Patient Stories

A 72-year-old female patient was admitted to the ICU with respiratory distress pending results of COVID-19 testing. The patient was endotracheally intubated and presented with significant total body weakness. Nursing consulted speech-language pathology secondary to difficulty establishing a typical "yes/no" response (e.g., head nod/shake, thumbs up/down) with this patient. At the time of the consult, the patient had no way to communicate her wants/needs or to participate in discussions surrounding her medical care and the important decisions that needed to occur (e.g., tracheostomy, power of attorney, etc.).

Due to staff restrictions in patient rooms, the speech-language pathologist (SLP) coached the nurse from outside the room how to work with the patient in identifying a consistent and reliable gesture. Of note, the patient was able to consistently blink her eyes; however, medical staff reported that eye blinks were difficult to interpret because the patient also experienced drowsiness throughout the day. The SLP coached the nurse to start with both the patient's upper and lower extremities (i.e., arms and legs) to detect any volitional movement. Unfortunately, the patient was unable to move either her arms or her legs to any degree. Next, the nurse assessed the patient's ability to shrug her shoulders or move her head in any direction, both of which were too fatiguing for the patient. Lastly, the SLP coached the nurse to instruct the patient to push her tongue into her cheek around her endotracheal tube.  Positively, the patient was successful in consistently and reliably executing this movement, and a "tongue in cheek" was established as the patient's "yes" response. 

The patient now had a way to indicate "yes, that's my choice" during partner-assisted scanning via the low-tech communication boards available on the unit. With her glasses on, the patient was able to see the nurse visually point to each choice on the communication boards. The nurse would pause after pointing to each option, waiting to see if the patient was indicating "yes, that's my choice" by pushing her tongue into her cheek. This was particularly helpful, as the patient did not have her hearing aids available and the medical professionals were difficult to understand with the need to wear personal protective equipment (PPE). Using this approach, the patient was able to both ask questions and make decisions about her care through the use of the available medical decision-making boards, critically maintaining autonomy during this tragic time.

To establish the coordination of care among providers, the nurse posted a sign above the patient's bed identifying the patient's "YES" response and providing instructions for partner-assisted scanning. Before shift change, the nurse taught her team how to successfully implement partner-assisted scanning so that all medical staff could ensure the patient was understanding and participating in her care.

The nurse also taught the patient's 25-year-old granddaughter about her grandmother's current communication strategy. Her granddaughter was able to explain this to other family members, as there was only one visitor permitted in the room at a time. Most importantly, the patient was able to use a custom communication board her family created to tell her granddaughter "I love you" via partner-assisted scanning.