Patient Stories

Joe is a 56 year old male who was transferred by ambulance from a small rural hospital due to severe abdominal pain secondary to an abdominal mass. He had a history of hypertension and suffered a left CVA six years ago resulting in limited literacy skills, expressive aphasia, and moderate dysarthria.  Prior to the CVA, Joe was employed as a truck driver for UPS. He has been on disability since the onset of the CVA.  He is separated from his wife and lives with his daughter and her family.

Upon admission, he appeared alert, but was unable to answer and questions related to medical history or length of current medical concerns.  Expressive language was marked with significant word finding deficits and dysarthria. He had no viable aided or unaided communication system(s) upon admission.  His daughter arrived by car within the hour reported that family members "understand" about one-third of what he tried to say at home, although she understood "most" or what he tried to say. She explained that he rarely used gestures to supplement his speech, and often just "smiled or nodded" during conversation.  He had been seen for 8 weeks of traditional therapy after his stroke, but no follow up treatment or Augmentative and Alternative Communication options had been explored in the last six years.

During the course of his stay, his general demeanor was described by the physician as compliant and cooperative, but the nursing staff was concerned about his lack of ability to understand information about the surgical procedures and diagnostic tests that were being performed and to ask follow up questions.

What are the barriers to successful patient-provider communication in this scenario?  

• Language issues. While English was Joe's first language, his stroke left him unable to ask questions or even ask for information to be repeated when he didn't understand what was being said to him. He had a diagnosis of Expressive Aphasia. His comprehension was relatively intact.
• Communication vulnerability. Med-Surg nurses suspected that Joe had questions and concerns, but unless his daughter was with him when information was being provided, they were unable to have him successfully ask questions. Since he was used to taking a passive/listener role, he did not make any sustained effort to be understood and often shrugged his shoulders when asked if he had any questions.
• Health literacy. According to Joe's daughter, Joe was not a complainer and although he was in significant distress, she was the one to insist that he come to the hospital on the night of his admittance.
• Cultural considerations. Joe was a "macho man" and inclined to disregard his own health needs and under report his level of pain.

What were some of the communication solutions in this scenario?

• Following a referral to the SLP dept. Joe was provided with and taught how to use a communication board, especially for relating pain levels and asking for clarification: "Can you say that slower?" "Can you explain that to me again when my daughter is here?" "I need my glasses."
• Staff were encouraged to use picture support when describing procedures and to make sure Joe has his glasses on.
• Medical staff were reminded to use short sentences and simple language whenever possible.
• Joe and his daughter were exposed to a variety of communication supports (high tech and low tech) during his 10 day stay and subsequently returned to the outpatient clinic for an Augmentative and Alternative Communication evaluation that resulted in a speech generating device report and script.