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This episode explores the value of communication in the ICU and the impact of our sedation and immobility practices on the basic human right of communication.
Episode Transcription
Kali Dayton 0:38
This episode is dedicated to communication and the ICU. This has taken me a long time to publish in part because it is so emotional for me, this hits home.
Really, this topic should be penetrating for all of us. We should all agree that communication is a basic human right. It was recognized as a basic human right internationally over 70 years ago with the United Nations Universal Declaration of Human Rights specified in article 19 that all people must have the right to be able to communicate. Yet now in 2022, in the ICU, we’re not always so clear or focused on the this foundational right of humanity. Yet this inherit right applies to all people, regardless of communication disabilities or language barriers. This freedom requires access to communication.
My daughter has a mitochondrial disease that impairs her muscle control, and therefore has significant delays in her speech. Cognitively, she is probably around her age of three years old. Though nonverbal, her right to communicate is sacred. She uses an eye gaze device which has given me an incredible appreciation for the technology that facilitates nonverbal communication. When patients are voiceless while on mechanical ventilation, their right to communicate should be preserved. immersing myself in the post ICU world to get glimpse into the struggles of being sedated and immobilized gave me a deep love for the utilization of communication in the “Awake and walking ICU”.
Most patients are strong and intact enough to write with a pen and paper, or text, because they are usually allowed to do so shortly after intubation. I now have a better understanding of the importance of the questions they write like, “Where is my daughter?”, “Can I text my husband?”. As a wife and mother, even being away from my children without updates in normal circumstances can cause me anxiety. I would have so many things to ask and tell my husband as we never go a day without talking or connecting.
I can’t imagine the agitation I would develop if I was desperate to ask if they were okay. If I had delirium and believed grave harm was happening to them and no one gave me a way to communicate, let alone answer the questions that weighed on my mind, I would probably start to pull up my restraints and try to sit up and use my hands to get my message across. I think we all get frustrated and even demoralized or offended when we are not allowed to talk or people talk over us or about us instead of to us.
This is the constant experience of many ICU patients get their questions and comments are often pertaining to life or death or desperate need to find a clarification while battling delirium. And yet we forget that they can and should be heard and understood. Even with a breathing tube in place. The ICU rehab organization through Johns Hopkins has a really great page about how to improve comfort with the endotracheal tube, and a list of ideas. Number three on that list is to give a patient a way to express themselves. Not sedation, but a pen, paper or device. I’ve included a link to that page on the blog.
So what if we ran for a communication tool before running for sedation? Would that make a difference in agitation, restraint and sedation use? How would it impact delirium and then overall patient outcomes if we expected wanted and allowed patients to communicate with us while intubated? What is it like for patients when they are battling delirium, or are keenly aware of the reality and are desperate to be understood and yet, left not only powerless but voiceless as well? I invited survivors to share with us the role communication played in their journeys through critical illness.
Chris Ross 5:08
My name is Chris Ross, and I am a survivor of very severe COVID. I am also a speech language pathologist with just over 30 years experience. As a speech language pathologist, my practice focused on children and adults who were what would be considered functionally nonverbal, meaning they could communicate some with spoken language, but generally to really communicate in a meaningful way, they needed some sort of other system. For some people, sign language. For some people, it was computers, picture boards, whatever allowed them to express themselves in a way that was meaningful to them, and the people who were communicating with them.
In November 2020, I was diagnosed with COVID, and became very, very ill over about a two week period. I had been in the hospital for about 10 days, when I really crashed and required mechanical ventilation. So the last thing I really remember, was somebody saying to me, you need to go on a ventilator, we’re going to call your family so you can talk to them. And we did that. The next thing I remember, was 12 days later, and somebody was waking me up saying, you got a lot worse, you’ve been on a machine called ECMO. It’s kept your heart and your lungs working while you’ve been ill, and you’re doing better now. At that point, I was still intubated. And the doctor said to me, you still require a ventilator. So we’re going to do a tracheostomy, and you’re going to get a feeding tube. So this was after 12 days of very, very heavy sedation.
I remember hearing that information, and then hearing things like, “Okay, we’re going to put your feeding tube in now.”, “Okay, we’re going to, you know, do something with the ventilator.” And I remember very severe coughing fits. But from the day they will be up until the day I was transferred to an LTACH. That was five days. And really, in my memory it was, could have been less than a day because I was still sedated and coming out of that sedation.
Also, during that time, I experienced very severe delirium and still have very vivid memories of things that didn’t happen. What is most remarkable to me during this time, as both a patient and a speech language pathologist was that I had no access to any type of communication system. I remember trying to use some sign language, because I do know some sign language and a nurse saying, “I don’t understand you. Trace in my hand what you’re trying to say.” And I was trying to tell her that I wanted to go home, and I was trying to understand why I couldn’t go home, I think at the time, too.
So there were those five days while I was still in the ICU were really my only form of communication was tracing into the nurses hand. Last day I was there, I was there preparing me to transfer to a long term acute care hospital, I had made myself more than clear, I thought, prior to going on the ventilator, that if going to that LTACH was NOT an option. I was in no way in favor of it. I didn’t want to go there. I knew the reputation from working in healthcare myself, and that my family had to do whatever they could to keep me out of there because I didn’t want to go.
Well, day five after waking up. I hear that’s exactly where I’m going. And I have no way to communicate my frustrations with anybody at that point. Somehow, and I’m not sure exactly how I got across to the nurses at the hospital that night that I wanted to call my family and my A foggy memory of that. I think I became very upset and was crying. And they were asking me a series of questions to try to guess why I was upset. And then they said, “Do you want to talk to your family?” And I said, “Yes.” So, you know, of course, this was when the hospitals were still quarantining, and you weren’t allowed into to, you weren’t allowed to have visitors and visitors were not allowed in the hospital.
So we got on, on FaceTime. And my daughter understands enough sign language, that she could figure out that I did not want to go to this hospital, I was upset about that. I wanted to go anywhere, but they’re, well, you know, having the frustration and the fears about going there and not having a way to communicate, while you’re already deep into delirium was probably just the perfect storm for the delirium did come worse for PTSD. When I think about the memories I have at that time, that was probably the scariest time in my life. Well, somehow, it was 2:30 in the morning when I was transferred to the hospital I didn’t want to go to to the LTACH. And that was not a figment of delirium. It truly was 2:30i n the morning, when I was transferred. It was Christmas Eve, and I was still very delirious.
The memories I have of that time are mixed with memories of delirium, and I’m still not even sure exactly what was true and what wasn’t. I get to this hospital, continue to experience delirium, continued to be scared with no way to communicate. But I remember thinking, “Well, for sure, there’s a speech pathologist here. I know there’s a speech pathologist here, who works here. Where is a communication board? Why don’t I have a communication board in my room, so at least I could point to pictures.” Well, that never happened, never came. A few days later, a respiratory therapist came into the room and got my family on FaceTime for me, then he tore off the bottom of a Kleenex box and gave me a pen. And that was to be my communication system.
I was so weak, I could hardly write, I could hardly hold a pen. At that point. I do remember having trouble figuring out how to hold a pen. But it was something and I ran out of room pretty quickly on that commute are on that Kleenex box, trying to practice what I wanted to write. And then finally getting the words out on in writing, I still was not provided with anything other than that Kleenex box and that pen for communication until my family sent in notebooks and dry erase boards and anything else they could think of to let me communicate or to help me communicate with them.
So I was able to start writing again, after practice. Every time I would wake up, I would try to practice writing a little bit, I’d write down questions or things that I wanted to say to my family just to have a way to communicate. Finally, about two weeks later from writing on after writing on our erase boards and notebooks of communicating with my health care team this way, I got a Passy Muir valve, a speaking valve and I was so thrilled to see that, again, as a speech pathologist.
I knew what it was, and I could not wait to get that on and start using it right away. From there, I got my voice back. I love when I look at my Facebook memories of that day, I felt like that was the most liberating day that I finally had a way to communicate. But I feel what happened to me is very common. And it’s it’s very concerning that there are so many people in ICUs, on ventilators who have no access to communication because communication really is a fundamental right, you know, and to care for your patients, you have to have some sort of ability for them to communicate whatever way that is if they’re unable to communicate verbally.
David Richards 14:40
Not being able to communicate effectively can be extremely distressing. My initial communication method while awake on the vent was blinking once for “Yes” and twice for “No”. Of course, this is only suitable for responding to questions. And at this stage, my mind was still in torment because the nightmares I experienced during my coma carried forward after I was brought around from weeks of sedation. In that world, my two young daughters had been kidnapped, which was more real to me than the world I was now awake in. And I had no ability to tell anyone or ask for help. It would be two days before my daughter’s visited me and released me from that scenario.
As the effects of the paralytics wore off, I was able to move my jaw more freely, and lip reading came next. Words like “yes” and “no” was straightforward, but stringing together more than a few words could be problematic. As some strength returned to my arms. The next stage was pointing at single letters on an alphabet board to spell words. But that would quickly become tiring. I could only communicate this way for a matter of minutes as my arm would soon weaken. And I would struggle to point out the correct letter, with my finger hovering at the one below or to the side, and the person reading would say they couldn’t understand which would often result in me giving up because I would be too tired or weak to repeat a phrase if misunderstood.
Next, I was presented with a pen and notepad. I drew circles and lines as I was too weak to form words and lost all dexterity. Following repeated attempts. My first written question was to my former partner and the mother of our baby son, I asked her, “Where am I”. One recurring nightmare I experienced included nurses who were involved in the kidnapping of my daughters. So can I trust these people who I see in nurses uniforms, and who had given me so much attention?
My second written comment was, “I’m frightened”- because I was experiencing a distorted reality driven by auditory and visual hallucinations. And many of the doctors and nurses had already entered into my delusions in a negative way. So I was very wary of their presence. My early writing was mostly unintelligible and littered with spelling mistakes. So I would have to clarify the message by mouthing the words, all of my written communications were saved and incorporated in my ICU diary, so I am able to look back at them.
The final increment in my communication progression, was having a Passy Muir valve attached to my trach. This allowed my voice to be heard and was by far the clearest method, but I could only tolerate it for short periods. My ICU event was 12 years ago. And I hope that improved methods of communicating more widely available to patients now. I’ve seen demonstrations of communication apps for tablet computers in the UK and the US. We’re typing an icon can represent an entire common sentence such as “My mouth is dry”, “I am uncomfortable”, “What is the date?”.
I have no doubt that having access to this method of communication would have improved my ICU experience greatly. By reducing my anxiety and frustration, and in turn, elevating my psychological state. This would also have benefited interaction with my visiting family and clinical staff. My only concern with this easier method of communication is that many patients like myself will be in the grip of delirium, and it may grow tiresome for nursing staff, having to repeatedly respond to delusional comments and family may be worried by what their loved one is telling them.
ICU survivor 3 18:32
After I was intubated and put into a medically induced coma, there was a time where they were changing levels of sedation I was under. And so I became more aware, and attempted several times to communicate by writing on the bed with my fingers to my mother. My mom told me I was very agitated and clearly kept trying to talk to her. But the nurses and doctors all told her to “leave me alone and to not allow me access to pen and paper”- in fear that I would ask them to discontinue my care. And I vividly remember trying to scream and cry because I was so frustrated at not being able to communicate what I was feeling.
I remember my mom sobbing next to me because of it. Eventually, my mom gave in and let me leave a pen and paper and I somehow wrote her a note. And in that, no, it was just me expressing the fear that I had and the pain that I was in. And that was really important for me to be able to express that. I think it’s so important not only as a patient to have access to communicate in some way, but also for your family. It’s such a scary time for everyone involved. And I think it’s helpful to bridge that gap. So you both don’t feel so alone in what you’re experiencing together.
ICU survivor 4 20:07
It was around June 17 2015, when I first woke up from being intubated. This started when the doctor said I had an allergic reaction to an anesthesia administered for a partial knee replacement. I could not move any part of my body or talk to the medical team or my wife. I had all kinds of tubes attached to me and I moved my lips toward my wife, and I tried to say, let me die. My legs and feet were the size of five gallon buckets due to blood clots and my legs. I remember them swabbing my lips with water. And they somehow got the message that I wanted a little watermelon juice in the water. That night a nurse brought in watermelon and rubbed a piece on my lips. I tell you, this may sound small, but to me it was everything. I wasn’t able to use a call button as I couldn’t move my hands. When I wanted something, I would take my wedding band and peck against the metal bed. After a couple days, I was able to raise my hand. One night, I needed something and I could see a nurse out the window. So I raised my hand, the nurse thought I was just waving at her and she waved back and went on about her business. This was so frustrating as I couldn’t speak at all, I could barely move my arms. This was my life for a couple of weeks until I got more mobile and started using the passenger valve.
Ille Gonzalez 21:19
So I was in a medically induced coma for 25 days, when I came out of that coma, I suffered some traumatic delirium, which puts you in a kind of strange place psychologically, on top of that I was on so many paralytics and drugs for so long without those sedation vacations, that I was completely paralyzed. And I had been traped. And I was ventilator dependent. So I had no way to communicate to the nurses, to my partner to anybody, because as many people say, “hey, I can read lips”, well, I only met two people in that entire four month period that could actually read lips.
So it kind of affected my ability to communicate, because I couldn’t write on a whiteboard or piece of paper, like a couple of the nurses asked me to do. I couldn’t point at a communication board. So we eventually my partner and I came up with a really low tech, assistive technology way where we bought a laser pointer online. And she glued it to my favorite baseball hat. But I was able to actually point with the laser at these letter boards. And they were they had words on there like “eyeglasses” or “reposition” or things like that. But if it wasn’t for that I wouldn’t have had any other way to communicate.
This really impacted me in a sense that I mean, it’s already tough enough when you’re dealing with that sort of physical deficit, I would say and then you can’t communicate with people. It just psychologically just damages you. So as a result, I was very agitated and depressed and things like that this whole time and actually suffered pics and had to go through PTSD treatment and stuff like that. The one thing I wish that I had a chance to to use while I was in the hospital was I wish I had a chance to use some of these communication tools that you know, they’re now they’re coming out with, like the Vidatalk. When I first saw this, it brought tears to my eyes. So I think this would have changed a lot of my recovery outcome and actually shortened it quite a bit. So anybody that has the power to do something about this, please find a way to give your intubated patients a voice and a sense of communication, so that they can do better and move quicker to getting back to some semblance of their normal lives.
Carol Billian 23:44
Back in 2018, I was hospitalized. I was in the ICU for 35 days. I had been sedated and was on a ventilator. for close to three weeks, I was on a ventilator because my colon had ruptured. And I was in septic shock. Unfortunately, I was not given the choice of whether or not I could be sedated. No one in my family knew enough to say, “I don’t want my daughter on sedation. I want her to be walking around while she is attached to a ventilator.” – That is an option that you and your family members have now, but you need to know about it.
The other thing that’s upsetting to me now is the fact because I was sedated, I had no means of communicating with my family members, loved ones, doctors nurses for that almost three week period of time. I have since come to learn that there are devices that are specifically made for this and it’s a tremendous help to the patient, to loved ones to all A medical staff who is there to help the patient.
And I’m here to urge you to ask for this type of thing. If you or a family member should be in need some type of device, recording device, it could be a telephone, it could be a whiteboard, even a pen and paper, at the very least, would be so helpful because you would be able to express what you need. If you are scared. You could say you’re scared, if you need something, anything, you could ask for it. They would be able to keep in touch with you letting you know how you’re doing. If I had had such a device, I know I would not have been as worried about my mom who was then at nine years old. I wouldn’t have been worried about my family, my brothers and my two nephews. Family is everything to me. And I now know that I could have had something like this. And I should have had something like this. So I want you to know all about it so that you can ask for it. Do not, do not be sedated, it will make your recovery much tougher.
ICU Survivor 5 26:20
When first on a vent and awake, I tried to use ASL. The staff thought that I was trying to pull my tube out until one of the cleaning crew told them what I was doing. They also tied my hands down. Eventually,. my husband brought in a pad and pen. Being unable to communicate made me more agitated, especially when they were giving me meds I have had with bad responses to. I believe they did keep me sedated-induced coma for as much as five days on at least five occasions on awakening me when they tried to wean me. Six years later, I’m trach and vent dependent 24/7. Whenever I need now hospitalization, I’m always in the ICU. I know many of the staff. My life is reasonably normal except for the gear. I participate fully in my community. I drive volunteer and go shopping.
ICU Survivor 6 27:17
When I was intubated, one of the hardest things was communication. Because being restrained I wasn’t able to have easy access to my phone to text or to handle writing on the clipboard. I also found writing was difficult because the IVs that were in my wrist. I wish that when the staff loosened my restraints that they were able to realize that they could…. that I wasn’t trying to pull my tube out, that I was just trying to find some way to communicate.
Kali Dayton 27:54
If we truly see our patients as human and respect their basic rights, then we will facilitate communication. If we do not have tools available for nonverbal communication, then we are not providing humane care. As a clinician, a patient’s ability to tell me their medical history medication record, wishes for their care goals for their future pain level and location, how they’re sleeping anxiety levels, any signs of delirium and so on, are key to my assessment and decision making.
We can do much more effective and thorough assessments and care when we avoid sedation and allow for communication with our patients. If you have ever lived or visited a country or environment in which no one around you spoke your language, then you may have a tiny glimpse into the frustration our patients feel when they try to use their restrained hands or look at us with panic and move their lips in seemingly senseless ways in desperate attempt to give us the message that they are panicked about.
I lived in El Salvador for eight months. No one around me spoke English. And initially my Spanish was laughable. Upon my arrival, I suddenly needed to go to an orthodontist. I traveled to a nice clinic in the Capitol, but my inability to tell them what I wanted or needed caused me angst. I laid there feeling so vulnerable as they messed with my mouth. And I had questions about what they were doing or planning to do that I couldn’t ask. In the end, when I looked in the mirror, I realized the procedure they had performed was not what I was really there for, but I couldn’t communicate it. I also felt like they treated me like I was incompetent or unintelligent because I couldn’t communicate with them.
I can only imagine what it is like as a patient in an ICU. Knowing my life is on the line and having so much to ask and say but being unable to do so and instead be ignored, restrained, and sedated when I attempted to communicate. Could there be a more dehumanizing approach to caring for patients? So what does it mean to a patient when they cannot speak but are allowed to write, text, point to a board, or use a device? Those survivors were eager to share their insights as well.
Susan East 30:22
My name is Susan East. The first time I had ARDS was very scary and frightening. I had never been sick. So to be that sick on a ventilator, and not know what was going on. It scared me. The doctors and nurses would come in and speak with my family, or they would all step in the hall and talk. But nobody spoke to me about what was going on with me. It made it worse for me and caused me a lot of anxiety.
‘The third time I had ARDS, I was in need of a lung biopsy and I was on a vent, my family and the doctor were in my room and the doctor was telling them that it was necessary to do a lung biopsy and to maybe see what was going on with my lungs. My family had told the doctor “No”-that it was very risky. And the doctor told him it was very risky. They didn’t feel like at that time that we’re willing to take that chance because I was so sick. I motioned for the doctor, I had a notepad, I had a pan on my table. And I motioned for the doctor to get her attention. And when she looked at me, I wrote down, “Can I sign?” and she asked me, “Are you asking me if you can sign for this procedure?” and I shook my head “Yes”. My family was very upset. But I felt like for me, I needed to do this if the doctor thought it was necessary, I wanted to go ahead and have it done. It made me feel even better, though, to be able to be in control of what was going on with my body and my condition. To be able to text to be able to write and communicate and to have people communicate with you can make all the difference in the world in your recovery.
Joan Johnston 32:31
September 18 2018 was the day that I will remember for the rest of my life. That was the day I was admitted into the hospital immediately given oxygen because I couldn’t catch a breath were lightheaded. My oxygen at that time was at 73. Fast forward three days later I was life flighted to Salt Lake City intubated tubes in my nose, IV, PICC line, but I was awake, woke up to a whole bunch of doctors, I was handcuffed to the bed. Well, the handcuffs were there just to keep me from pulling everything out of my mouth and the tubes out went through a short probably 24 hours maybe of ICU delirium.
Thinking back now after talking to other survivors that have went through this that were sedated they have told me that they suffer long term mental from being going through the ICU delirium through being sedated for so long, I am so thankful that I only had to endure that for a short 24 hours. As horrible as that was during my 17 day stay in the in the ICU, it was the most painful, traumatic event that I had ever been through. And I’ve given birth to three children, I would definitely rather do childbirth, than to go through that. And that time I had blown blood vessels in my eyes. I was however, they gave me a pencil and a piece of paper.
And I was able to communicate with my family, I was able to communicate with my doctor. At one point in time I remember asking my doctor if I was going to die. I remember my doctor turning to me and saying, “Only time will tell and that is up to you if you die.” Had I not been awake and asking that question and and just….. it was so freeing to be able to communicate and to even help my daughter with her homework and to communicate with them that way. My daughter what had prom that same that same time and I was able to communicate with her over phone of course but do chats with her and you know I got to write on the piece of paper, “You look so beautiful. I wish I was there.”
Taking a shower was probably the first time I was able to take a shower, being intubated and standing there with the tubes in my throat and down my throat but being able to bathe myself before then I hadn’t been able to bathe myself, I’d have somebody do it for me. But being able to stand up and shower, by myself was in privacy. And it was just the best feeling. It was amazing being able to walk the laps laps around the the facility and with the being intubated, it was hard. I won’t, I will nothing about this was easy. However, being able to walk around and get to strength. I had talked to survivors that had been into that had been intubated and sedated. And they had to go through physical therapy for many, many a long time.
Me personally, I was in there for 17 days, and was able to walk, talk, and walk out of the hospital. I didn’t have to do physical therapy. I went home on oxygen, but only for a short amount of time. Yeah, I as much as pain as I had to go through and how horrible it was for my family to watch. If I ever in fact, I moved to Tennessee, and I told my husband, I suppose if I ever start going downhill, and I get ARDS again, don’t you dare let them put me to sleep. Don’t you let them put me down. I want to be put over in Salt Lake, I want to be awake again. Because I’ve heard the stories of people that that haven’t been and I I would do it all over again. Because being able to communicate being awake, being able to spend those last times if I was going to have a laughter last time with my family awake is far more better than being asleep. And them talking and me not being able to communicate.
Kali Dayton 37:00
So what value does communication hold for ICU clinicians? Is it just another laborious task? Do we even have time for it? Or has it helped improve workload and job fulfillment?
Tami Altshuler, SLP 37:15
As a speech language pathologist in the ICUs, I work with our critical care teams to initiate sedation vacations for our patients were intubated or tricked event. I frequently attend ICU rounds and identify patients who are unable to communicate and may be kept sedated to prevent agitation or any frustration. And it sometimes takes a bit of advocacy and coordination. But once patients have access to communication, and the ability to ask questions or participate in their own care, they no longer needs to be kept sedated.
A few years ago, I worked with a teenager who was 14 at the time and he had a cardiac arrest. And he was in our pediatric ICU, intubated and sedated. And the team kept saying that every time they would take him off of the sedation, he would get really agitated and try to pull out all of his tubes. So they would resuscitate him. And I asked them if I could have a few minutes with him off of the sedation, and help him communicate. And they were able to take him off. And he immediately was able to communicate using an alphabet board. And the first thing that he expressed was he asked, “Am I going to die?”. And so we immediately brought in his family and the psychologist and the attending physician, and had a discussion with him about everything that he went through, and that he’s okay now and that he’s getting better. And when they went to put back the sedation, they didn’t fully sedate him. They only gave him a milder form of it. And that was really the start of the weaning process of sedation for him once he was able to communicate.
ICU revolutionist 39:22
So recently, I had a patient in the ICU who had been found down on the street, we didn’t really have any form of identification or past medical history. It was one of those situations where you come on shift, and everything’s kind of hitting the fan. So you just go in the room to get like at bedside report immediately. And they are just struggling to control this intubated patient, they are wilding out all over the bed, you know, arms and legs everywhere. And I looked at this patient and I was like, “Oh my gosh, what is wrong?” And they use they’re mit to kind of point towards the IV pole with all the medications we were trying to sedate them with, And I was like, “okay, is this about your medicine?”
And they nodded their head and I tried to educate them on the medications they were getting. And that wasn’t working. And I was like, “Okay, is this about something else about medication?” And they nodded their head, “Yes.” And I was like, “Okay, well, I am going to give you a whiteboard. And I’m going to give you a lone hand. That hand we’ll use to write and just don’t pull anything out of your mouth, Okay? It’s really important. You don’t pull anything.” and they nodded their head, “Yes”.
So they start writing. And the only thing they write on the whiteboard in all capital letters, was “RISPERDAL”. At which point, I audibly swore I was like, “Oh, my gosh, okay.” I was like, “You take Risperdal at home?” They’re nodding their head “YES! YES!” Like very emphatically, like, “Okay, I think we think we found our issue here, folks.” So we were able to get them their home psych meds, and get in touch with the family, actually. And 12 hours later, we had a patient completely off of sedation, compliant, ready to mobilize. But in that moment, nothing was going to sedate them because they needed their anti psychotic, they had a history of schizophrenia.
Austin 41:08
My intubated patients are awake. I have such an easy time understanding what they need, whether it’s needing to use the bathroom, wanting to be suction, feeling anxious, whatever it may be. So it’s always so much easier to communicate. They have less or no sedation, when I first started, kind of taking a deep dive into this podcast and listening and kind of practicing. You know, my day to day patient care, I started noticing that my delirious and confused patients had such a difficult time understanding what was going on.
That’s when I began realizing that patients I was waking up after co workers had quote, “snowed”, just needed, like constant reassurance and reorientation. Once they were awake, and everything was a little bit more lucid, the confusion about why they were not able to drink water, or why they even had a breathing tube in place became significantly clearer. So I often tell patients, when I first wake them up, not to get too stressed about having a hard time communicating at first. Kind of go over, like, I honestly will sit there and reiterate time and time again, “Hey, you know, my name is Austin, I’m your nurse, you’re in the hospital, you have a breathing tube in place, you your hands are restrained, so that you don’t take your breathing tube out, you know, it’s such and such day, it’s this time, your family’s here with you, you know, this is what’s going on.”
And so once I’ve kind of given them an update on everything, and continue reiterating that they, you know, as time as the shift goes on, rather, everything gets a little bit more clear. So I love having family involved, super, super helpful. For the most part, if you can educate the family on how to orient the patient, how to continue orienting the patient, and how to properly keep the patient calm. I know a lot of times, some of my co workers will get frustrated with having family in the room, and I’m always trying to help like, educate my co workers. It’s not necessarily there in-the-way if you put them to work and give them a task or a job, it’s so much easier.
You’ll have to answer some questions here and there on why you know, the patient’s doing this, or, you know, why the, you know, the monitor is beeping, you know, but once they’re involved, and they have a job, you know, it can be super helpful on you know, making sure you know, delirium, you know, is clearing or the confusion is clearing and you know, you can continue to wake them up, I really liked one of the more recent podcasts with the neuro ICU, the A2F bundle, and the neuro ICU. And in regards to like, patient assessments, I’ve not had any significant neuro changes on patients. But recently, I was able to assess whether or not my patient was having, you know, they had like some slight ST elevation. And I was able to like correlate, “Hey, are you having chest pain? Or do you feel differently is, you know, is anything different?” And they were able to answer yes or no questions. It’s not necessarily a guessing game of, “oh, there’s some, you know, ST elevation there, maybe they’re having a STEMI” or, you know, you can easily correlate, you know, current chest pain, or, “Hey, do you feel different?” you know, do you is there some increasing shortness of breath, and so on and so forth.
So, I’ve actually kind of gone back to family, I’ve started kind of citing, you know, this particular podcast in my family and patient education. So, I’ll walk in,”Hey, you know, I’ll be your nurse today. What I’m going to do is, we’re going to work on decreasing some of the sedation that we’ve had, you know, going and waking your loved one up.” So I’ll tell people, you know, that I’m going to decrease sedation and that will hopefully help, you know, decrease confusion. I’ll kind of explain what delirium is and families are instantly on board. So, when I tell him like, hey, this could potentially, you know, shorten your loved one’s stay in the hospital, you know, this is going to be your job moving forward, keeping your your loved one, you know up to date oriented, it’s really, you know, I’ve really noticed significant improvement. And so, lots of education, lots of you know, bettering my assessment, keeping keeping my patients awake. I’ve really, really, really loved this podcast and I’ll continue listening, and keep it going. Thank you.
Heidi Engel 45:32
Hi, my name is Heidi Engel. I’m a physical therapist and a large academic medical ICU. And this is the story I want to tell about a patient we will call Becky. Becky’s story is not unusual for what I see happening in our ICU, and how valuable it is for patients to be awake, and mobile and able to communicate. So my day tends to start with walking through the ICU, do my own individual rounds. And what that means is I look in on the patient, I greet the family if they are there, and I’m meeting them or just saying hello. And the other thing I do is I look at the ventilator. I’ve already read the medical chart to see what’s happened to the patient over the course of the past few days. I know their history. And I just like to see what’s on the monitor what’s running on the IV pole, what’s happening on the ventilator.
And on one particular morning, I looked in on Becky and she had been intubated now for two days for an acute respiratory distress syndrome, and a pneumonia in a baseline cancer diagnosis. And the ventilator was set on a pressure port pressure support settings, not very high settings at all. However, I noticed that Becky, who I knew before she needed to be intubated, and who I also knew was mobile and valued being able to get up and walk around and had very good strength still. What I noticed was there was 20 micrograms a prop before running, dexmedetomidine running, and on continuous drips and for sedation level was something at a RASS minus three.
So I was curious as to why she was sedated at 10 o’clock in the morning and what had happened, and what was our plan for the day, when would we be waking her up and getting her moving? And there was not the nurse was on break. But our wonderful respiratory therapist was sitting at a computer nearby. And so I went over to him and I asked him what’s happening with Becky today. And he said, “Well, earlier in the morning, when you weren’t here, they did a spontaneous awakening trial. And the nurse went into the room, turned off the sedation, and left the room again. And so Becky was lying alone in the bed waking up really for the first time since she had been intubated two days earlier. And she started flailing. And she was strong enough the respiratory therapist happened by just at the moment to see her reaching for her ET tube, about to pull it out.”
So he went in, and he managed to secure the ET tubing and tell the nurse what had happened. And as a result, they actually turn the propofol back on. So I asked the respiratory therapist if he was still going to be available in an hour. Yes, he was. And then I asked the physician and I asked the nurse if we could try again. It’s not unusual for me to receive some more quizzical looks when I make this request. But I followed it up with saying I’ll be there. I’ll keep her family member there. The respiratory therapist has agreed to just watch all the vent in the tubing the entire time. She really should be able to breathe comfortably once we get her up and I really believe if we explained to her what is going on. She won’t try to reach for the two. So we did this we turned off the sedation and it’s fairly common for or requests to turn off the sedation to be met with, “Well, I’ll turn it down. But I’m really not comfortable turning it all the way off.”
There are a lot of rationales I hear for weaning all the sedating medications, we need the precedex, weaning the propofol, reducing the dosage, not wanting to turn it off. And sometimes I have to start with that point. But it’s very difficult to communicate with the patient. Even when you have to have the dosage of their sedating medication, it’s everything, everything is so much easier with communication, with movement. If the sedation is just off, and that includes precedex.
Anyway, we, we gradually were able to with the sedation off, wake back up, and we did what we always do. We explained to her very calmly what was happening, and we explained it to her again and again. And we asked her to please very much not touch the tube. And we had her family member right there next to her doing the same thing. She loves Christian music and her family member began to sing to her it was lovely. And that and that brought her around and woke her up. And finally once we had her sitting up and then eventually standing up and then moving over to a chair and then comfortably placed in the chair. And realize nothing medically had changed between initial sedation wake up number one early in the morning where no one was in the room. The sedation just turned off, the patient left lying there with restraints and our hands tied to the bed rails.
Medically not a single thing happened between that moment. And a few hours later when I came back, and instead we woke her up. We had the music playing. We had the family present, we had a lot of calm explanation for the patient of what was happening. We washed her face, we combed her hair, we gave her a back rub. We gradually helped her stand up, we got her settled into a chair we put she had her own personal blanket in the room, we put the blanket over her in the chair, we had her loved one, sitting right in front of her the whole time we had the respiratory therapist available to suction the secretions out of her.
And we gave her paper and pen. And she was able to write and she would tell us what she needed and she would indicate that, you know, she felt like she was getting enough air. And then we would explain to her how the ventilator acts as exactly the opposite of normal breathing and how distressful that can be, but she was still needing the ventilator right now. And we had to help her find ways to adapt to it. We had her friends talking to her later on on an iPad. And a few days later, when she was excavated, and in a regular hospital room, I went to say hello to her. And I asked Becky, what it meant for her to be able to be awake and communicating openly with her family and openly with us while she was still in the ICU and on the ventilator.
And she said it was the most reassuring thing, it was the one thing that gave her hope. And it meant everything to her to be able to have her friend communicating with her, and for her to be able to express her needs and her fears to us in return. So Becky is doing very well. She’s still needing treatment for her cancer. And we have kept a journal for her. So we also wrote down the entire experience of what happened with her in the ICU in her in her ICU diary, which has continued to be her journaling experience out on the floor as well. So that’s a good story. And I wish many more similar stories for the future of our ICU and an ICU is everywhere.
Kali Dayton 54:53
So let’s be clear, depriving patients of the opportunity to communicate is not usually malicious. It is cultural. One of my first shifts with an intensivist that was brand new to the “Awake and Walking in ICU” provided a glimpse into the contrasting perspectives we have. Lifeflight brought us an intubated patient she had advanced muscular dystrophy and was in septic shock and acute respiratory failure from aspiration pneumonia. She arrived sedated. But the nurse habitually took off sedation. I had called her sister and was almost at the patient’s doorway when this new intensivist was passing by and exclaimed, “Woah! Hey, hey- she’s she’s awake!” and turned to me and said in panic, “They need to turn up her sedation!” distracted by the phone call, I quickly said something like, “Hey, no, she’s okay.” And hopefully my said “I’ll explain more in a bit.”
I proceeded into the patient’s room and had the sister on speakerphone. The sister was asking important questions about the location of her young daughter. And if she was okay. The patient was able to mouth words, shake her head, give thumbs up and eventually write a little bit, as was her baseline with muscular dystrophy. I felt eyes on me and I looked at the doorway to see the intensivist still standing there, but in shock with his jaw dropped. I realized that he was having a paradigm shift as he realized that the patient could communicate. He wasn’t intending to violate her human right to have access to communication. He just didn’t expect her to be able to communicate with us, because she had a breathing tube which in his mind meant to be automatically sedated.
Hopefully in that moment, the patient seemed more human to him and her right and ability to communicate was clearly demonstrated to him. The family wasn’t able to be with her right away and we learned from the patient that there was an ongoing custody battle between her, the daughters unstable father, and the reservation counsel as the mother and daughter were Native American. Despite her advanced disease process and critical illness, this young mother stayed awake and participated in dangling while she was intubated.
Because we allowed her the opportunity to communicate, we were able to facilitate the involvement of the reservation counsel and lawyers to expedite the resolution of custody matters. This ensured her daughter was safe, no matter what happened to the patient. That alone brought relief to her anxiety. She was able to make the decision to have a tracheostomy, as her respiratory muscles were falling victim to her muscular dystrophy. Her family didn’t have to make that decision, and she told us what she wanted.
Avoiding sedation and allowing for communication protected this mother and daughter, as well as preserve the mother’s autonomy and independence. She had the right to decide on her care and her daughter’s future- despite being on mechanical ventilation. We honored that right. This would have been a completely different scenario for both of them, had she been sedated and/or not able to communicate. In episode 20 there are stories about patients that were allowed to choose to discontinue life preserving measures. They signed their pension paperwork, sent off final emails, decided who was present and said their goodbyes, all because they were allowed to be autonomous through communication tools.
One patient in the “Awake and Walking ICU” was a young widowed father. He was engaged to a wonderful woman that had already stepped in as his stepmother to his children. He was battling severe ARDS and when he was informed that he needed to be prone, sedated and paralyzed. He wrote to the staff that he wanted to be married first, to make sure his fiancee had full custody of the children in case he didn’t survive. The team scrambled and within the next few hours, they had a marriage certificate and officiate flowers, cake and some humble decorations. And while he was a maximum ventilator settings, his wish was honored and he was sedated knowing that his children would be okay.
He did not survive more than a few days beyond that. This team’s value of the patient’s dignity and autonomy naturally lead them to find ways for him to communicate and make his final wishes known. So now we all understand why communication is so important. Yet, let’s be real. It’s not always so easy or simple. It’s great when a patient wakes up right after intubation and has the cognition, strength, and dexterity to hold a pen and paper, or text on their phones. This should be a huge plus in caring for appropriate patients that way. And those instances a pen, clipboard, whiteboard, iPad, or cell phone with basic texting tools are sufficient, though even that can be tedious to the patient to have to write out every single word and letter. Yet, those tools work. You don’t have to have fancy equipment.
But what about the exceptions in which patients have to be sedated for a period of time, and then become delirious weak or clumsy with their hands? Do we give up on them is their right to communicate on pause. So in formulating a plan for success to become “Awake and Walking ICUs”, we need to have an appreciation for communication, the expectation for it, and then the tools to facilitate it. I think communication is an essential part of mobility. Before throwing a patient out of bed, we need to give them a chance to express their concerns, pain, discomfort, preferences in task or music before and during mobility.
I’ve even had a patient right, quote, “Be careful with my tube” as they were anxious that the clinicians wouldn’t be cautious with their ET tube. By allowing them to express that concern and then addressing it, they were able to mobilize with comfort and confidence. I was recently at a mobility conference and as we were doing scenarios, I pretended to be the patient with ICU acquired weakness and delirium. I realized how incomplete the scenario was without a communication tool like Vidatalk, as I really got into character laying in that hospital bed pretending to be really delirious agitated. I imagined that the vulnerability, angst and questions I had as a patient, but then had no way to express them or have them addressed.
Even in the pretend scenario, I realized that this made me as a patient, less interested in doing whatever mobility task they wanted me to do, because I wanted to be heard and understood first. We must have adaptive communication tools for our patients. My three year old daughter can talk with her eyes, or the slight tap of her weak and clumsy fingers. So why can’t our patients do the same while fighting for their lives surrounded by strangers?
So again, reach out to me and let’s chat about how to use this technology to support changes in sedation management within your team, as well as how to address your unique and maybe not so unique barriers. Of course, the argument may come up with the same response of quote, “We don’t have the resources.” So okay, listen, there aren’t studies I can throw out that prove that allowing patients to communicate will directly decrease hospital costs…. But let’s piece it together.
Go back to Episode 95 and review the financial sinkhole that sedation and immobility create. When communication technology like Vida talk makes communication easier and quicker for clinicians and patients, then we do better assessment, catch complications sooner provide better care, and ultimately decrease and prevent sedation use, which leads to a plummet in delirium and agitation rates and helps us be more successful with early mobility.
This all plays into the ultimate goal of getting them off the ventilator sooner, having them walk out the doors, and avoid a bucket list of expensive complications that they would be vulnerable to if we were to respond to their attempts to communicate with sedation. I feel confident that whatever something like Vitatalk costs, there will be a significant return on investment in so many ways, but especially financially. Help your financial stakeholders understand the financial value of the ABCDEF bundle, and why supporting communication through proper staffing ratios and technology will ultimately benefit their bottom line.
Of course, an episode on communication wouldn’t be complete without the reminder to involve speech language pathologists right away. If they’re intubated, newly extubated, and especially newly trach’d…. As you’ve heard from the survivors, some of the best moments of their whole hospitalization was when they finally had a passy muir valve or finally had a way to communicate. SLPs are the experts. They are part of the delirium SWAT team, bring them in before you run to sedation. Let’s avoid the torture of muzzling our patients with sedation or withholding tools for communication during the most vulnerable, stressful, terrifying, and pivotal time of their lives.
I am grateful for clinicians and technology that have humanized my daughter’s mortal experience. I love their ability to empower her to make her thoughts and needs matter and be known. As fellow human beings, our patients have a right to communicate. We need them to be a part of their survival. As we strive to humanize the ICU, let us bring in communication as an essential part of saving lives.
To schedule a consultation and connect on social media as well as find supportive resources including case studies, ebook, episode transcripts, and citations to research please visit the website www.DaytonICUconsulting.com
Transcribed by https://otter.ai
References
https://www.tandfonline.com/doi/full/10.1080/17549507.2018.1428687
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541189/
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.
American Hospital Association. The patient care partnership: Understanding expectations, rights, and responsibilities. Retrieved 01/2009 http://www.aha.org/aha/content/2003/pdf/pcp_english_030730.pdf
Ashworth P. (1980). Care to communicate. (RCN Research Series ed.). London: Whitefriars Press.
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.
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.
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.
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.
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.
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.
Bergbom-Engberg I, & Haljamae H. (1989). Assessment of patients’ experience of discomforts during respirator therapy. Critical Care Medicine; 17(10):1068–1072.
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.
Beukelman DR, Garrett KL, & Yorkston KM. (2007). Augmentive communication strategies for adults with acute chronic medical conditions. Baltimore, MD: Paul H Brookes Publishing Co.
Carroll SM. (2004). Nonvocal ventilated patients’ perceptions of being understood. Western Journal of Nursing Research; 26(1):85–103; discussion 104–12.
Carroll SM. (2007). Silent, slow lifeworld: The communication experience of nonvocal ventilated patients. Qualitative Health Research; 17(9):1165–1177.
Casbolt S. (2002). Communicating with the ventilated patient — a literature review. Nursing in Critical Care; 7(4):198–202.
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.
Christensen M, & Hewitt-Taylor J. (2007). Patient empowerment: Does it still occur in the ICU? Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 23(3):156–161.
Clark NM, Cabana MD, Nan B, Gong ZM, Slish KK, Birk NA, et al. (2008). The clinician-patient partnership paradigm: Outcomes associated with physician communication behavior. Clinical Pediatrics; 47(1):49–57.
Connolly MA, & Shekleton ME. (1991). Communicating with ventilator dependent patients. Dimensions of Critical Care Nursing: DCCN; 10(2):115–122.
Costello J. (2000). AAC intervention in the intensive care unit: The Children’s Hospital Boston model. Augmentative and Alternative Communication; 16(3):137.
Dale CR, Kannas DA, Fan VS, Daniel SL, Deem S, Yanez III ND, et al. (2014). Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Annals American Thoracic Society; 11(3):367–374.
Divi C, Koss RG, Schmaltz SP, & Loeb JM. (2007). Language proficiency and adverse events in US hospitals: A pilot study. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care / ISQu;, 19(2):60–67.
Ebert DA, & Heckerling PS. (1998). Communication disabilities among medical inpatients. The New England Journal of Medicine; 339(4):272–273.
Finke EH, Light J, & Kitko L. (2008). A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication. Journal of Clinical Nursing; 17(16):2102–2115.
Forbes MO. (2007). Prolonged ventilator dependence: Perspective of the chronic obstructive pulmonary disease patient. Clinical Nursing Research; 16(3):231–250.
Fried-Oken M. (2001). Been there done that: A very personal introduction to the special issue on augmentative and alternative communication and acquired disorders. Augmentative and Alternative Communication: 17:138–140.
Garrett PW, Dickson HG, & Whelan AK. (2008). Communication and healthcare complexity in people with little or no English: The communication complexity score. Ethnicity & Health; 13(3):203–217.
Granberg A, Bergbom Engberg I, & Lundberg D. (1998). Patients’ experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome. part I. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 14(6):294–307.
Hallenberg B, Bergbom-Engberg I, & Haljamae H. (1990). Patients’ experiences of postoperative respirator treatment — influence of anaesthetic and pain treatment regimens. Acta Anaesthesiologica Scandinavica; 34(7):557–562.
Happ MB. (2001). Communicating with mechanically ventilated patients: State of the science. AACN Clinical Issues; 12(2):247–258.
Happ MB, & Paul B. (2008). Silence is not golden. Geriatric Nursing; 29(3):166–168.
Happ MB, Roesch TK, & Garrett K. (2004). Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: A feasibility study. Heart & Lung: The Journal of Critical Care; 33(2):92–101.
Happ MB, Sereika S, Garrett K, & Tate J. (2008). Use of the quasi-experimental sequential cohort design in the study of patient-nurse effectiveness with assisted communication strategies (SPEACS). Contemporary Clinical Trials; 29(5):801–808.
Happ MB, Baumann BM, Sawicki J, Tate JA, George EL, Barnato AE. (2010). SPEACS-2: intensive care unit “communication rounds” with speech language pathology. Geriatric Nursing; 31:170–177.
Happ MB, Seaman JB, Nilsen ML, Sciulli A, Tate JA, Saul M, Barnato AE. (2014). The number of mechanically ventilated ICU patients meeting communication criteria. Heart & Lung: The Journal of Critical Care; 44(1):45–49.
Happ MB, Garrett KL, Tate JA, DiVirgilio D, House MP, Demirci JR, et al. (2014). Effect of a multi-level intervention on nurse — patient communication in the intensive care unit: Results of the SPEACS trial. Heart & Lung: The Journal of Critical Care; 43(2):89–98.
Happ MB, Walaszek L, Von Visger T, Weber M, Vermillion B, Chipps E, Patak L. (2014). 603: Usability and acceptability testing of an iPad communication application in the intensive care unit. Critical Care Medicine; 42:A1505.
Happ MB, Sereika S, House MP, Seaman JB, Tate JA, Nilsen ML, et al. (2015). Quality of care and resource use among mechanically ventilated patients before and after an intervention to assist nurse-nonvocal patient communication. Heart & Lung: The Journal of Critical Care; 44:408–415.
Kelleher S. (2006). Providing patient-centred care in an intensive care unit. Nursing Standard (Royal College of Nursing (Great Britain): 1987); 21(13):35–40.
Khalaila R, Zbidat W, Anwar K, Bayya A, Linton DM, Sviri S. (2011). Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. American Journal of Critical Care; 20:470–479.
Leathart AJ. (1994). Communication and socialisation (1): An exploratory study and explanation for nurse-patient communication in an ITU. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 10(2):93–104.
Leathart AJ. (1994b). Communication and socialisation (2): Perceptions of neophyte ITU nurses. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 10(2):142–154.
Marra A, Ely EW, Pandharipande PP, Patel MB. (2017). The ABCDEF bundle in critical care. Critical Care Clinics; 33:225–243.
Magnus VS, & Turkington L. (2006). Communication interaction in ICU — patient and staff experiences and perceptions. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 22(3):167–180.
McCabe C. (2004). Nurse-patient communication: An exploration of patients’ experiences. Journal of Clinical Nursing; 13(1):41–49.
Menzel LK. (1998). Factors related to the emotional responses of intubated patients to being unable to speak. Heart & Lung: The Journal of Critical Care; 27(4):245–252.
Nilsen ML, Morrison A, Lingler JH, Myers B, Johnson JT, Happ MB, et al. (2018). Evaluating the usability and acceptability of communication tools among older adults. Journal of Gerontological Nursing; 44(9):30–39.
O’Halloran R, Hickson L, & Worrall L. (2008). Environmental factors that influence communication between people with communication disability and their healthcare providers in hospital: A review of the literature within the international classification of functioning, disability and health (ICF) framework. International Journal of Language & Communication Disorders / Royal College of Speech & Language Therapists; 43(6):601–632.
Patak L, Gawlinski A, Fung NI, Doering L, & Berg J. (2004). Patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart & Lung: The Journal of Critical Care; 33(5):308–320.
Patak L, Gawlinski A, Fung NI, Doering L, Berg J, & Henneman EA. (2006). Communication boards in critical care: Patients’ views. Applied Nursing Research: ANR; 19(4):182–190.
Pennock BE, Crawshaw L, Maher T, Price T, & Kaplan PD. (1994). Distressful events in the ICU as perceived by patients recovering from coronary artery bypass surgery. Heart & Lung: The Journal of Critical Care; 23(4):323–327.
Pham K, Thornton JD, Engelberg RA, Jackson JC, & Curtis JR. (2008). Alterations during medical interpretation of ICU family conferences that interfere with or enhance communication. Chest; 134(1):109–116.
Reed CC. (2008). The role of education and innovative communication tools in improving non-verbal communication. Summer Institute on Evidence-Based Practice: University of Texas Health Sciences Center.
Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, et al. (2002). Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Critical Care Medicine; 30(4):746–752.
Salyer J, & Stuart BJ. (1985). Nurse-patient interaction in the intensive care unit. Heart & Lung: The Journal of Critical Care; 14(1):20–24.
Schou L, & Egerod I. (2008). A qualitative study into the lived experience of post-CABG patients during mechanical ventilator weaning. Intensive & Critical Care Nursing: The Official Journal of the British Association of Critical Care Nurses; 24(3):171–179.
Smith S, Hanson JL, Tewksbury LR, Christy C, Talib NJ, Harris MA, et al. (2007). Teaching patient communication skills to medical students: A review of randomized controlled trials. Evaluation & the Health Professions; 30(1):3–21.
Trotta RL, Hermann RM, Polomano RC, Happ MB. (2019). Improving nonvocal critical care patients’ ease of communication using a modified SPEACS-2 Program. Journal for Healthcare Quality; Jan 3. doi: 10.1097/JHQ.0000000000000163. [Epub ahead of print]
Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, et al. (2005). What can hospitalized patients tell us about adverse events? learning from patient-reported incidents. Journal of General Internal Medicine: Official Journal of the Society for Research and Education in Primary Care Internal Medicine; 20(9):830–836.
Williams ML. (1992). An algorithm for selecting a communication technique with intubated patients. Dimensions of Critical Care Nursing: DCCN; 11(4):222–233.
Vidatalk App: https://www.youtube.com/watch?v=PPpcoNNseZI
SCCM APP: https://www.sccm.org/Communications/SCCM-App-Events-App
List of ways to improve comfort with ETT:
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