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Guide for Hospitals on Best Practices for Communication with Individuals with Disabilities

Note: This guide is not legal advice but is a best practice document 
put together by several Colorado-based disability rights organizations. (April 9, 2020)

This document contains the following sections:

Communication Best Practices

Reasonable modification of policy

Best Practices for Specific Disabilities

QUESTIONS?

COMMUNICATION BEST PRACTICES

To communicate with people who have different levels of ability and may be considered as having a disability

These are some quick tips for first responders and hospitals during an emergency.  In normal situations, the obligations are much more expansive. Training on and clear policies that are regularly updated is expected.  The Americans with Disabilities Act obligations are in place even during emergencies. Some practices may need to be altered during the emergency, but effective communication must be provided.

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What is effective communication?

Communication that is as effective for persons with disabilities as it is for persons without disabilities.  Many people with disabilities may need reasonable accommodations to support alternative methods of communicating.  Ask if the person uses a communication device or needs accommodations.

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What is the obligation of a hospital or other provider?

To provide auxiliary aids and services as needed to ensure effective communication, and to modify policies, practices, and procedures as needed unless the modification fundamentally alters the program, service or benefits.
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Who determines the appropriate auxiliary aids or services?

The primary consideration should be given to the individual with a disability’s desired aid or service.  The entity can offer alternatives or make final decisions only if the communication is equally effective.  BEST PRACTICE IS TO ALWAYS MAKE THIS A COLLABORATIVE PROCESS.  Always ask the person, “What can I do to help with communication?”
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Reasonable modification of policy:

If someone needs another person they know in order to communicate, the hospital must modify policies as long as the modification does not create a fundamental alteration to their service.  Allowing a family member or interpreter, who is capable of acknowledging the risk, to be in the room to assist with essential communication is likely a reasonable modification of the policy that generally prohibits visitors.  This is particularly true if the individual is unable to use a device (iPad, Smartphone, etc.) to communicate. While policy modifications may be needed, it is necessary to always assume the person with disability is the final decision-maker regarding treatment, unless otherwise proven to be different with provided documentation such as Medical POA, POA, or guardianship.

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The following assumptions are acceptable:

  • That people know their communication needs and if they are able to express those needs will tell you.  (Sometimes severe anxiety might get in the way of this but usually people are happy to help someone that is trying to help them).
  • That people with all types of disabilities will have the same gamut of reactions to news that they or a loved one have COVID-19.That people with all types of disabilities have the same level of preparation (or lack thereof) with regard to advance directives as the rest of the population.

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 The following assumptions should not be made:

  • That people with severe disabilities have guardians.  This includes those who clearly lack capacity.
  • That people with significant speech or communication impairments all have an intellectual disability.
  • That people with intellectual disabilities cannot make decisions about their lives.
  • That someone that may require support with decision-making should have a guardian.
  • That people with very significant disabilities would reject lifesaving measures or have a poor quality of life or would see life on a ventilator as a tragedy.
  • That because you believe you understand the communication you are receiving, the other person is fully able to understand and participate in the communication. Communication must be both expressive and receptive to be effective.
  • For someone using ASL or sign, do not assume they can or can’t hear you or their ability with sign language is flawless. Confirm understanding by asking clarifying questions. Especially with an interpreter. They too can make mistakes.

Blue line with three diamond shapes in the middle
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Best Practices for Specific Disabilities

The following sections are organized by the description of the person needing communication support.

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A person who is Deaf

  • Is there a sign language interpreter or agency/company you can have on contract to use via Video Remote Interpreting (“VRI”)?  Set up contracts and protocols, provide training and make sure there is an available phone or tablet. This should be an RID certified interpreter (Registry of Interpreters for the Deaf). Depending on the complexity of the communication, a medically certified interpreter might be necessary.
  • Make sure that all staff have been trained and know how to use VRI, and that equipment is somewhere they can find it quickly.  Please note that VRI might be routed out of state and you might not get a certified interpreter that is required in Colorado unless you ask for this.
  • Note-writing is OK for people who request it or have become deaf later in life, many people born Deaf are limited in English so any note-writing done in emergency should be confirmed with an interpreter at the earliest possible moment.
  • Once an emergency has passed (e.g. patient admitted and somewhat stabilized) an in-person interpreter should be summoned, especially on the request of the patient(s) who is Deaf.   Rural hospitals call RISP.   Urban hospitals should have a contract.  For list of interpreters go here.
  • See guidance from the National Association for the Deaf

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A person who is Hard of Hearing

  • Lip reading will not work through masks. Get some masks with clear plastic windows and have it on site for such patients.
  • Move to a quiet room when possible.
  • Note writing.
  • Have some iPads to type on and sanitize between uses.  Notepads should also be made available as some older people with hearing loss do not use technology. All pens and supplies must be disinfected/wiped down between uses.

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A person who is Non-Verbal

People who are non-verbal do not all have the same challenges.  They may or may not understand what you are saying.

  • Do they have a device to help them?
    • An iPad, a communication board
  • Are they able to write questions and answers?

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A person with a Speech Impairment

  • If they are not with someone that can assist, ask them to repeat it.
  • Many people with speech impairments may spit (non-purposeful) some when they talk, so use a mask.
  • A face shield may be easier for them to use than a mask.
  • Ask yes no questions when possible; yes will be something going up (thumb, head, smile, etc.)
  • If you cannot understand a word, ask them to spell; if you cannot get letters, you start spelling.
  • Have a large letter board and let them point to letters, someone will have to hold it up. If they communicate this way, they might have it on them, unless they were taken into a hospital by ambulance.

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A person who is Blind:

  • NEVER take away mobility aides including white canes or guide dogs.
  • Have accessible documents (Word is preferable) you can email to someone so they can use a screen reader on their device
  • If you cannot use a Word document or the person does not have email, have someone available to read the document for the person.
  • Braille is going to be a challenge unless you have enough to give patients their own copy of the documents.  You cannot have one patient use it after another and it cannot be read with gloves.
  • This is important for advance directives.

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A person who has Low Vision

  • Large and very large print.  Any documents need to have copies in large and very large print (18 and 24 font).
  • Magnifiers that can be sanitized.

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A person who has an Intellectual or Developmental Disability

  • Speak to the person appropriate to the chronological age, do not speak to the person as if he or she is a child (unless they actually are a child).
  • When a person can’t or does not respond to your requests or questions; it does not mean they are not being compliant. Sometimes they just can’t speak or need more time to process before responding.
  • Interactions with authority figures can often bring up traumatic experiences for people with I/DD.
    • If a person isn’t responsive, consider also that they may be in a state of panic or “fight or flight”
    • Give them time and understand that no one is at their best in a crisis situation.
  • Remember to use clear language, avoiding metaphors and idiomatic phrases.
    • Some people with I/DD may do better with very literal communication and when asking a question, endeavor to be specific.
    • Do not ask, “do you have a weapon?” ask, “Do you have a gun in your pocket right now?” or “Do you have a knife in your pocket right now?”
    • Use plain language rather than medical terms.
  • Do not speak directly to a caregiver about a person with I/DD
    • Ask the person with I/DD for permission to talk to their caregiver if you need clarification, etc.
  • Many people with disabilities live with aging caregivers who may also be vulnerable to COVID-19 at this time.
    • People with disabilities may be reticent to leave their family member.
    • Remember that many of these family units have been together, in a very intimate environment, for many decades.
    • When dealing with family members and people with disabilities, consider the increased level of fear that might come with separation.
  • People with I/DD experience the same range of emotions as anyone else.
    • When assisting a person with I/DD, think also about how your communication might need to overlap with communication tips for anxiety, agitation, etc.
    • Remember that about 80% of people with I/DD also have a co-occurring mental health diagnosis.

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A person who has a Mental Illness (depression, bipolar depression, schizophrenia, etc.)

  • Situations of extreme stress can increase symptoms of depression leading to individuals inability to see reality – they may view them as better or worse than the situation warrants.
  • Do not force choices on individuals in this mental state. They would be based on misinterpretation of facts.
  • Be cautious of phrases like “It’s not that bad”, or “You are overreacting.”  For the person in a heightened mental state it is that bad and they aren’t overreacting.

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A person who has Severe Anxiety

  • Realize that anxiety can manifest like hostility, unwillingness, or outright anger. People in the middle of a severe anxiety attack can act and appear very stubborn. This is often due to the overwhelming fear of what comes next.
  • Offer a quiet room when possible.
  • Ask them what usually helps them when they are anxious.
  • Do NOT tell them to calm down.
  • Explain what is happening now, next, and after that. Often knowing the steps help ease the fear of the unknown.
  • Realize that for many anxiety attacks are a chemical imbalance in the brain – similar to adrenaline – where something triggers a surge of chemicals that lead to panic. Often the only option is to ride out the wave until the balance of chemistry in the brain is restored
  • Ask if they have someone who they want to help them with communication and offer a phone if they do not have it.
  • When a person can’t or does not respond to your requests or questions; it does not mean they are not being compliant. Sometimes they just can’t speak or need more time to process before responding.
  • Don’t try to make them make long term plans because they are in survival mode and long-term planning might be out of their reach. (Unlikely this will happen, but long term might mean a few hours away for the person.)
  • Ask them if they need a break or time to gather their thoughts.

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A person who has Severe Agitation

  • Offer a quiet room when possible.
  • Do not threaten, ask what would help.
  • Do NOT tell them to calm down.
  • Speak to the person appropriate to the chronological age, do not speak to the person as if he or she is a child (unless they actually are a child).
  • When a person can’t or does not respond to your requests or questions; it does not mean they are not being compliant. Sometimes they just can’t speak or need more time to process before responding.
  • Don’t try to make them make long term plans because they are in survival mode and long-term planning might be out of their reach.
  • Ask them if they need a break or time to gather their thoughts.

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QUESTIONS?

CALL THE COLORADO CROSS-DISABILITY COALITION (303-839-1775) or email covid@ccdconline.org.

These organizations contributed and are trusted resources. Thank you for contributions.

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Important Notice
CCDC’s employees and/or volunteers are NOT acting as your attorney. Responses you receive via electronic mail, phone, or in any other manner DO NOT create or constitute an attorney-client relationship between you and the Colorado Cross-Disability Coalition (CCDC), or any employee of, or other person associated with, CCDC. The only way an attorney-client relationship is established is if you have a signed retainer agreement with one of the CCDC Legal Program attorneys.

Information received from CCDC’s employees or volunteers, or from this site, should NOT be considered a substitute for the advice of a lawyer. www.ccdconline.org DOES NOT provide any legal advice, and you should consult with your own lawyer for legal advice. This website is a general service that provides information over the internet. The information contained on this site is general information and should not be construed as legal advice to be applied to any specific factual situation.

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