Intro Before All Assistance for the patient Yes\No Signs Intelligible speech Communication through writing Spelling through pointing / Glance Pointing to pictures Object / person identification Level of alertness of the patient

Dear family member, caregiver or friend

The Guideline is Partially Funded by
the Jewish Federations of North America

This guide was written for you

Intro

One of the most important components of caring for a sick or injured person is communication.

It allows patients to express themselves, talk about their pain or difficulties, ask for things and accept help from others.

If someone you love or care about is hospitalized and has difficulty communicating, there are various ways to promote and enable communication. This guide, written by the
experts of the Ezer Mizion AAC Omer center team, will provide you with basic tools for communicating with the patient.

By completing the detailed questionnaire, you will identify the most suitable communication method for the patient—whether that’s spoken communication, writing, using a letter board, picture board, or pointing to objects. This process ensures the most effective communication approach tailored to the patient’s needs.

For Frequently Asked Questions

Attention

The tools detailed in the guide enable communication through the use of Augmentative and Alternative Communication (AAC) strategies to compensate for speech that has been temporarily or permanently
impaired.

These tools promote immediate communication without disrupting the process of speech restoration. They are intended to support the process and enable communication even when the patient is unable to speak.

Attention

The purpose of this guide is to equip speech therapists and/or family members with appropriate tools when a hospital speech therapist is not readily available and is unable to provide close supervision.

In any case, we recommend that you ask a doctor in the department to refer the
patient to the hospital speech therapists and to work with them as much as
possible.

Attention

Improving communication can be a delicate and complex process. To encourage advancement, be patient, invest time in learning the steps and
follow the instructions.

Attention

This guide is written in the masculine form but refers to all genders.

Supporting Comprehension

Start

Communication difficulties are generally regarded as the inability of patients to speak or express themselves.

However, in many cases the real  difficulty is their inability to listen, follow and understand what is being said to them. There are many reasons for this, including – among others – pain, medication, cerebral edema, emotional difficulties and more, all leading to fatigue, incoherence, or lack of concentration.

The first step is to rule out problems in receiving information:

 

4 / 1

Assistive devices

Make sure that the patient (if he generally does), is wearing his glasses, hearing aids or dentures. Where hospitalization conditions prevent use of such aids, be aware of this issue and take it into account. Seek appropriate solutions (e.g. Use written explanation for a patient who has difficulty hearing and cannot wear a hearing aid.)

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Supporting Comprehension

Start

Communication difficulties are generally regarded as the inability of patients to speak or express themselves.

However, in many cases the real  difficulty is their inability to listen, follow and understand what is being said to them. There are many reasons for this, including – among others – pain, medication, cerebral edema, emotional difficulties and more, all leading to fatigue, incoherence, or lack of concentration.

The first step is to rule out problems in receiving information:

 

4 / 2

Assistance in Orientation

Help patients orient themselves in time and space by hanging a clock, calendar and orientation board close to them. Having this knowledge or “control” will help with their emotional and cognitive state. Click here to download an orientation board

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Supporting Comprehension

Start

Communication difficulties are generally regarded as the inability of patients to speak or express themselves.

However, in many cases the real  difficulty is their inability to listen, follow and understand what is being said to them. There are many reasons for this, including – among others – pain, medication, cerebral edema, emotional difficulties and more, all leading to fatigue, incoherence, or lack of concentration.

The first step is to rule out problems in receiving information:

 

4 / 3

Support in Writing

When you say something to the patient, write it down clearly and show it to him at the same time (on a whiteboard, tablet screen, etc.). For instance, if you tell  him that you are going out now and will return in the evening, write: “I’m going now, I’ll be back in the evening.”

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Supporting Comprehension

Start

Communication difficulties are generally regarded as the inability of patients to speak or express themselves.

However, in many cases the real  difficulty is their inability to listen, follow and understand what is being said to them. There are many reasons for this, including – among others – pain, medication, cerebral edema, emotional difficulties and more, all leading to fatigue, incoherence, or lack of concentration.

The first step is to rule out problems in receiving information:

 

4 / 4

Support with Object

Present messages visually using images and not just verbally, especially when the patient has difficulty reading. For example – show him an x-ray image when you tell  him that he is being taken  for an x-ray or show  him a pillow when you ask him if  he needs a pillow, etc.

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Helping patients express themselves

“Yes” and “no” tools

When a person is sick or injured, his speech may be temporarily or permanently impaired.

There are many ways to communicate with him and different communication methods may be required at different stages of the illness or injury, depending on changes in his condition.

The first step is to verify that the patient has a way to pronounce or express the words “yes” and “no”. Also, there should be an additional sign for saying ‘I mean something else’.

Ask the patient to show you how he says or expresses “yes” and “no”. Repeat the request 2-3 times and explain that you are doing this to make sure you understand the signals.

If you were unable to get a clear response, ask yes and no questions involving tangible objects in the room. For instance: Hold up a pillow and ask if he wants another pillow. Point to the light switch and ask: Do you want me to turn the light off? turn the light on?

Ask knowledge-based questions (Is your name Max?). Explain the purpose of the test to avoid seeming condescending.

Check the response to the question and record the methods of the responses to “yes” and “no”.

Does the patient manage to consistently indicate/point to 'yes' and 'no'?

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Assistance to the patient to express himself

A minute before conitinuing

It is recommended to implement the following steps

Inform relatives, visitors, staff members and anyone who comes into contact with the patient about his “yes” and “no” signals. If necessary, hang a sign with the signals over or next to the bed. Click here for a sample signboard

Assistance to the patient to express himself

A minute before conitinuing

It is recommended to implement the following steps

Ask each question clearly and wait for a response. Don’t immediately repeat the same question multiple times. People who are not well need time to process and respond.

Assistance to the patient to express himself

A minute before conitinuing

It is recommended to implement the following steps

When the patient has several options, outline the options clearly before you ask the question so the patient knows what the options are and can choose in advance.

Assistance to the patient to express himself

A minute before conitinuing

It is recommended to implement the following steps

Always show an additional choice other than “yes” or “no”. The answer to the question may be “I mean something else” or “I don’t know”.

Establish "yes" and "no" signals

"yes" and "no" signals

Is it possible to establish sings for Yes and No?

Try to teach the patient to say “yes” and “no” by using movements or gestures that you have seen him perform (you raised your hand, you said ‘yes’). Choose significantly different responses for “yes” and “no” (for example, closing your eyes for “yes” and moving your hand for “no”). Responses that are too similar (such as one blink or two blinks) can confuse both the patient and those trying to understand him .

Do not give the patient conditional instructions. Such as: ‘If you want to say yes, blink’ ‘If you want to say no, raise your hand’.   Such sentences are complex for patients who lack concentration or have difficulty understanding. Say a simple sentence: “You raised your hand, you signaled yes.”

If the patient is unable to move his body, but can shift his gaze to the right and left, use the “yes” and “no” cards: Always hold “yes” on the patient’s right (your left) and “no” on the patient’s left (your right). Ask “yes” and “no” questions and encourage the patient to look at the appropriate card each time. Check what distance between the cards is appropriate for the patient.

Click to download “yes” / “no” cards

Attention

The patient needs response time. Ask the question clearly and slowly and wait. Do not repeat the question over and over.

Give the patient time to learn the signals. Practice the signals with the patient (a little at a time) until they are clear to you and to the patient.

Keep other visitors and staff informed of the patient’s response signals. If necessary, hang a sign with the description of the signals on the back or over the patient’s bed. click here for a sample signboard.

Does the patient manage to clearly indicate 'yes' or 'no'?

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Communication through intelligible speech

Intelligible speech

Check whether the patient is able to communicate using speech and whether this speech is intelligible to others.

Verify that the patient’s lip movements are clear (even if they do not utter a sound)

Ask the patient to pronounce his name

Ask the patient to count to 10

Ask a question that you don’t know the answer to

Now, check how intelligible the patient’s speech is to you, to the rest of the family and for the staff.

Is the patient's speech understandable?

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The most appropriate communication device for the paitent you have described is

Mediated Speech

intelligible speech

Try to guide the patient to speak more intelligibly in one of the following ways

Speak word by word and raise a finger to indicate that the word is complete (for example: “I” > raise a finger > “want” > raise a finger > “to” > raise a finger >”sit” > raise a finger).

Say the first letter in an incomprehensible word, or point to the first letter of the word on a letter board.

Simplify the message or say it in other words.

Get closer to the patient, look at his lips and repeat the message you heard to check and confirm that you understood it correctly.

If these suggestions did not help, Continue with the guide

Feedback Questionnaire

It is important for us to receive feedback in order to make improvements for you

"*" indicates required fields

Are you a:*
The patient for whom I am seeking a communication solution is hospitalized due to:*
If you are not an SLP, have you used the services of an SLP during this hospitalization?*
Did you request a consultation with the staff of The Omer Communication Center?*
Did this Guideline assist you?*
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Establish communication through writing

Communication through writing

How do we check if it is possible to establish communication through writing?

Give the patient a whiteboard and a marker (if you don’t have a whiteboard, use a sheet of paper on a hard surface).

Write the patient’s name on a sheet of paper and ask the patient to copy it.

Ask the patient to write a familiar word (for example ‘bed’).

Ask the patient to write an answer to a simple question (for example, write your spouse’s name).

Ask the patient to write an answer to a knowledge or memory question (for example, tell me where you went on your last trip? How was it?).

Check if his handwriting is legible.

Attention

It’s easier to write while sitting, not lying down! Therefore, have the patient sit (if possible) and place the writing surface at his elbow with  his hand supporting it.

Does the patient write the answers comprehensibly?

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The most appropriate communication device for the paitent you have described is

Writing

Communication through writing

Follow these instructions:

Embrace communication through writing. Buy a whiteboard and an erasable marker and place it in the most convenient and accessible place for the patient.

Prepare a list of frequently used messages and stick  the list to the side of the board to spare the patient the hassle of writing them over and over again. For instance:

Common words: I, want, yes, no, thanks, more, enough, where, when, why.

Frequent requests: lie down, drink, bring, cover, pain.

Names of close people, personal belongings, etc.

Example of erasable chart with frequently used words


							

						

												

							

						

						

															
                

                        

                            
Feedback Questionnaire

                            
It is important for us to receive feedback in order to make improvements for you

							
"*" indicates required fields

                        

                        
Are you a:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
The patient for whom I am seeking a communication solution is hospitalized due to:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
If you are not an SLP, have you used the services of an SLP during this hospitalization?*

			

					
					
			

			

					
					
			

			

					
					
			
Did you request a consultation with the staff of The Omer Communication Center?*

			

					
					
			

			

					
					
			
Did this Guideline assist you?*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

        
  
            
            
            
            
            
            
            
            
            
            
            
            
        

                        

                        

		                
		                
										
						

						

							
						

					


					

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Establish spelling through the use of pointing or eye gaze

					
spelling by pointing

				


				


					

						

							
How to verify finger/vision spelling

						

						

							Attention
									

										
											Finger spelling
											

										
										

											
Make sure the patient is in a comfortable position to point (support shoulders or elbow as needed).


Choose a printed letterboard or a keyboard on a tablet.


Virtual tablet keyboard – there are different kinds of keyboards, including the device keyboard. Do not use the mobile phone keyboard due to its small size. The ‘Let’s Talk’ (Bo Ledaber) app allows writing and playing the message aloud.

Note! Pressing a touch screen can be difficult for a patient lying in bed, especially when he is weak or is suffering  from clouded consciousness. If typing problems arise, try writing on a board or pointing to a printed letterboard.


A printed letterboard can be a large letterboard arranged in columns or a board with smaller letters, accompanied by common messages. The available options are listed here


A Spelling Chart for Frequently Used Words, Alphabet Pointing Display with Frequently Used Words Organized according to Qwerty Arrangement, Spelling Charts to be Used with Pointing


If you chose a printed board, print it on a color printer and laminate it. The patient may need a board on a different size sheet. We recommend A4 and A3 sheets. Check what is suitable.


Place the board on a firm, stable surface in a position convenient


for the patient to point to.


Ask the patient to point to specific letters, one at a time.


(For instance: “Point to the letter d”).


Ask the patient to spell his name by pointing. Then ask  him to spell the name of the street  he lives on.


Each time he points to a letter, repeat the letter aloud, write it with a marker and ask for confirmation that you understood it correctly.


 


											

												
  

												

													
Pressing a touch screen can be difficult for a patient lying in bed, especially when  he is they are weak or is suffering  from clouded consciousness. If typing problems arise, try writing on a board or pointing to a printed letterboard. 


												

											

										

									
Attention
									

										
											vision spelling
											

										
										

											


There are two options for spelling by sight: a transparent communication board or a large spelling board.


There are patients who are able to operate a computerised eye gaze system –  computer which is operated by using one’s eyes.  These systems require alertness, concentration, and ability to learn and therefore are mostly appropriate for rehabilitation departments and less so for inpatient hospitalisation units.


											

												
  

												

													
												

											

										

									
						

													

								
Attention  

								

									








If the patient has difficulty in pointing to letters of the alphabet either with his hand or by eye gaze due to a visual disability, he can probably be assisted to spell messages through the use of visual scanning, in which he chooses the letter he wants from a list which is read to him.













								

							


							
						

							
							

							

								

									
								

							

						

						
						

							
Is the patient able to spell messages using a letterboard?

						

						

							
							
						

					


					

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The most appropriate communication device for the paitent you have described is 

					
Spelling

					
spelling by pointing

				


				


					

						

							
following these guideline

						

						

							

							
Hand the patient a letterboard to point to.


Choose the most comfortable board from the three options


A Spelling Chart for Frequently Used Words , Alphabet Pointing Display with Frequently Used Words Organized according to Qwerty Arrangement, Spelling Charts to be Used with Pointing and adjust the size to enable comfortable hand movement.


If the patient points with his eyes, it is recommended to find out where you can get a transparent spelling board in your area or via the Internet.


Be sure to say aloud the letter the patient pointed to and then, when he has finished,  say the whole word. At the same time, write the letters  he selected on  the whiteboard. Ask for confirmation that  you understood them correctly.


Try to spare the patient unnecessary effort. If he starts to spell a word and you can guess the continuation, say the word and ask for  his  approval (and also later in the sentence).


Prepare a list of common words and place it next to the letterboard or on the other side to save the need for repeated spelling (e.g. a message like ‘get out of bed’.) For a database of common example words, click here


 

							

						

												

							

						

						

															
                

                        

                            
Feedback Questionnaire

                            
It is important for us to receive feedback in order to make improvements for you

							
"*" indicates required fields

                        

                        
Are you a:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
The patient for whom I am seeking a communication solution is hospitalized due to:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
If you are not an SLP, have you used the services of an SLP during this hospitalization?*

			

					
					
			

			

					
					
			

			

					
					
			
Did you request a consultation with the staff of The Omer Communication Center?*

			

					
					
			

			

					
					
			
Did this Guideline assist you?*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

        
  
            
            
            
            
            
            
            
            
            
            
            
            
        

                        

                        

		                
		                
										
						

						

							
						

					


					

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Establish communication by pointing at images 

					
Pointing at images 

				


				


					

						

							
How do we check if it is possible to rely on pointing to pictures as the basis for developing communication?

						

						

							
									

										
											Finger pointing
											

										
										

											
Make sure the patient is in a comfortable position for finger pointing (support shoulders or elbow as needed).


Place 4 picture cards in front of the patient, accompanied by the written word.


Ask him to point to one word at a time: “Where is the…?”.


To view an example of A Test for Picture Recognition click here


										

									

									

										
											Pointing by gazing
											

										
										

											
Prepare or bring a picture frame, without a picture (so that only the frame remains). Choose a frame that is slightly larger than your head


Paste the 4 word cards in the corners of the frame as described in the previous section


Ask the patient to look at one word at a time: “Where is the…?”.


To view an example of A Test for Picture Recognition at a Glance click here


										

									
						

						

							
Does the patient point to pictures with his hand or by looking ?

						

						

							
							
						

					


					

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The most appropriate communication device for the paitent you have described is 

					
Icon message boards

					
Icon message boards

				


				


					

						

							
Here’s how to use them

						

						

							

							
Choose an icon message board from the options offered here. The boards have 3 levels. Each level includes a pair of double-sided boards so that the pair of boards is glued back to back. One board deals with urgent messages and the other board deals with conversation.


You can also prepare a personalized icon message board or change some of the icons/messages that appear on the boards offered here. The boards can be prepared manually or by using a common computer software (such as PowerPoint). Photos can be taken or downloaded from web image databases


To download communication boards

							

						

												

							

						

						

															
                

                        

                            
Feedback Questionnaire

                            
It is important for us to receive feedback in order to make improvements for you

							
"*" indicates required fields

                        

                        
Are you a:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
The patient for whom I am seeking a communication solution is hospitalized due to:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
If you are not an SLP, have you used the services of an SLP during this hospitalization?*

			

					
					
			

			

					
					
			

			

					
					
			
Did you request a consultation with the staff of The Omer Communication Center?*

			

					
					
			

			

					
					
			
Did this Guideline assist you?*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

        
  
            
            
            
            
            
            
            
            
            
            
            
            
        

                        

                        

		                
		                
										
						

						

							
						

					


					

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Establish communication through the identification of objects and people

					
Objects or people identification

				


				


					

						

							
How do we check if it is possible to rely on the identification of objects and people as the basis for developing communication?

						

						

							
									

										
Ask the patient to point to a body part (such as the leg), a person in the room (such as the person holding the rose), and an object in the room (such as the door).


									

									

										
If the patient cannot point, ask him to look towards the body part, the person in the room and the object.


 


									

									

										
If it is not clear to you whether the patient understood the request, check whether the patient looks or tries to point at objects or people in the room on his own initiative, and whether he shows satisfaction when the object or person  he looked at or pointed at is brought to him.


									
						

						

							

							
Pointing can be done with the finger, the whole hand or by eye gaze.



							

						

												

							
Does the patient manage to point with  his hand or look at objects?

						

						

							
							
						

					


					

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The most appropriate communication device for the paitent you have described is 
 
					
Pointing at objects

					
Pointing at objects

				


				


					

						

							
following these guideline

						

						

							

							
Encourage the patient to use hand or gaze pointing to communicate – to point to an object in the room or to select an object from a number of objects presented to the patient on a tray (such as: several foods, music CDs or personal belongings).


Click to view an example of a tray for choosing

							

						

												

							

						

						

															
                

                        

                            
Feedback Questionnaire

                            
It is important for us to receive feedback in order to make improvements for you

							
"*" indicates required fields

                        

                        
Are you a:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
The patient for whom I am seeking a communication solution is hospitalized due to:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
If you are not an SLP, have you used the services of an SLP during this hospitalization?*

			

					
					
			

			

					
					
			

			

					
					
			
Did you request a consultation with the staff of The Omer Communication Center?*

			

					
					
			

			

					
					
			
Did this Guideline assist you?*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

        
  
            
            
            
            
            
            
            
            
            
            
            
            
        

                        

                        

		                
		                
									
						

						

							
						

					


					

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Is the patient alert?

					
patient alertness

				


				


					

						

							
Notice the patient's indicators of alertness:

						

						

													

						

							

							








Touch the plus icons in order to learn the signs of alertness of the patient









							

						

												

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Keep a record of the times in which the patient is alert (be aware that these can be affected by various factors, such as medication)

								

							

							

								
								

								
Try to establish eye contact with the patient

								

							

							

								
								

									
Check if the patient's gaze follows what is happening in the room

								

							

							

								
								

									
Ask the staff working with the patient for information regarding the patient’s level of alertness

								

							

							

								
								

									
Check whether the patient tries to react to you

								

							

						

						

							
Is the patient alert for at least a few minutes?

						

						

							
							
						

					


					

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Keep a record of the times in which the patient is alert (be aware that these can be affected by various factors, such as medication)

							

						

						

							
							

								
Try to establish eye contact with the patient

							

						

						

							
							

								
Check if the patient's gaze follows what is happening in the room

							

						

						

							
							

								
Ask the staff working with the patient for information regarding the patient’s level of alertness

							

						

						

							
							

								
Check whether the patient tries to react to you

							

						

					


				

			

			

								

					
					
According to the description of the patient we will reccomend to develop
 
					
Create a pleasant and relaxing environment that encourages communication. 

					
patient alertness

				


				


					

						

							
Follow these instructions:

						

						

													

						

							

							
Take advantage of the patient’s alert times to communicate. Do not try to elicit communicative responses from the patient when he is sleepy.


Play music that the patient likes Make sure the volume is pleasant, not too loud.


Share pictures of family members, relatives, and friends with the patient.


Gently touch the patient. Hold and caress his hand. Follow how he reacts to touch and see what pleases him and what doesn’t.


Take the patient outside to the fresh air, if possible


Use the tools that support understanding as detailed at the beginning of the guide.

							

						

													

								
Attention  

								

									
Sometimes the patient understands instructions but cannot control his body movements. He may be alert but unable to understand the text due to impaired language functions in the brain. Sometimes there is control over eye movements or the direction of the gaze. Try to find even the smallest movement that indicates understanding. Even if there is no evidence of understanding, keep talking. The understanding may appear gradually.

								

							


																				

								
Note

								

									
Sometimes a computer operated by eye gaze can detect patient reactions and gestures that are difficult for a person to detect. If necessary, you can consult with therapy professionals (speech therapist or occupational therapist) to check the gaze reactions using a computer. However, the use of a computer is very tiring, and requires a long process of learning and adaptation. Therefore, this solution will often not be relevant in the hospital, especially when the patient’s condition changes over time. Therefore, the simpler  methods of communication described here are recommended, at least in the first stages of hospitalization.

								

							


													

							

						

						

															
                

                        

                            
Feedback Questionnaire

                            
It is important for us to receive feedback in order to make improvements for you

							
"*" indicates required fields

                        

                        
Are you a:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
The patient for whom I am seeking a communication solution is hospitalized due to:*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			
If you are not an SLP, have you used the services of an SLP during this hospitalization?*

			

					
					
			

			

					
					
			

			

					
					
			
Did you request a consultation with the staff of The Omer Communication Center?*

			

					
					
			

			

					
					
			
Did this Guideline assist you?*

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

			

					
					
			

        
  
            
            
            
            
            
            
            
            
            
            
            
            
        

                        

                        

		                
		                
										
						

						

							
						

					


					

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When the patient is sleeping, dozing or not fully conscious 

					
patient alertness

				


				


					

						

							

						

						

													

						

							

							
When the patient is sleeping, snoozing, or isn’t fully conscious it is very hard for him to be communicative with those around him.




At this stage we would recommend enabling the patient to listen to his favorite music, and we would recommend touching the patient in a pleasant manner and talking to him.




In Israel, a system called EyeCon is available which is used for the rehabilitation of patients who are partially conscious to assist in the advancement of communication with the patient.  The system is based on the advanced analysis of brain waves measured by an EEG band tied around the head of the patient.




For more information about this tool press here.

							

						

												

							

						

						

							
						


						

															
                

                        

                            
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