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Kali discusses what would happen if we expected to be able to communicate with all patients on mechanical ventilation. How would that impact our practices? What role does communication play in patient survival and outcomes?

Episode Transcription

Kali Dayton

What would happen if we expected to be able to communicate with all of our mechanically ventilated patients? How would that change our focus, practice and patient outcomes? Dr. Lance Patak has spent his career advocating for greater humanity and communication in the critical care world. Dr. Patak, thanks so much for joining us.

Dr. Patak

Sure. Thank you, Kali, for inviting me.

Kali Dayton

So can you give us a little outline of your career and what led you to be so invested in communication in the ICU?

Dr. Patak

I become invested in a patient’s life in her recovery, she had a bilateral lung transplant, she was previously an opera singer, her daughter was very engaging, I think, you know, that helped a lot of us become stakeholders and her recovery. She went on from having an endotracheal tube to get into tracheostomy and had this for months, and eventually ended up passing away, unfortunately.

And then that night, we developed this two sided, laminated, you know, dry erase board that was made out of, you know, styrofoam and dry erase surface from Kinkos. And we went back to the hospital and used it with her. And it was it was brilliant. And at that point in time, I thought, you know, I basically discovered sandals, you know, it’s now something as simple as a pair of sandals can be used by everybody. But our director of evidence based practice at the time, Dr. Anna Kolensky, I was referred to her for, you know, making any sort of clinical practice change.

And she said, “Well, let’s look at what the evidence shows.” And when we looked at the evidence, well, there had been no research done on what was actually effective. And, you know, while it may be intuitive to have words and phrases on a board, that may not be shown to actually be the most effective methods. So I was then pressed to do a research study, which I was very reluctant to do. I was, you know, this was not my trajectory. I just wanted to solve a problem.

And so we, we went about doing this research study, we designed it in a in a way that we would basically be presenting patients with a list of survey questions, open ended questions, asking them, you know, things that they would want to communicate things they didn’t get to communicate, what were barriers to them being able to communicate what what was helpful. What did providers do that, you know, made it possible just to try to glean from every direction from patients, what would be best to help them communicate while they’re intubated and unable to speak.

We approached them within 24 hours of the tube coming out. And we only approach patients that had accumulated at least two days of intubated experience. So it was for optimal recall. And then also to have at least some point of reference that they could, you know, talk about. And we approach a total of 149 patients 13 Questions survey and got tremendous feedback about this communication board. And it became apparent that you know, our idea was it would be a two sided Dry Erase laminated board. So a clipboard, so that you could slide paper in and out because sometimes patients can write legibly, and the board would be too limiting at that point. But then when their writing becomes illegible, they can just start using the dry erase board.

But the clipboard was too heavy, the weight of a clipboard, we couldn’t find a clipboard that was lightweight enough to that a patient could actually lift it. And we removed the metal clip and made it a plastic clamp. And so we just basically had to abandon the clipboard altogether and just say, well, we’ll just save that for when patients can right. So the human factors that had to go into making a communication board for critically ill patients to yours was far from being intuitive. And it really required gathering all these small details. And that’s how we developed the easy board.

Kali Dayton

As you explain all that I am just astounded by how much work and thought that goes into creating that kind of tool. So why at the time was communicating with your patients so important to you? And what did you learn about it being important to your patients?

Dr. Patak

Sure, so why was this so important? You know, I guess, you know, as healthcare providers as nurses, you know, we go into this field because we want to help people. And, you know, when you if you were to see someone who had fallen off their bike, your instinct would be to help them up, right, especially if you saw them suffering. And, you know, to just walk by that experience witnessing it, it’s kind of counter to what is most intuitive to, you know, people who go into health care. And so I think I was just driven to, to to address that suffering.

That goes on behind, you know, being trapped behind that ET tube and the powerlessness. The interviews that I heard, so, I mean, we had 45 minute interviews with each of these 149 patients, I heard stories that you would not believe. And I mean, I know though co workers that I worked with, they were all phenomenal nurses, I don’t think any of us and I probably was, you know, maybe no. But you know, the things that we don’t realize that are happening because there’s no voice, there’s no narrative put to the experience, it’s all silence.

It’s not, we’re not experiencing it, we’re experiencing walking into a room, hanging meds, doing things on time, changing dressings, giving, doing all these tasks, it’s all task oriented behavior. But what we should be doing when we walk into a room is first before we do anything else, unless we have to run in and resuscitate them, we should be walking up to the patient and saying, Hey, since the last time I walked in this room, is there anything that you’d like to communicate with me, and empower them give them a sense of power, because they’re just lying, they’re powerless, completely have no control. Nurses have always been the gatekeeper for all patient care.

Doctor’s orders are not a nurse’s make or break, you know, a patient’s experience. And so if that patient’s going to get the opportunity to communicate, it’s going to be because a nurse is taking care of that patient values that and it’s going to make sure that happens and isn’t going to give up, it’s going to make sure they have the right tool in place, it’s going to be sure that the patient is given enough time to participate and seek that information out. You can’t just walk into a room and talk to a patient and expected the nod and be okay with everything. You wouldn’t be okay with that. And Neither would I.

Kali Dayton

I hadn’t thought of it that way. Because I haven’t experienced that you’re totally right. I want to articulate my thoughts, my feelings, my needs. But sometimes, just with my patients being awake, I feel like we kind of get along muster by just with nods and hand signals and short words on a on a board. But you’re right, I wouldn’t be okay with that I wouldn’t feel connected.

Dr. Patak

Is being connected. But also, I mean, I would say you know, something’s working, you know, there’s no reason to change it. But that patient may be looking around and realizing there’s no other options. So they’ve somehow accepted that muted experience, and really being in a passive voice throughout the entire recovery until something really pressing comes to mind. But they’re constantly like the patients, they told me, you know, I tried to tell them, and I couldn’t. I tried to tell him and I couldn’t. And no matter what you do, you try to get it across, but nothing works. And eventually you give up. And this is what all these patients do. At some point they give up.

And I think there must be some psychological component to delirium, where, you know, I remember taking care of patients and doing horrific dressing changes to wounds, and the patient literally be non responsive, but not on any sedation, like they have totally left their body. And at what point of being trapped behind a tube and a ventilator and being there day in and day out. You know, not knowing what’s going on, you’re not being provided the opportunity to communicate, do you withdraw and completely have to leave your body in order to survive that experience? Is this really like, you know, our standard of care? Is this really how we consider standard of care? Because it’s not in our chart. We don’t have to check a box that we’ve communicated with the patient. We don’t have to chart a temperature. You know, four hours hasn’t gone by where temperature is not check where someone can say, “Hey, you didn’t check a temperature.” No one is going through electronic medical record. No one’s going through ICU rounds and saying, “Hey, you haven’t communicate with your patient all day.” But no one is doing that who’s doing that? No one.

Kali Dayton

And that makes so much sense because nurses have such good intentions. But we are so busy and survivors have mentioned things like wanting to write on a board trying to write on the board signaling that they want to communicate and having their hands swatted away. And maybe the nurses didn’t understand what they were trying to communicate, maybe they were just used to patients being unresponsive, sedated, completely delirious. But survivors are talking about the frustration being locked in their body being completely isolated. But that was not a focus communication was not an emphasis. And we’re not trained as ICU nurses, to communicate with our patients. And when we have an altered form of communication, so as you’ve created this tool to open up the gateway of communication, how have you seen that impact patients short and long term outcomes?

Dr. Patak

Sure what Yeah, it’s interesting you say, this, making this tool has kind of served as a gateway because we actually had one of our patients was a producer. And he was very verbose. Every time I asked him a question. He went on, kind of like very, very long winded and never, never kind of stopped talking. But he one thing was very enlightening when he said, you know, he said, I want to actually read his quote, okay,

it says, “It would create an interface between the patient and the staff, that would, in a way formalize the requirement that they pay attention to what the patient is trying to say, even if I didn’t use it, I could waive it and say, I matter, I could be heard. It would be like a passport. I have a stake in this. It’s not just about you acting on me. It’s about my being able to tell you what I want what I’m doing.” And he says, “I believe that concept itself is very strong, because it would both obligate the staff to stop and listen with a fresh year, instead of saying, ‘Oh, well, they’re in tubed, they can’t talk, let’s just write them off.’ That could inspire that is to say, instill hope, and empower those who are not as strong willed as I am.”

And that was his quote, and it’s very powerful, it really kind of gets that message of a gateway, right? Like here, here, we have now an opportunity to implement a communication tool, how do we now then adopt this as a systematic practice to provide communication aids or augmentative communication resources to patients who need them, even as simple as a pair of you know, their glasses, and hearing aids, these are also communication tools, if I’m talking to you and you don’t have your hearing aids, and you can hear me, so, um, you know, this, this can also, you know, misdiagnosed delirium, and, and I remember hearing this at our presentation at IHI last December.

One of the presenters was sharing her experience where everyone had kind of diagnosis patient as being locked in and completely non responsive and delirious. And, you know, someone provided him hearing aids, and he heard and he like, came to life, like as if you put batteries in the back of a, of a toy. And she couldn’t believe it. And she’d never forgotten that experience. And so, I mean, is, is real basic and simple sometimes, right? Are, we want to save the glasses and the hearing aids and put them away somewhere safe. But that’s not where they should be. They should be beyond in the patient’s ears and things. You know,

Kali Dayton

it’s just such a shift in perspective, Dr. Patak. I mean, for decades, we’ve so deeply sedated, so we have a communication wasn’t even anywhere near possibilities. And now that we’re transitioning to this humane care scene and treating our patients as human. Now we have to really evaluate those things that were never even an option before. I am humbled by hearing that story about the patient getting hearing aids because I had a patient years ago that had West Nile meningitis, and he wasn’t allopathic. But time went on and he everything’s gonna be getting better. But he still wasn’t responding to us. And it was a speech therapist that came and put the amplifier headphones on and asked him to open his eyes and he opened his eyes and he thought every command it was wholly oriented and was absolutely there. I don’t know how long how long he had been there. But he was deaf, completely deaf. And it was so humbling. How long was he isolated for a while we forgot those elements of communication.

Dr. Patak

Right? And so, you know, when we, you know, at my job, you know, at Seattle Children’s Hospital, we have this culture of safety. And when everyone people encounter a near miss, or perceive an opportunity where something could have been missed, but they caught it, or let’s say a real mess. You know, you look at systematic processes that are in place and you say, “Okay, how can what can we put into place to prevent this from happening again?” So if you look at a situation like that, you say, “Okay, how do we prevent a patient from not having their hearing device made available?”

When they’re in the hospital, you have to kind of look at systematic processes, well, you can’t send it home with the patient. If the patient has, you know, some sort of communication vulnerability where they need devices, whether it be glasses, hearing aids, or communication boards, or whatever it is, then this needs to be part of a communication plan. And a communication plan should be a part of every single patient’s care plan, have a patient who can’t communicate, using their voice, who can command you know, when you come in, don’t come into a room and what you do and ask questions, if you can’t verbally communicate with your providers, there should be a communication plan in place. And that should be shared across the interdisciplinary team. And when you look at this ABCDEF bundle, you go, “Okay, if communication is the central core to this program, where is the communication plan? Okay, we’ve got C. C says, consider a different drug of sedation or analgesia, okay?”

Well, that’s a missed opportunity. C should be communication of communication as the central platform for the A through F bundle. But if you look for this bundle, I mean, the devils in the details, there’s absolutely no mandate, no mandate, that any of these patients who are intubated, are trained, and can’t speak, that there’ll be a communication plan in place, or even what a communication plan would consist of. So there’s a gap.

Um, you know, and then when you look at other things that create accountability, like documenting, if you went to a chart and temperature wasn’t documented for three days, would you assume that the temperature was just taken, but it just wasn’t abnormal? And some no one? Document? No, you think that no one knew if the times you say, Well, I have no idea if this patient was febrile during this time, or was cold. And this is why the blood pressure and heart rate were so low. So if it’s not documented, it’s really not part of the patient care, right. It’s just some ad hoc, you know, privileged opportunity, if you happen to have a nurse that knows enough about it or cares enough about it.

Maybe they have the app on their own device, and they use it. But that’s not systematic adoption, you certainly can’t drive outcomes with ad hoc situations specific or provider specific interventions. So you know, I’ve looked at this bundle, and looked at systematic change and how would, and I can, I can provide you an idea of what I think if we were to implement four new elements of performance within this bundle, that would centralize the patient’s ability to communicate, when they can communicate, it would be, you know, doing a checks and balances with communication in the ICU rounding period. So when that sedation is turned off at 4am.

You know, the, the doctors they come around, and you know, when they ask about the antibiotics, if, if the cultures are back, and if they’re matching the culture sensitivities, they ask about communication. Is the patient able to communicate? No, okay, well, what have we provided them? What tools don’t work? Have we called a speech language pathologists to come to the bedside and make recommendations? Okay, great. We’ll follow up with those recommendations later. And then you’d look in the charting and the charting along with vital signs and other things, you would have documented what communication tool the patient uses, that’s effective. And that might change from day to day, one day, they might be able to write with pen and paper, the next day, they need, you know, the communication board, you know, or maybe, you know, this patient can’t do any of that. And they can just do hand gestures.

Kali Dayton

But it would be so much information for us. I mean, what’s causing the change in capacity? Is it delirium, is it a weakness is that it would tell us so much to be able to look back and charting and see what has changed and make us ask why. And I think it would help our diagnostics.

Dr. Patak

That makes a lot of sense. Yeah, it would tell a story, right? Because a patient’s cognitive and physical capabilities, they wax and wane and that’s why there’s not One tool that, you know, fits all. And that’s why you need the full armamentarium of tools and devices and also why you need, you know, to call phone a friend sometimes and have a speech language pathologist, make some recommendations.

But you know, there’s a speaks to program out there that Dr. Mary Beth Happ has put together. And this has been actually shown to create sustainability, in practice, change, and improve the way in which providers are able to pick and choose and use a variety of different tools to help patients communicate, it’s SPEACS-2. And right now it’s available for free, anyone can go to it, it’s 6 10 minute session, so a total of one hour. And you can get CEUs for it as well. But it kind of goes into all the counterintuitive nuances of what actually makes provider more successful and being able to use tools and use hand gestures and think still.

Yeah, I was funny. I just mentioned, there’s a story that I heard at this. Also this IHI presentation, one provider walks into the room and says, squeeze my hand once for yes, two for now. The next one comes in the room, it says blink once for yes, two for now. The next one comes in and says squeeze my finger to free us one for now the patient can remember what’s going on. They can’t keep up with it. But each provider thinks they’re being Hey, I’m being patient centered. I can they are. Yeah, but there’s a reason why everyone should be changing what the rules are, in terms of what means what, but all this stuff could be on a dry erase board in the room and people could be consistent. And that’s that’s not intuitive to me. I’ve just learned that myself. And I’ve been, you know, involved in this for 40 to 30 years.

 

Kali Dayton

Yeah, that is, I had never even thought of it that way. Because we do we do that we do. What makes sense to us in the moment, but you’re stepping back and looking at the big picture. And especially from the patient’s perspective, right? And how have you seen this approach? impact patient care?

Dr. Patak

Sure. So um, I would say, I don’t know that we actually have you ever really seen systematic adoption. And, you know, there was a huge effort back in, I think, 2009, maybe 2011, we were working with one of the directors of the Joint Commission, who was in the health disparities division. And she was such a champion, Amy Wilson Stroms. Such a champion for patient advocacy.

And looking at the standards of care around patient communication at the time, there wasn’t even any direction on what providers should do other than, you know, there was there’s really nothing specific. And also there was actually new standards written at that time, I think, in 2011, new elements of performance around standards of care. And the best that they could do actually, was to write these new standards that communication tools should be provided to patients. But the the level of standard was non punitive, if not fulfilled.

In other words, let’s say there’s three different categories of standards of care category A, if you don’t comply, you get dinged for it, you get points off, and you have to reconcile the problem. Level B, they’re basically suggestions, but you don’t have to fulfill them. And that’s where this fall. So the best they could do was write them, but not require that anybody follow them. And so they’re just, they’re just lingering there as suggestions, still no mandate. And, you know, Dr. hat came out with an article just recently, four decades later, where are we now? And it’s crazy. I mean, if any of these voice if any of these patients actually had a voice at the time, you know, we would in real time be aware of this tragic, silent crisis that’s going on. But none of us are called out on it at the time because none of these patients are able to do that for themselves. And, you know, it’s it truly is a silent crisis.

Kali Dayton

Well, we’re still struggling with getting sedation lightened and turned off. I know. I mean, what? So that’s one of the barriers, how to standardize it. But what comes before allowing patients to communicate allowing them to have functional brains. Right. And, and we still struggle with with that we have research from 20, 30 years ago showing that the nation’s harmful, it hurts patients. And yet we continue to do it.

And I think communication has fallen by the wayside in so many ways along with our persistent sedation culture. But I love the focus that you bring back into realizing that these are humans that we’re treating not just bodies, not just individual organs. These are people with souls that need connection interaction need to know that they can be heard and have their needs met. And how would you What recommendations would you give to the ICU community to be able to standardize this to move in this direction to have this shift in perspective and priority?

Dr. Patak

Yeah, I get what you’re saying. It’s almost kind of a catch 22? At what point do you break the cycle? So you wean the sedation off at 4am, you make rounds at 6am? You You know, start your breathing trials and then 11am, the patient, you know, comes to can’t communicate, becomes panic stricken, shakes, the bad, gets misinterpreted as trying to pull the tube when they’re just trying to tell you to suction that to you. Or they want to know when the tube is coming out, or their mouth is full of saliva and they can’t swallow, or they’ve got a hair in their mouth.

You know, these gestures get misinterpreted, you know, and at some point, the sedation gets turned back on. Because you know, we’re ignoring the patient or we’re ignoring the fact that sedation causes harm. I think we’re doing it because it’s the best alternative to letting that patients suffer. So what does it what does a provider have three options, right? No, let’s call it four. They turn the sedation off, they can do one of four things, they can activate the patient, great, perfect, or they can communicate with the patient, the patient can get activated. And then or they can just sedate the patient, are they gonna let them suffer? And so they’re not going to probably let them suffer. So they’re going to re-sedate the patient.

Kali Dayton

Which, I have to interject. Sedation is not liberation from suffering. It just masks their suffering.

Dr. Patak

Yeah, I get it.

Kali Dayton

We don’t see the suffering it underneath. That’s my little interjection because we hardly ever sedate patients here because we… because we don’t want them to suffer. But it’s uncomfortable for us to see them be anxious and confused and delirious. And so it’s more comfortable for us to mask it with sedation. But that is one of the options. That is what happens. That’s, that’s the way I learned study certifications, which is not what they’re meant for. But as a travel nurse, they just said you just turn the probe down enough to see them flail fours, then you know that they’re uncomfortable, and you turn it back on.

Dr. Patak

Yeah, it’s too unfortunate. So I mean, I think the Society for critical care medicine really needs an overhaul on their ABCDEF bundle. And you know, we have a letter to the editor that was recently accepted, that kind of highlights the need for communication, to be re examined. And that it’s really not about you know, communicating with the family. Although that’s great, and engagement with the family and the patient. It’s about the patient communicating with you. And this impacts everything.

So I’ll give you an example. I had a physical therapist, I’m gonna say her name is Nicole. She said, this is so important. I can’t tell you the number of times I come to the bedside to do rent, pass a range of motion, physical therapy, early mobility. And the nurse stops me from going in the room and says, Please, don’t go in there and wake her up or wake him up. I just got them settled. And because the patient has no means to communicate, because they’re terrified and trapped, you know, the nurse has nothing else to work with except the medication. So she pre sedates the patient, she gets them. The last thing she wants is for that patient to get early mobility, because they will undo everything they just got done doing to get them settled, because they’re avoiding not avoiding, but they’re just there’s this absenteeism around communication, and it’s completely absent from the care paradigm.

I don’t get it. I mean, for decades, we’ve been talking about this, what is it going to take for this to become routinary Just as routinary as a vital sign, you know, every four hours, you’re assessing the patient for their ability to communicate unless they’re sleeping. Um, and you always walk in the room and let them communicate before you do anything. thing else, you have this embedded in your ICU rounds, and it’s challenged, and it’s answered.

And there’s a checks and balances, there’s referrals to speech language pathologists, there’s electronic medical records that include communication method that gets documented on an hourly basis. There are communication plans in place that clearly articulate what’s needed to optimize this patient’s ability to communicate. And lastly, there are quality assurance, observation audits, where someone is anonymously, you know, observing patient care, and they observe on a consistent basis providers when they walk in the room, approach the patient and provide them their care plan directed communication tool, as the first intervention, and they don’t turn their back on the patient.

Because the you know, you walk out of the room, looking at the patient, making sure they’re not left with a need on acknowledge, then you can keep your sedation off, then you can mobilize your patient, then you don’t have to worry about waking the bear, so to speak. As you know, it might be suggested when someone goes in to do early mobility, range of motion exercises to someone who just got, you know, settled, so to speak.

Kali Dayton

Oh, Dr. Patak, I love it so much. It just speaks so much truth to me. And it feels right. It feels like what medicine should be. And I know that it can be I see it so much in my awakened walking ICU, that we can see our patients and treat them as humans when we allow them to be awake and talk to us and we can connect with them. I am so grateful for all your wonderful work and vigilance over this aspect of medicine and critical care. And I I think that you will see fruits of your labors in the time to come.

Dr. Patak

Well, hopefully with this, one of the positives from this crisis. And I realize you know, delirium has, let’s say, all just you know, 20 different, you know, contributing factors. And yeah, there’s this cytokine cytokine surge, and, you know, there’s sepsis and everything, but when it does fall on us, because we have failed to communicate or allow this patient community. And we are sedating, when we have other options, and it’s not the other factors, then we are contributing to harm, and we are part of the problem. And we are part of the the delirium rates being persistently high. And we are part of the mortality, all the complications that ensue from this.

Kali Dayton

I love it, I think with our COVID survivors, at least I’m seeing younger and younger people coming in. And when they have spent weeks been sedated, and they come out of this with cognitive deficits, PTSD, all the things. I expect to see them on social media, and coming back to the medical field and saying, what happened to me? Why Why am I like this? Why is my life like this? They’re gonna have a new voice that we haven’t heard the older generation have yet. And it’s gonna come back on us. And I think that is when we’re going to be very obligated to open the gateway and actually talk to our patients moving forward.

Dr. Patak

Well, thank you for creating a platform to increase awareness. And, you know, eventually we will get there and I feel like the time is now.

Kali Dayton

I think so. Thank you so much for being a part of it and leading it.

Dr. Patak

Thank you so much.

 

Transcribed by https://otter.ai

 

 

 

Dr. Lance Patak’s communication app, Vidatak, and research:

https://vidatak.com 

Patak L, Gawlinski A, Fung NI, Doering L, Berg J. (2004). Patient’s reports of health care practitioner interventions related to communication during mechanical ventilation. Heart & Lung — The Journal of Acute and Critical Care 33(5), 308–320.

 

More resources about communication in the ICU:

1. Albarran AW. (1991). A review of communication with intubated patients and those with tracheostomies within an intensive care environment. Intensive Care Nursing; 7(3):179–186.
2. American Hospital Association. The patient care partnership: Understanding expectations, rights, and responsibilities. Retrieved 01/2009 
3. Ashworth P. (1980). Care to communicate. (RCN Research Series ed.). London: Whitefriars Press.
4. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. (2004). The canadian adverse events study: The incidence of adverse events among hospital patients in canada. CMAJ: Canadian Medical Association Journal = Journal De l’Association Medicale Canadienne; 170(11):1678–1686.
5. Balas MC, Vasilevskis EE, Olsen KM, et al. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Medicine; 42(5):1024–1036.
6. Barrere CC. (2007). Discourse analysis of nurse-patient communication in a hospital setting: Implications for staff development. Journal for Nurses in Staff Development: JNSD: Official Journal of the National Nursing Staff Development Organization; 23(3):114–122; quiz 123–4.
7. Bartlett G, Blais R, Tamblyn R, Clermont RJ, & MacGibbon B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. CMAJ: Canadian Medical Association Journal = Journal De l’Association Medicale Canadienne; 178(12):1555–1562.
8. Bergbom-Engberg I, Hallenberg B, Wickstrom I, & Haljamae, H. (1988). A retrospective study of patients’ recall of respirator treatment. (1): Study design and basic findings. Intensive Care Nursing; 4(2):56–61.
9. Bergbom-Engberg I, & Haljamae H. (1988). A retrospective study of patients’ recall of respirator treatment. (2): Nursing care factors and feelings of security/insecurity. Intensive Care Nursing; 4(3):95–101.
10. Bergbom-Engberg I, & Haljamae H. (1989). Assessment of patients’ experience of discomforts during respirator therapy. Critical Care Medicine; 17(10):1068–1072.
11. Bergbom-Engberg, I, & Haljamae H. (1993). The communication process with ventilator patients in the ICU as perceived by the nursing staff. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 9(1):40–47.
12. Beukelman DR, Garrett KL, & Yorkston KM. (2007). Augmentive communication strategies for adults with acute chronic medical conditions.Baltimore, MD: Paul H Brookes Publishing Co.
13. Carroll SM. (2004). Nonvocal ventilated patients’ perceptions of being understood. Western Journal of Nursing Research; 26(1):85–103; discussion 104–12.
14. Carroll SM. (2007). Silent, slow lifeworld: The communication experience of nonvocal ventilated patients. Qualitative Health Research; 17(9):1165–1177.
15. Casbolt S. (2002). Communicating with the ventilated patient — a literature review. Nursing in Critical Care; 7(4):198–202.
16. Chang VT, Hwang SS, Feuerman M, Kasimis BS, & Thaler HT. (2000). The memorial symptom assessment scale short form (MSAS-SF). Cancer; 89(5):1162–1171.
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