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Guidelines for Medical Professionals

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Compiled and written by Earle Baum Center of the Blind

April 2004

Printed copies of this pamphlet are available free of charge from the Earle Baum Center of the Blind, Santa Rosa, CA.

Objective: This information is provided as a guideline for medical staff members who interact or provide care to blind or visually impaired patients.

Treating The Patient As An Individual

When you encounter blind, deaf blind or visually impaired patients, you will be encountering people with a broad range of visual impairments. Some may have assistance needs; others will not. It is important to regard each visually impaired patient as an individual deserving of the same dignity and respect as any other person you serve during your workday.

Roughly three-quarters of the population who are “blind” are not totally blind, i.e., they have some residual vision. Some may use a white long or support cane, others may use a dog, and still others may not use Braille or a mobility aid at all. Thus, staff should be observant and, when in doubt, ask if the patient has difficult seeing. Demographic data indicate that a significant number of individuals with vision loss are elderly and frequently experience multiple disabling conditions and often are in denial regarding their visual deficits. This population is growing rapidly. There are also a growing number of children with vision loss who also have additional disabilities.

Many visually impaired patients actually have what is known as “low vision.” Some can see primarily in the periphery of their visual field, as if the center of their vision were blocked. Others can see only in the central portion of their visual field, as if looking through a tunnel. Still others have some vision in all sectors of their visual field but what they see is distorted or blurred in some way. Many who are visually impaired function best under specific lighting conditions. Most often, direct lighting that does not produce glare or shadows makes it easier for such persons to perform tasks.

Please keep in mind that it is not always the patient who requires auxiliary aids or services. For example, a parent who is blind may be required to grant consent for his or her child’s surgery. The contents of the consent form must be communicated effectively to that blind parent. In most cases, this can be accomplished by reading the consent form to the patient or by providing the form in Braille, on audiocassette, disk, CD or via email on request. The Earle Baum Center can assist you in the preparation of these materials.

In diagnosing, remember that the eyes of many people with visual impairment may not react normally to light or movement. For example, the pupils of people with cataracts or whose cataracts have been removed may remain dilated at all times. Patients with nystagmus can have “roaming eyes” that may or may not indicate emergent neurological problems. If in doubt, ask an ophthalmologist to provide additional information.

The following scenarios and tips provide guidelines to support you in providing care that is not only thoughtful and beneficial but is ADA-compliant. Additional opportunities for improving access to facilities and services are also suggested in the conclusion.

General Guidelines

THE SCENARIO:A person enters the hospital room of a visually-impaired patient and, without identifying herself or the reason for her visit, noisily sets something down on the tray holder next to the bed, and then leaves without a word.

THE PROBLEM: What just happened? Who was this visitor? And what did she leave? Is it the patient’s lunch, a procedure tray or some other delivery?

THE SOLUTION: The employee enters the room and says, “Good afternoon, Mr. Bennett. I’m Carla Smith, a dietary aide. I’ve placed your lunch tray on the bedside table. It’s a cold roast beef sandwich today with a green salad, cake, and coffee. Do you need any further information about your tray?

Relax, slow down, and let consideration be your guide. The kind of confusion that is created by thoughtless behavior such as that described above can be alleviated by a simple shift in awareness and sensitivity. In most cases, the patient is familiar with living with diminished sight and with helping others to assist their needs.

Don’t make assumptions. The blind and visually impaired have visual acuity or functional deficits associated with their vision loss that may vary widely. For example, the same person may have perfectly adequate travel vision during the day but may find mobility to be more difficult at night under low lighting conditions. Someone who shows no outward signs of visual impairment may need assistance in reading her bill. Respond to your patient’s needs on an individual basis.

When in doubt about what to do, just ask. A simple “What can I do to assist you?” will provide the opportunity for the patient to tell you what, if anything, you can do.

In cases where it appears the patient has limited experience dealing with vision loss and self-direction is difficult, explore options with the patient for providing accommodations while allowing the individual to maintain personal control and dignity.

Using words such as blind, visually impaired, seeing, looking, and watching television is acceptable in conversation. Using descriptive language, including references to color, patterns, and the like is also OK.

When referring to patients with disabilities, refer to the person first, then the disability, for instance, “The patient in 439 who is blind.” Rather than “The blind man in 439.”

Speak to the patient in normal conversational tones. It is not necessary to raise your voice.

Guidelines for Greeting/Orienting

Address the person by name, if you know it.

Identify yourself by name and function and the reason you are there.

Stay in one place, if possible, when you speak. It is hard for a blind person to try to face a speaker who is constantly moving around.

Verbalize and demonstrate procedures before they are performed and identify injections or medication, the dosage, and what it is for before administering, e.g., “Mr. Bennett, I’m Pete Walters, an EKG technician. Have you ever had this procedure before? No? Well, I’ll first be placing an EKG lead on your chest. Would you like to see what the instrument looks like?”

Identify unusual odors and noises and alert the patient to what the procedure you are about to perform might feel like.

If the person is with a companion, avoid using that person as a go-between. Address your questions and comments directly to the patient. For example, rather than asking, “Does he want the TV on?” direct the question to the patient.

Read fully, upon request, and provide assistance, if necessary, in completing consent forms, financial responsibility forms, bills, menus, and other documents if they can’t be supplied in accessible media. If you are asked to read aloud to a patient, be sensitive about privacy—find a private room or area before proceeding.

Guiding The Blind and Visually Impaired

The scenario: A customer service assistant has just directed a visually impaired patient to a restroom down the hall from the waiting room. He watches as the patient hesitates in the hallway, appearing uncertain which way to go.

The problem: The assistant rushes out from behind the counter, grabs the patient’s arm, and says in a loud and deliberately slow way, “Here, let me take you there.” And proceeds to walk quickly down the hallway, pulling the patient by the hand. They stop at the door to the restroom and the assistant leaves the patient saying loudly, “It’s through that door.”

The solution: The customer service assistant approaches the visually impaired patient and asks in a normal speaking voice, “May I be of assistance in showing you the way to the restroom?” When the patient says yes, the assistant offers his arm, allowing the patient to hold his arm just above the elbow. The assistant walks at a comfortable, normal pace about a step ahead of the patient and when they reach the door to the restroom the assistant says, “The door to the restroom is a step ahead of us. The door is opening away from us on the left.” Passing through the door with the patient still holding his arm, the assistant allows the patient to catch the door as he passes through it. Before the assistant leaves the patient he ascertains that the patient wishes no further assistance.

When guiding, identify changes in terrain, such as stairs, narrow spaces, or escalators by hesitating briefly as you approach them and explaining what you are about to do.

Be specific in your directions and use right or left as they apply to the person being guided. Say, “There is a door on your right.” Rather than “There’s a door up ahead.”

When seating a patient ask him if you may show him the back of the chair. If the response is yes, simply place the patient’s hand on the chair back.

Access to Information

It is most important to first ask how your patient prefers to receive information from you. It is also useful to ask the patient how you can recognize that your message has been understood.

When confirming or reminding a visually impaired patient of an appointment it may be most effective to communicate by phone rather than sending a printed appointment communication by mail.

Because of the wide range of visual impairments it is important to have all of the following options to most adequately deliver information:

Large print (materials given to visually impaired patients should be in a minimum of 18 pt. bold, Arial or other sans serif typeface; avoid italics.)

Computer disk or CDs

Audio tapes

Braille

Brailtrak tactile communicator (an inexpensive device that contains Braille and raised character alphabet and numerals.)

Reading aloud (be sensitive to ensure that private information is not overheard.)

Writing on the palm (in the case of some deaf blind patients.)

Handling Medical and Related Transactions

The scenario: A visually impaired patient submits a prescription to a pharmacy assistant. The assistant tells the patient she will call her name when her prescription is ready. “Miss Smith, your prescription is ready!” the assistant announces loudly several minutes later. The other people in the waiting area look up and watch Miss Smith make her way to the counter. The assistant gives the patient two bottles of pills in a bag. She also hands Miss Smith a ten-dollar bill and four one-dollar bills in change for a $20 bill on a $6 co-payment.

The problem: Which bill is which? And which bottle contains what medication?

The solution: So that the patient does not have undue attention drawn to her, the pharmacy assistant gives Miss Smith a vibrating pager that goes off silently when her prescription is ready. The assistant explains that the medications are in “talking” containers and demonstrates how, when activated, the chip affixed to each bottle announces the name of the medication. When giving change, the assistant identifies and counts out each bill, placing them in Miss Smith’s hand. “That’s a ten…and four ones: one, two, three, four. Do you have any questions for me? No? The pharmacist would like to speak to you about your medications now. His station is located at this same counter about four steps to your right. The way’s clear so please step to his station and wait there. He will be with you in a moment.”

There are a variety of methods to aid visually impaired patients in identifying and dispensing their medications including:

Dymo and Braille labeling

Audio recordings of medications and their dosages

Different sized bottles or containers with notes kept about the contents of each size package

Rubber bands and paper flag-type labels that can be in Braille or large print using a wide point felt tip pen

Talking medicine bottles

Braille and raised character pill dispensers

Drug information sheets, printed in large type

When prescribing liquid medication, provide the patient with dispensing containers that have tactile measuring lines.

Handling Currency

Visually impaired people identify currency by either folding the denominations in different ways or placing them in different areas of a wallet or purse. Bills should be individually identified and counted as they are handed to the patient.

It is not necessary to identify coins. The different sizes and edges of coins provide aids to identification for the visually impaired person.

Credit cards should be handed to patients after imprint, not simply laid on a counter or table.

A piece of cardboard or a plastic or a metal signature template can be used to indicate where the signature is required on credit card slips. Ask the patient, “May I show you where to sign?” Then guide their pen hand to the template edge where the signature line begins. Signature templates are available at no charge from the Earle Baum Center of the Blind.

Orientation and Mobility

Do not leave doors ajar.

Tell the visually impaired or blind patient if you move any furniture or equipment.

When moving a person into a hospital room, let him examine the furnishings in the room. An adequate orientation for a patient at the beginning can foster independence throughout the stay. This can be done by allowing him to trail the wall to learn the order of the doorway to the hall, the doorway to the bathroom, the windows, chairs, closet, etc.

Orient the person to the controls of the bed, paging system, TV and radio. Give other directions that are important, such as, “When you are facing the sink, the toilet is on your left. When you are seated on the toilet, the paper is on your right.”

When dealing with specific orientation to objects like chairs, the sink, and other fixtures, remember the patient sees with his hands. Don’t assume you know what the patient needs simply by observing behaviors.

Do not touch or remove mobility canes unless requested to do so. Do not interfere with guide dogs. If the person is accustomed to using a cane, he or she can be encouraged to use it in her room if she wishes. If it is necessary to remove a cane, tell the person you are removing it and where it can be retrieved.

If you leave a person alone in an unfamiliar area be sure he or she is near something to touch to maintain contact with the physical environment.

Communicating in an Emergency

The universal sign for communicating an emergency to a deaf blind individual is by drawing the letter X on the back of the person with the fingertips.

If the individual has a guide dog do not interfere with the owner’s control of the animal.

It is important, even in emergencies, to guide visually impaired individuals calmly and at a normal pace.

There are personal alert systems that convert sounds from sources such as a smoke alarm or telephone into vibrations that can be felt by a person who is deaf blind.

Departing/Discharge

Before you leave a person who has just been moved into a hospital room ask one more time if there is anything you can do to help. He may wish to review how to operate the TV or need some other small assist.

Sighted people use many nonverbal cues that visually impaired people cannot detect. We may smile or wave, for instance, rather than saying goodbye. When you are leaving, tell the person you are going and say good-bye with a touch on the shoulder, a tap on the person’s arm or a handshake.

Staff should be aware of the range of abilities of persons with vision loss and the availability of equipment and devices that can make self-care possible, e.g., talking thermometers, talking blood pressure and glucose monitoring equipment, and dosage measuring devices. A list of sources for these devices is available from the Earle Baum Center.

For the newly blinded patient, whether vision loss is caused by accident, illness, or is incidental to the hospital admission, staff should consult with state and local blindness service delivery agencies to ensure immediate services and continuity of care after discharge. Please contact the Earle Baum Center if you have any questions regarding service providers in your area.

Be sure your patient can perform all self-care tasks required after he leaves the hospital or center. For example, it may be difficult for a low-vision patient and impossible for a blind person to tell if his skin color has changed and, therefore, ascertain that it is necessary to apply the ointment prescribed. In these and similar instances, be sure the patient has alternative methods to use (e.g., if the skins feels crusty) in taking care of himself or has someone to assist him after discharge.

Additional Accessibility Suggestions

The information contained in a web site should be equally accessible to all members and potential members, whether sighted or otherwise. An option can be included on the site to allow users to provide specific information on how to better accommodate their particular disability.

All information currently provided via newsletters, flyers, membership forms, info cards, brochures, etc., should be in accessible formats for the visually impaired, including procedures for securing assistance, if desired, when entering your facility.

Be cognizant and sensitive to problems of glare, ambient lighting, and white noise that can interfere with the patient’s ability to see or hear. By providing another light or turning off an air filter, for example, you can greatly improve the environment and enhance communication for both of you.

Remove all protruding objects (either on the floor or overhead) and any other clutter or obstructions that cannot be safely navigated by an individual with a dog guide or cane.

A national directory of services for persons who are blind, deaf blind, or visually impaired is available from the American Foundation for the Blind.

To ensure continuity of care for the newly blinded child, parents should also be advised of their child’s right to a free appropriate public education provided by the local school district.

Remember that the Earle Baum Center of the Blind is YOUR local resource. Do not hesitate to contact us if you would like any additional information.