Alternative communication for patients in intensive care

Alternative communication intensive care

for patients

in

Jayne Easton

This paper aims to discuss the various alternative systems of communication that may prove to be of benefit to patients on intensive care units who have been rendered non vocal. The differing approaches are presented in a broad but structured framework and work through a logical progression of systems to be investigated.

well as their

INTRODUCTION

disability

Patients who are unable to communicate are not a rarity in intensive care units. However, the potential of alternative communication modes as a means acutely

of facilitating ill, increasing

ing anxiety receive

to some extent,

onset

intubationj nature

group

Intervention of ways patients

tion

from

the

who these

The

as with

brain

differs and

Often

‘yes/no’

ill, rapid

on minimal will

be

evaluation

should

Firstly, de-

informaunable

to

system thought to be appropribe unable to tolerate more than sessions

with

the speech

patient’s

physical

and

cognitive

therapist. abilities,

Jayne Easton BSc(Hons) Senior Speech Therapist, Assistive Communication Aids Centre, Speech Therapy Department, Frenchay Hospital, Bristol EiS16 1 LE 75 February

1988

the

activity). patient

fatigue,

almost

Firstly,

is to establish

correctly

information in order

may be able to nod

use eye movements,

i.e.: look

for ‘No’ (a blink

In short, use

certain

the response

any

response due to

movement

consistently

can be harnessed

if

to elicit

as this can be confusing

can

however,

point

The patient

his head,

which

and

without

for this purpose. points

to bear

must be reliable;

There

in mind. secondly,

a

response is required for both ‘Yes’ and ‘No’, if the patient is told to respond only for the affirmative this can cause a lot of confusion. portant

as

to acA com-

In this way nursing

a lot of valuable

be avoided

reflex

are,

or trial of any

can be

process

to be functional

starting

up for ‘Yes’ and down of

finally,

technique.

response.

questions

this type of reply.

non vocal.

needs

an essential

or shake

training

are extremely patient

accepted

system

temporary damage.

learning

a new communication

munication

and,

immediately.

to

in a number

minute

Manuscript

in a protracted

permanent

or spinal

assessment

in a lengthy

communication ate. They may lo-15

(such

be of a more

are chronically

the

involved

they phrase

this group

patients

since

nor the patient

staff can gather

will have to be made

participate

staff

a trau-

has been with

the nursing

may be

nature

acquired

unstable

have often suffered which

newly

very

impairment

or it may

if there

cisions

is only just starting

of their

be

a reliable

to speech

of a temporary

since

in the and reduc-

recognition.

This patient matic

communication their confidence

neither quire

acceptance

may

responses Simple

that

everyone

are and and

clear

patient’s bedhead purpose (Fig. 1). When starting

knows

encourages instructions may

prove

to consider

Thirdly, what their

it is im-

the patient’s use of them. stuck

to

the

beneficial

for this

the various

altern47

48

INTENSIVE

CARE NURSING

I hok -UP pt YES ..--I ho& DOWN -- fbr No

I

that

la4

d+lnSwLr Fig. 2 Neck type artificial larynx with intra oral adaptations.

Fig. 1 Simple instructions informing the listener as to the patient’s method of communication.

ative

forms of communication

patient,

available

to the

one needs to bear in mind who the com-

munication

partners

are likely to be in addition

to the ward staff,

and whether

there

are any

special needs to be taken into consideration, as hearing loss (which would preclude artificial larynges or electronic pairment

(which

precludes

voices), visual imthe use of printed

messages or visual displays),

illiteracy.

vironment

for example,

patient

is also important;

is being

automatically

machines

that combine

siderable

background

such

the use of

The

monitored

to produce

en-

if the by

quite a con-

noise, again the use of an

electronic

voice or artificial

unhelpful.

Bearing

larynx

may prove

these points in mind, one can

then start to actively consider which alternative communication

system would be optimal for the

patient. Initially, for those with unimpaired oral musculature, the possibility of using an adapted form of oral communication gated

as this is going

Fig. 3 Patient demonstrating the use of a neck type artificial larynx.

is always investi-

to be by far the fastest

method of conveying a message. This group would typically include patients who have had tracheostomies resulting from temporary or permanent respiratory difficulties, for example, patients with high spinal breaks (C2 and C3) where the innovation of the diaphragm has been partially or completely affected. Often these patients will already be mouthing words to make

their needs known and some may prefer to continue in this mode rather

than use an artificial

larynx (Figs 2 & 3) or an intra oral vibrator

(Figs

4& 5).

Non invasive modified speech approaches The artificial

larynx consists of a vibrating

head

INTENSIVE

on the patient’s

CARE

preference,

their

ate an oral tube or pressure their ability patient

to activate

is unable

ficial

larynx,

taught

this for the patient,

button

is then permanently

tinual

electronic

is unable

wish

available intra

adapted oral

attached

to an armband;

against

the mouth permanently either

in position

generator

can

small

paddle

brow.

Figure

by being

is held

attached The

on and

to tone

off using

be attached

a

to the eye-

a ‘one off’ adaptation

for a patient

head

into

which

or a headband.

can

8 shows

the arm-

introduced

tube

be switched that

was produced use gross

being

a plastic

a pair of glasses

an

generator

(Fig. 7) the tone gener-

on, sound

through

6 shows

tone

by squeezing

the ribcage

ator is switched

due to poor commercially

Figure a

con-

If the patient

are several with

sigThe

for as long as

speech.

versions.

vibrator

have

thus creating

oral vibrator

there

be

and can

they

pressed

sounding

arti-

can

communicate.

the words,

dexterity,

relatives

once

to

to use an intra

manual

band

and

If the

type

the electrolarynx

that

mouths

to toler-

larynx.

the neck

staff

nalled

the patient Fig. 4 lntra oral vibrator.

the artificial

nursing

they

ability

39

on the neck wall, and

to operate

how to position

activate

NI’RSING

that

who was only able to

movement

to activate

the

tone

between

the

generator.

Semi invasive modified speech approaches This approach medical clude ecting Fig. 5 Patient demonstrating the use of an intra oral vibrator.

which,

when

held against

the air in the pharynx;

the neck wall, vibrates

thus as the patient

mouths

calls for good

staff closure

and

air through

the larynx.

tracheostomy

the cuff is deflated. lated

or have

time

may

that

or that

who have been ventitube

apprehensive

the gradual

in-

redir-

This presumes

tube is cuffless

Patients

be very

here

thereby

had a tracheostomy

this additional

necessitate

Options

of the tracheostomy,

the patient’s

having

liaison

therapists.

airway

for some

initially closed.

introduction

This

about may

of this idea

the word an electronic sounding voice is produced. The intra oral vibrator consists of a tone

using a bung to close the tracheostomy, perhaps for only 30 minutes initially, and building up to

generator which is

the amount the patient’s

through mouths ‘voice’). decision

held in delivered

the hand, directly

the into

sound from the mouth

a slender plastic tube (again the patient words around the tube to create a For those who use artificial larynges the between the various models will depend

of time the tracheostomy tolerance and confidence

is closed as increases.

If the tracheostomy tube cuff has to be inflated either to prevent aspiration or to allow the patient to be ventilated at night, then a fenestrated tracheostomy tube may be required to

.io

INTENSIVE

CARE NURSING

Figs 6 617 Modified oral vibrator. The tone generator is attached to an armband which is pressed against the ribcage to initiate the electronic tone.

Fig. 8 Specially adapted intra oral vibrator where the patient initiates the tone using a cheek switch.

facilitate

the passage of air to and from the lungs

via the vocal cords when the tracheostomy

tube is

occluded.

Invasive modified speech approaches For those patients who are permanently supported by a respirator, who again require that the tracheostomy tube cuff be inflated at all

can be used times, then a Portex Vocalaid (Fig. 9). Here an additional source of air is routed through the larynx, enabling the patient to speak. Comments from patients using this systern would indicate

unpleasant

that it can on occasions be to have cool air constantly pumped

through the vocal cords as this tends to dry out the airway- mucosa. This problem can easily be overcome

by inserting

a ‘Y’ tube into the airline

Fig. 9 Portex Vocalaid

Fig. 10 Insertion of ‘Y’ tube.

so that air is only redirected

to thr patient’s vocal

must be to enable

the patient,

who is perhaps

cords on closure of this tube with the patient’s

severely

thumb (Fig. 10).

assurance that he can gain the nurse’s attention

those

patients

who

handicapped,

to have

the if

required. Despite the high staff to patient ratio on intensive care units, the patient who is physic-

Non oral approaches For

physically

ally disabled as well as unable to vocalise, can feel cannot

using a modified speech approach,

communicate

extremely

other options

be unable to call for assistance. A range of simple bleeper alarms that are sensitive to minimal pressure can be used to allay the patient‘s anxieties.

exist but these provide a much slower means of communication. The first consideration here

vulnerable

if they think that they will

52

INTENSIVE

CARE NURSING

Fig. 12 Written/p1

ing. A ‘low tech’ system to the patient Fig. 11 Pencil grip.

the listener, if the

These the

can be easily positioned

patient’s

reliable

body

control,

over

next to any part of

which

for example,

move

his head,

the

double

sided

velcro

patient’s

pillow.

they

have

some

if the patient

alarm

can

and

can

be attached

stockinette

by

to

the

which

patient

course,

the

patient

nurses’

attention,

always

considered

sufficient mode

hand

has

a means

of gaining

the

first

oral

is handwriting.

control

on providing

but

patients

pencils

rather

on their a

supine stable

position, providing base for writing,

(Fig.

11) if grasp

couraging

has

the patient

magipads

the person

such

as this being

can

make

or

is in the

a clipboard or a more providing pencil grips been

affected,

and

to print

their

message

normal script is illegible (Fig. 12). Much of course, is common sense, but simple writing

may

the

an ineffective

communication. Unfortunately, still under the misapprehension

difference or effective

enif

of this, advice of

many people are that a ‘high tech’

alternative will be inherently better than writing. However, this is not necessarily the case as the patient may have to spend a long time learning to use a new piece of equipment to enable them to communicate at the same rate that they could using

a well learned

automatic

skill such as writ-

state.

prefer

Of

to use a

to writing

or may

needs

and occupational

range

area

the

netic

keys are

is

a selection

functional

that

14).

Some

visual abilities

define

what

the patient can see. At this stage, apist would also be considering whether

keyboard the

target

involves

at all, that is, some mag-

(Fig.

spelling

points

the Canon

and

or a keyboard

of the patient’s

if

and

or not we need to

for example

well spaced

to help

conand,

the strength

whether

or no pressure keyboards

sessment

can point

(Fig. 13)) an expanded

is enlarged,

minimal

to establish,

is and so on. These

a mini keyboard,

Communicator

by the speech fine motor

this is, what

in turn will determine

where

out therapist

of the patient‘s

of the movement

consider

aids/system

or not the patient

accurate

of To

to use, a brief as-

to be carried

the status

and may there-

communication

therapist

so, how

posture

for the patient

sessment

to be made,

between means

with value

means supplementary for other circumstances.

which be feasible

trol, whether

be using this

its success with

than biros when

with

in preference

tions depending

firstly,

approach

Patients

may already

of communication,

depend

non

the

anxious,

may actually

require fore communication establish

Once

is in a highly

system

attractive

contact

find that they are only able to write in some posi-

would

Direct selection

be more

can be of psychological

some patients

technical

may

since it will promote

for of whole

cursory

as-

also needs

size of symbols the speech therwhether or not

communication words

would

or be

required. If the patient is unable to point using his hands, eyepointing is a possibility. To use this system a perspex chart with vocabulary items in each of the four corners is placed between the

INTENSIVE

Fig. 13 Canon Communicator (mini keyboard)

and the listener. The patient then eyepoints to one of the four corners and if there is more than one vocabulary item, they can further differentiate their selection by colour coding. This means that the patient would identify the colour surrounding that vocabulary item and eyepoint to the appropriate block of colour on the perspex frame (Fig. 15). Although the listener will require some training to use this system, the patient can become very proficient in using it in a short period of time. Although it involves some concentration, the physical demands made on the patient are minimal. Providing visual accuity and eye movement have not been affected, this is a system that can be used with the severely physically handicapped. patient

Scanning systems For patients with inadequate control of their hands or head for use of the direct selection (pointing) approach, it may be possible to use a scanning mechanism with a single or multiple switch input. To use a scanning system one reliable motor action needs to be identified which can then be harnessed to operate a switch. This, in turn, will be used to start and stop a light or indicator moving over a number of vocabulary items (Figs 16 & 17). If the patient is unable to operate one of the commercially available

CARE

K1’RSIKG

3 3

Fig. 14 Magnetic Keyboard.

switches, it may be necessary to have one custom built by the hospital medical physics department. This, of course, requires close liaison between nursing staff, therapists and the technician. Generally, scanning systems are only used as a last resort as they are extremely slow to use, and cognitively quite difficult for the patient to cope with since they are having to associate a motor action with the movement of a light which they have to stop via their motor movement to indicate a message. If the patient is demonstrating any difficulty in concentrating or attending, this system will be extremely difficult to implement. Scanning systems can also prove to be quite complex and time consuming for the nursing staff to set up and dismantle. Systems that are expeditious to assemble will encourage use and minimise frustration to the patient. It is better to have a basic system that is used and of benefit than one whose complexity can provide infinite facilities that are never used. If, due to visual impairment, the patient is unable to see a scanning light, the listener can be taught to scan letters of the alphabet vocally. Providing the patient has a means of indicating, they can stop the listener at the appropriate letter, for example, the listener may say, ‘Is it a vowel sound? Is the letter between “B” and “N”, “N” tO “z”?’ The patient can indicate one of these three sections, the listener then scans

54

INTENSIVE

CARE

NURSING

Fig. 15 Eyepointing frame.

Figs 16 & 17 Row column scanning system to compile message via switches.

through within

the

letters

of

the

alphabet

verbally

that section.

In addition

to the alternative

communication

systems mentioned, the patient should always be encouraged to use any natural modes of communication, such as facial expression and gesture, at their disposal as an adjunct to any other communication systems suggested.

CONCLUSION Patients who wake to find themselves in an intensive care unit must experience an overwhelming sense of fear and anxiety relating to their -__ For furthrr information regarding different types of communication aids/systems mentioned, please contact author.

thr

INTENSIVE

current

situation.

pounded lighten they

This,

of course,

by the inability

must

them as to the circumstances were

wellbeing

admitted, of their

with alternative surely facilitate

their

family methods

ofsuch

providing

of communication,

an assessment advice

and

group,

The

the

patients. intensive

hospital

speech in

speech

therapist

of the patient’s assistance

must

and

nurses

can

the about

best help

ofcommunica-

the tools to offer the patient

very positive

very negative

for

deal to learn

but the advent

:I 3

in what

and traumatic

may be seen as a

period

in their lives.

an appropriate

contact

offer

therapists

this patient

tion aids is providing

system

make

how speech

is still a great

NC’RSING

mode

communication

There

something

should

department.

the

patient.

ofcommunication

care

therapy

which

status,

appropriate

and so on. Intervention

alternative staff

to en-

under

medical

the management

As a first step towards

be com-

to ask questions

CARE

will

needs

and

acquiring

an

References Dowden P, Beukelman D R, Lossing C (1986) Serving non speaking patients in acute care settings: intervention outcomes. Augmentative and Alternative Communirati&, Vol 2, No 2, 38-44.