Patient Stories

Medical Issues: Hospital admission for surgery: aortic aneurysm. Temporary communication vulnerability in the ICU secondary to respiratory complications , intubation and medication. Possible end of life decisions.

Background: Widowed, Italian-American who immigrated to the United States 50 years ago and worked in the steel mills. English as a second language and hearing impaired.

Mr. G., 82, has limited literacy skills and interacts primarily within the immigrant Italian community. He was recently hospitalized for an aortic aneurysm, which was successfully repaired surgically. Following surgery, Mr. G., a long-time smoker, developed respiratory complications and was transferred to the intensive care unit (ICU) and intubated with mechanical ventilation. Mr. G. was often combative when alert and frequently attempted to extubate himself, therefore, anxiolytic medications were prescribed to calm him. Visitors spoke to him only in Italian. Mr. G. became visibly upset when his visitors left, refused to take his medications and attempted to get out of bed.

Members of the medical staff tried, but were unable to discuss treatment options. Mr. G.'s daughter indicated that her father was hard-of-hearing, but he never had hearing aids. Medical care required maintaining ventilation and medications to improve pulmonary health, decreasing anxiety about procedures to minimize the need for medication, and addressing end-of- life issues and discharge planning. Barriers to effective communication included:  
Language issues. Mr. G. understood and spoke some English, but his primary language was Italian. Hospital staff spoke only English.
Communication vulnerability. ICU nurses couldn't understand Mr. G. because of intubation and his limited English. Mr. G. didn't understand the nurses because they spoke rapidly, did not look directly at him when speaking, and did not recognize his hearing difficulty. Also, the ICU was very noisy and anti-anxiety medication made him groggy.
Health literacy. Mr. G. did not understand why he was in the ICU or what was happening to him. He was confused by the consent forms. Some procedures were not administered because verbal attempts to inform him were not successful.
Cultural supports. Discussing end-of-life issues with social workers, Catholic clergy, or family in culturally appropriate ways was difficult given Mr. G.'s medical condition and treatment, as well as his speech, language, and hearing problems.

New Standards: Effective Communication, Cultural Competence, and Patient- and Family-Centered Care

The new Joint Commission standards will help in the effort to remove barriers to successful patient-provider communication.

The medical record contains information that reflects the patient's care, treatment, and services(Standard RC.02.01.01). According to this standard, Mr. G.'s language and hearing issues must be identified at admission and documented in the medical record. For example, after asking Mr. G. to point to his preferred language on a pictorial admissions form, the hospital would likely provide a trained interpreter to obtain a valid health history. 

The hospital effectively communicates with patients when providing care, treatment, and services (Standard PC.02.01.21). Areferral to the speech-language pathology/audiology departments could be initiated at admission. Following a brief assessment (Garrett, Happ, Costello, & Fried-Oken, 2007), an SLP might provide Mr. G. with simple AAC supports and training (e.g., a nurse call signal, a tablet and gel pen, a simple voice output device, or a low-tech communication board containing needs-based messages and questions in Italian and English). The SLP might also coach the ICU staff to speak slowly and directly to Mr. G., using visual supports to augment his comprehension. An audiologist might provide a temporary amplification device, marking the on/off switch and posting a chart explaining its operation. Medical instructions (consents, explanations of ventilation and tracheotomy, etc.) could be in plain language, with Italian and/or pictures to increase comprehension.

The hospital respects, protects, and promotes patient rights(Standard RI.01.01.01).At admission, Mr. G. could ask that his daughter be allowed to stay with him and talk to the doctors and nurses. Staff could use the "teachback" method—ask Sal to retell information (via translators, if necessary) to ensure he comprehends consent forms and instructions (Weiss, 2007).