Communication with a Nonverbal Patient About End of

Communication with a Nonverbal Patient About End of

Communication with a Nonverbal Patient About End of Life Choices
*Marta Kazandjian, MA CCC SLP BCS-S 1,2; Fernando Kawai, MD FACP 1,2; Maureen Peters, LCSW, ACHPSW 1;

Karen Dikeman MA CCC SLP 1,; Cynthia X Pan, MD FACP AGSF1,2
Silvercrest Center for Nursing and Rehabilitation, 2NewYork-Presbyterian Queens, New York
Nonverbal patients who are seriously ill are
vulnerable to restricted access to palliative
care. These patients have a potential
disadvantage in manifesting preferences for
end of life (EOL) decisions. Even when the
patient has capacity, providers may rely on
surrogate decision makers because of
communication barriers. Medical speech
pathologists have expertise to offer options
for reliable response systems, enabling
communication beyond "yes" and "no" and
help determine an individual's linguistic
capacity. Providers can then promote patient
autonomy, and ensure both beneficence and
justice. Such interdisciplinary collaboration
strengthens the ability of the palliative care
team (PCT) to advocate for non-verbal,
seriously ill patients even at EOL, and be a
model for culture change in any setting.

53 y/o bilingual Spanish and English speaking male with endstage ALS, trach/vent,
recurrent infections and hospitalizations, quadriplegia. Pt admitted to a post-acute
nursing facility after a hospitalization for pneumonia. Pt is awake, alert and has
capacity. He is severely dysarthric and aphonic due to ALS, tracheostomy and
ventilator dependency. Pt does not tolerate upper airway flow for voicing purposes.
Pt had previously indicated his wish for removal from ventilator.
He has a Spanish-speaking sister who represents him and is at his bedside 24/7,
and an estranged son. Health care providers often spoke to his sister due to the
challenges associated with communication. An effective and reliable response
system was first established with an upward eye gaze for "Yes" and eye closure for
"No". The speech pathologist instructed the patient in the use of an EYELINK2 TM
which enabled the patient to spell on an alphabet board using only eye gaze.
Palliative care consult was called for goals of care discussion. After explanation of
prognosis during a family meeting, the patient requested a DNR, DNH and palliative
removal from the ventilator. Sister and estranged son were opposed to plan. Via
FaceTime, the son tried to convince patient to change his mind. Patient spelled "I'm
pissed". Nursing staff expressed concerns against vent removal given the alertness
of the patient.
Palliative care team mediated conflict and eventually both son and sister agreed to
honor patient's expressed wishes. Prior to extubation, son was able to say "I love
you Dad, and thank you". Patient was able to express his love in return. Patient
expired 35 minutes after palliative wean. Primary caregivers were emotionally
overwhelmed, and the PCT provided debriefing and emotional support.

1. Identify potential gaps in effective
communication with seriously ill, nonverbal
2. Describe essential approaches to communicating
with seriously ill, nonverbal patients.
3. Provide a framework for promoting ethical and
meaningful communication for nonverbal
4. Describe the impact of a palliative care team
(PCT) in promoting culture change regarding
withdrawal of life sustaining treatments in a postacute nursing facility.


Effective communication is essential to
ensure autonomy for seriously ill,
nonverbal patients.

Medical speech pathologists can be vital
members of the interdisciplinary Palliative
care team to facilitate communication and
align care with patient goals.

Palliative care teams can manage conflict
and promote culture change in post-acute

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