinically speaking Giving a Crucial Voice to Non-Verbal Clients By Lois Brown, Invacare Corp. assumptions, and give everyone the benefit of the doubt. That means making direct eye contact, asking them about their care, and adopting the belief “Able until proven unable.”

Many healthcare professionals I work with, especially in the home, will tell you that most times there is no established, consistent communications method among family and team members. At a minimum, we can begin by asking what the agreed-upon communications system is for this individual. In a hospital setting, the care team can post a sign above the hospital bed that indicates that method. Simple, yet impactful!

A Matter of Interpretation

There are times when the family can best interpret what the patient is trying to say, and therefore the strategy is to wait for that interpretation so the patient is included in the process.

Utilizing closed-end questions (yes/no) versus open-ended ones during the patient evaluation can yield important information. Remember, communication strategies can range from a magnetic MagnaDoodle drawing board to a paint or communications device application on an iPad or iPhone, to a simple yes/no, thumbs-up/down or a letterboard with a headlamp.

Another aspect of communication is establishing a method to ensure learning and carry-over. For those prescribing and fitting wheelchairs, it is important to document the patient’s ability to safely and successfully operate the mobility device being prescribed. With a communication issue, it will be important to determine how the person is best able to learn.

For instance, do they learn better by listening, watching, writing or a combination of methods? Asking them to perform specific mobility tests and observing outcomes may be the only way to determine their skills and satisfaction with the device.

Another important recommendation is to refer the patient to a speech therapist, who can determine the best long-term communication strategy.

It took Lili’s husband and me to ensure she had a voice: an iPad, a MagnaDoodle, and later, a pen and paper that ultimately allowed her to be an active participant in her care. Please do your part to ensure everyone’s voice can be heard.

This article originally appeared in the Seating & Positioning March 2011 issue of Mobility Management.

About the Author

Lois Brown, MPT, ATP, is the rehab clinical education specialist for Invacare Corp., Elyria, Ohio. She is a frequent presenter on seating & mobility topics at industry events.

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