KOMUNIKASI PADA PASIEN

YANG DIRAWAT DI ICU

DESI ARIYANA RAHAYU
 KONDISI PASIEN DI ICU

2
 KONDISI PASIEN DI ICU

• SADAR
• PENURUNAN KESADARAN
• TERPASANG VENTILATOR
• KONDISI PALIATIF
• PASIEN END OF LIFE (EOL)
KOMUNIKASI PADA PASIEN PENURUNAN
KESADARAN
&
TERPASANG VENTILATOR
 Evaluating the Effectiveness of Communication in Ventilator-Dependant
Tracheostomy patients utilising Above Cuff Vocalisation:
The ICU Functional Communication Scale
S Wallace$, J Lynch*, L Nicholson$, M Wilson$, R Purcell$, BA McGrath+
Speech & Language Therapist, *Tracheostomy QI Project Lead (ICU Charge Nurse), +ICU Consultant
$

Acute Intensive Care Unit, University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester. M23 9LT

National guidelines recommend early recognition of communication Our aims were to develop and trial a new simple scale to evaluate the
problems and involvement of Speech & Language Therapy (SLT) in ICU. effectiveness of functional communication in patients utilising ACV and to
Ventilator-dependant tracheostomy patients requiring cuff inflation determine whether the scale could be used consistently by both SLT and
have airflow excluded from the upper airway, limiting the ability to non-specialist ICU staff.
communicate by vocalisation/speech.
Our service introduced ACV using standard Smiths-Medical (Ashford, UK)
Above Cuff Vocalisation (ACV) is a method of communication allowing Blue Line Ultra Suctionaid (BLUS) tracheostomy tubes to facilitate
additional gas flow to be delivered via the subglottic suction port of the communication. Scale parameters (below) were devised by consensus
tracheostomy tube exiting via the larynx, in patients unable to tolerate amongst SLT, nursing, medical and physiotherapy staff. The scale was
cuff deflation. This technique does not require a tube change to a trialled in five consecutive patients undergoing ACV.
specialist ‘talking tube’ and is well tolerated. Resultant speech quality is
variable and success needs monitoring, however existing ICU functional
assessment scales are lengthy, may require training, focus on physical
function or disability and are unsuitable for speech .

It should be emphasised that ACV should not be undertaken by non- The ICU Functional Communication Scale was effective in detecting small
specialist staff without experience of the technique. improvements in communication ability and can be used effectively by
multidisciplinary staff as part of a range of tools to evaluate the impact of ACV.
This simple scale has the potential to be applied across all ICU patients.

Simply defining communication problems may facilitate early SLT referral and
communication goals and monitor communication outcomes. Larger studies are
References
1. KA Wilkinson, IC Martin, H Freeth, et al. NCEPOD: On the right Trach? 2014. www.ncepod.org.uk/2014tc.htm.
required for validation of our scale and further detailed study of the scale and
2. R Khalaila, W Zbidat, K Anwar, et al. Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation .
Am J Crit Care. 2011;20:470-479.
3. M Kunduk, K Appel, M Tunc, et al. Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy
of ACV and its clinical efficacy is on-going.
tube. Respir Care. 2010;55:1661-1670. The authors gratefully acknowledge the Global Tracheostomy Collaborative (www.globaltrach.org) in sharing
4. V Pandian, CP Smith, TK Cole, et al. Optimizing Communication in Mechanically Ventilated Patients. J Med Speech Lang Pathol. 2014;21:309-
318. experience and protocols regarding the use of ACV, especially Mrs Tanis Cameron, TRAMS team, Austin
5. A Christakou, E Papadopoulos, I Patsaki, et al. Functional Assessment Scales in a General Intensive Care Unit. Hospital Chronicles. Health, Melbourne, Australia. www.tracheostomyteam.org). This work was carried out as part of a project
2013;8:164–170 funded by the Health Foundation’s Shine programme. The Health Foundation is an independent charity
6. GPICS Guidelines for the Provision of Intensive Care Services.
https://www.ficm.ac.uk/sites/default/files/GPICS%20-%20Ed.1%20%282015%29.pdf working to improve the quality of healthcare in the UK. The authors have received unrestricted funding
7. NICE guidelines CG83. Rehabilitation after critical illness in adults. March 2009. https://www.nice.org.uk/guidance/cg83 from Smiths Medical to evaluate BLUS tubes for the purposes of ACV in a future study.
Non-Verbal Communication
 Facial expressions
 Gaze
 Head movement
 Posture
 Interpersonal distance
 Touch
 Voice
Adapted from Hall JA, Affective and Non-Verbal Aspects of the
Medical Visit, The Medical Interview, Lipkin M Jr, Putnam SM, Lazare A
eds., Springer 1994 p. 499
KOMUNIKASI PADA PASIEN PALIATIF
&
END OF LIFE
 WHO definition of palliative care

Palliative care is an approach that improves the

quality of life of patients & their families facing
the problem associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification,
impeccable assessment & treatment of pain and
other problems, physical, psychosocial and
spiritual.
http://www.who.int/cancer/palliative/definition/en/

8
PRINSIP KOMUNIKASI PASIEN END
OF LIFE


Crucial to convey:
1. Seriousness of illness
2. Expected course
3. Treatment options, risks and benefits
4. Empathy, Support and Caring


Helpin decision-making/advance care planning

Aid in alleviating pain and distress
Effective Communication

 Skill which can be learned

 Convey information
 Build trust
 Convey empathy and caring
 Decision-making
 Improve quality of care
Goals of Communication at EOL
 Convey respect & understanding for the patient
as a person
 Convey information about illness, likely course
and treatment options
 Convey empathy and support
 Convey appropriate hope
 Develop a treatment plan in context of person's
value history
 Arrange F/U and ongoing caring and support
Barriers due to Patients & Families
 Misunderstandings
 Biases
 Lack of knowledge of death
 Re-alignment of family roles
 Lack of support, coping mechanisms crisis
 Physical & emotional depletion
 Strong emotions
 Differences in values, beliefs and culture
Barriers due to Healthcare Providers

Depth of relationship  Fear of emotions (own &

 with patient others)
Fears of uncertainty in  Personal beliefs,
 values
diagnosis/prognosis  Bias
 Personal & professional  Fears of being messenger
experiences with illness
 Iatrogenic complications
& death
 Fatigue, psychological &
 Unrealistic expectations
of success
emotional stress  Inconsistent approach:
Fears of own mortality

“mixed messages”
 Lack of education
Barriers due to Healthcare System

 Time constraints/Size of practice

 Lack of previous relationship
 Lack of privacy in hospital/clinic/hospice
 Interruptions
 Critical importance of communication
Six key components
1. Talking with patients in an honest and straightforward way.
2. Willing to talk about dying: Not abandoning/avoiding the dying patient.
3. Giving bad news in a sensitive way: Balancing being realistic with
maintaining hope.
4. Listening to patients.
5. Encouraging questions.
6. Sensitive to patients readiness to talk about death.

Weinrich et al. Communicating with dying patients within the spectrum of medical
care from terminal diagnosis.
AIM 2001; 161: 868-874; Curtis, J Gen Intern Med 2000; 16:41

15
Communication at the EOL-Preparation

 Review chart and test results

 Discuss with other team members:
1. Purpose
2. Information that needs to be conveyed
3. Team's perception of the patient's/family's
knowledge, understanding, emotional state
 Decide who will be present
 Ask patient if they want information to be
conveyed to family/surrogate instead
 Fix a time/aim to avoid interruptions
A 9-Step Approach to Communication
at EOL
1. Start the meeting
2. Agree on purpose
3. What does patient/family/SDM know?
4. What information is necessary for
decision-making?
5. Share the information/respond to
emotions
A 9-Step Approach to Communication
at EOL

6. Discover goals/hopes/expectations/fears:
“Values History”
7. Address their needs
8. Develop a plan
9. Follow up
Common Emotional Response to
Patient/Family Emotions
Things to Avoid

 Diversion
 Withdrawal
 Jargon
 Provision of false hopes of cure or greater
likelihood of benefit
 Inappropriate destruction of hope
Better Responses – Things to do
 Don't be afraid of silence
 Don't abandon
 Don't make promises
 Don't give false reassurances
 Recognize the power of non-verbal
communication
 Develop a plan with patient and
 family
Explore goals, hopes, expectations
and fears
Patients’/Families' Responses When
Faced with Unexpected or Bad News
 Shock  Disbelief
 Grief  Denial
 Fear  Displacement
 Guilt  Depression
 Anxiety
 Anger
 Bargaining From Buckman R., How to Break Bad

 Over-dependency News: A Guide for Healthcare

Professionals, Johns Hopkins
 Shielding University Press Baltimore 1992
Talking with Families
of Capable Patients
 Done only with patient's consent
 and knowledge
Serious illness may mean patient
 and family =
unit of care

 Supporting family may help


family support loved one
May help them express love and

caring
Need time to express emotions
Be prepared to arrange for
When Families are Separated by
Distance — Common Problems
 News conveyed over the phone and/or by
other family members
 Misunderstanding and miscommunication
common
 Anxiety, guilt, disbelief, denial, anger
common

 Sense of urgency/Seen as
“demanding”
When Families are Separated by
Distance — An Approach
With a capable patient's consent & knowledge
 Be prepared to give bottom line first and
explanations later
 Start at the beginning and be flexible
 Crucial to ask them what they know
 Acknowledge the difficulties of living away
 Recognize and deal with emotions
Communication Over the Phone
 Introduce yourself & ask who you are speaking to
 Keep it clear and simple
 Invite them to hospital/office for more details
 Listen for emotions (tone of voice)
 Difficult silences: Shock? Understanding? Asleep?
 Be empathetic
 Address practical concerns: Driving? Others to call?
Anyone there to support?
When Language is a Barrier
 Arrange for a translator Ideally
 not a family member Role is to
 translate NOT expand
 Confidentiality
 Warn translator about nature of news/purpose of
meeting in advance
 Give information in small chunks and check
understanding
Professional as Patient
or as Family Member
 Increased educational needs
 Illness may affect ability to think and cope
 If treated as a colleague may not receive needed
empathy and support
 Acknowledge expertise and give support
 May not have in-depth knowledge of current
illness and Rx
https://www.youtube.com/watch?v=LTD7WCGMqWI&list=PLbzY
KxJWmOlI2eodac2Wo3O5jMS_-K0Jq&index=6

https://www.youtube.com/watch?v=vpPX70V_zIY&list=PLbzYKxJ
WmOlI2eodac2Wo3O5jMS_-K0Jq&index=7