The Effect of Therapeutic Communication on the Recovery of Comatose Patients

James Madison University

Fall 2015
Nursing Research
Group 16: Tianna Groulx, Allison Loftus, Chantasy Cottrell, Caroline Cheatham, Olivia DeFillipo,
Lauren Hooper

Introduction
Comatose patients are often treated and talked about as if they are not there. We wanted to
research to see if this type of treatment makes a difference in their outcomes. We wanted to know, can
speaking to a patient as if they are awake and aware, or exposing them to familiar voices, help bring them
back to their baseline? This is an important problem for nursing practice considering nurses are the ones
with patients most of the time and who communicate most with the patients.
Comparison of Articles
All of the articles reviewed were studies of patients in vegetative or comatose states and figuring
out whether or not familiar voices were beneficial in helping the patients return to baseline. In most
studies, patients showed greater response to familiar voices and sounds, showing that there may be an
emotional response occurring while in a coma or unresponsive. One article that was of specific interest
found that a man who spoke only Polish before going into a coma had all English speaking nurses and
when he woke up, he was able to speak English, thereby proving that there was some sort of mental
functioning while he was in a coma (Tapson, 2015). All of our articles had similar outcomes to this one,
proving that auditory stimulation while in a coma is helpful. Most of the articles addressed that higher
frequency of auditory stimulation led to better outcomes than simply intermittent communication with the
patients.
Contrasting Articles
A few differences included the types of familiar auditory stimulation that were used. Some
studies used in-person voices speaking to the patients, while others used MP3 recordings of familiar
voices. The outcomes were also measured using a variety of mechanisms including the Glasgow Coma
Scale, EEGs, vital signs, MRIs, SMART scores, etc. Some of our studies measured whether the patients
could hear while in a comatose state, and others measured whether or not any auditory stimulation helped
the patients return to baseline. Some studies also focused more on how often the patients were spoken to
while some did not really worry about the duration or amount.
Limitations
We believe there has been a general gap in the research that we found, considering many of the
better articles we found were much older and we could not use them for our project. It was difficult to
find many different studies from the recent years that pertained to our topic. A lot of the research studies
that we found also did not hold the research for long enough, and were unable to ever see the long term
outcomes of the patients studied.
A lot of studies had a limitation in the sample sizes and found that they were too small. The mean
sample for the studies was about 21 with the largest sample size being about 40. That being said however,
a lot of the studies also discussed the difficulty in getting families of comatose patients to participate in
the study. Another limitation was the lack of effective ways to measure clinical outcomes and treatment
effectiveness. There is no consistency in the methods used to measure treatment effectiveness, everyone's
baseline is different so it is difficult to compare patients. Time was also a limitation because it is hard to
measure patients outcomes at the same time everyday, for example taking vital signs and measuring the
glascow coma scale. The patients that were being studied did not all enter a coma at the same time so it is
difficult to compare their outcomes. The research should have been done for a longer period of time and

followed all of the patients from the time they entered the coma to the time they got out to be most
effective.

Implications for Nursing Practice

Overall, our studies show how important it is to provide comatose patients with auditory
stimulation in order to improve their chances of returning to baseline. Nurses are advocates for their
patients and play a crucial role in their care. It is important that nurses are aware of the benefits of verbal
communication with comatose patients, especially since nurses are the ones that spend the most time with
the patients. Family education becomes very important in teaching family members to still spend a lot of
time with their loved one and talk to them, even though they are not able to respond to them. As the nurse,
it is also important to still treat your comatose patients as if they are awake and speak to them in similar
ways that you would to your awake patients. When performing any type of intervention, the nurse and
other health care providers should explain what they are doing to the patient. It is also important to not
talk negatively about your patients in front of them even though they seem like they cannot hear.
Conclusion
Overall, we found that verbal communication with comatose patients can have many positive
effects on the level of consciousness and overall degree of recovery. Consistent and honest
communication with your patient and the patients family is always important. Even though the individual
studies varied, none of the studies showed that communication led to a negative outcome. Nurses have the
capacity to heal patients through interventions other than just medicine.

Summary of Studies Evidence Table

PICO: Does therapeutic communication help adult comatose patients in the hospital get back to
their baseline?
1. Table of Evidence
Author/Year
LOE

Sample

Study
Purpose

Variables

Instrument
s with
Validity
and
Reliability

Results/Statistical
Evidence

Tapson, et al.,
(2015)

N=1
middleaged
man;
nonEnglish
speaking

To understand
the cognitive
effects of
communicatio
n during a
comatose
state

Communicat
ion and
comatose
state

Western
Neurologic
al Sensory
Stimulation
Profile
(WNSSP)
and
Glasgow
Coma
Score
(GCS)- all
show
reliability/v
alidity

Neuropsychological
rehabilitationcontributed to
improving
functioning and
quality of life after
traumatic ABI
patient could not
speak English before
his TBI, but when he
awoke after several
years of being in a
coma, he was able to
understand English,
which may be a
result of years of
being spoke to in
English by nursing
staff.

Regularly
speaking to a
comatose
patient may
have a lasting
positive
neurological
effect on the
patient

N=15
twelve
male and
three
female
from 2
acute
rehab
programs
from a
large
urban
communi
ty, all
either

To investigate
neurobehavio
ral and
neurophysiolo
gical effects
related to
sensory
stimulation on
global
neurobehavio
ral
functioning,
arousal, and
awareness.

Sensory
stimulation
and
comatose,
vegetative,
or minimally
conscious
states

Disorders
of
Consciousn
ess Scale
(DOCS),
ComaNear-Coma
(CNC)
scale,
paired ttest,
functional
MRI
(fMRI)
all show

Patients who
received FAST for 4
weeks had more
clinically
meaningful
neurological gains
compared to the
group not receiving
any structured
sensory stimulation

Auditory
stimulation,
rather than no
auditory
stimulation,
improves the
patients
arousal level
and
neurological
outcomes.

LOE 4

Pape, et al.,
(2015)
LOE 2

Summary/Co
nclusion

comatose
,
vegetativ
e, or
minimall
y
conscious
states,
mean age
of injury
that
causes
that state
was 35.1
years
Joo F. F. L.
Simes , Luis
M. T. Jesus,
David Voegeli
, Celso Martins
, Andreia Hall,
David
Simpson, 2012

N=10,
unconsci
ous
patients

To understand
the effects of
auditory
stimulation on
comatose
patients
physiological
parameters
and
monitored
curves

Auditory
stimulation
and
comatose
state

Wilcoxon
test,
Friedman
test, and
ANVOA
(trouble
finding
reliability
and validity
information
regarding
these tests)

Stimulation with a
familiar voice
resulted in greater
changes for the same
parameters during
the functional
assessment and
stimulation phase
and participants also
presented relevant
change during the
presentation and
orientation phases.

Communicatio
n with
comatose
patients can
have a positive
effect on their
recovery

N=40,
unconsci
ous
patients,
mean age
= 34

To examine
the effect of
an SSP on
recovery in
unconscious
patients after
traumatic
brain injury

SSP and
unconscious
patients

SMART
score:
evaluated
with
content
validity
index of .89
and
reliability
coefficient
of .91

Providing repetitive
SSP for 2 weeks can
enhance
consciousness
recovery in
traumatic-braininjured patients

Communicatio
n with
comatose
patients can
have a positive
effect on their
recovery

N=30,
from two
ICU
units, had
to have a
disorder

To identify
the influence
of music and
voice
messages on
patients with

Music and
voice and
comatose
states

GCS and
RSS, the
Fishers
exact test,
t-test, the
Mann-

Significant
alterations in O2
sats, RR frequency,
systolic blood
pressure, diastolic
BP.

Patients with
altered levels
of
consciousness
do have the
ability to hear

LOE 5

Pornnipa
Urbenjaphol,
Chanokporn
Jitpanya,
Surachai
Khaoropthum,
2009

reliability/v
alidity

LOE 2

Puggina,
Claudia, Silva,
Julia, Santos,
Licio, (2011)

LOE 1

of
conscious
ness,
GCS
between
3-8, RSS,
R5 or R6,
have
hearing
function
preserved
, and
written
consent
from
family

disorders of
consciousness
and the affect
on their vital
signs and
facial
expressions

Tavanger,
ShahriaryKalantary,
Salimi,
Jarahzadeh,
Sarebanhassan
abadi (2015)

N=40,
comatose
patients
admitted
ot the
ICU, age
15-75,
GCS less
than 8

To examine
the effect of
family
members
voice on
comatose
patients level
of
consciousness

N=30,
traumatic
and nontraumatic
comatose
patients,
age 1575,
hospitaliz
ed in ICU

To assess
changes in
level of
consciousness
during 14 day
period of
auditory
stimulation by
familiar voice
in comatose
patients

LOE 1

Goudarzi et al.,
(2014)
LOE 3

Whitney
test (trouble
finding
reliability
and
validity)

facial expression:
statistical was found
, there was more
significant results in
the voices of family
members than music
interventions

as proved by
vital signs and
behavior. The
stimulus from
family
members is a
lot higher than
other auditory
stimuli,
showing that
maybe there is
an emotional
involvement
too.

Family
members
voice and
comatose
states

GCS, data
was
analyzed
using the
SpSS-15,
Chi-square
test, t-test,
and paired
test

The GCS from

baseline showed no
statistical
significance on the
1st day. But on the
10th day indicated
significance, there
was a positive
correlation with the
families voice and
the level of
consciousness

Family
members
voice has a
positive impact
on a comatose
patient's level
of
consciousness.

Auditory
stimulation
and
comatose
states

Glasgow
coma scale,
data was
analyzed
using Chisquare,
Fisher
exact,
Freidman,
independen
t t-test.

There was a
statistically
significant
difference between
daily mean level of
consciousness
during 14 days in the
experimental group
(those who received
familiar auditory
stimulation), but in
the control group, no
difference was seen
between daily mean
level of
consciousness
during 14 days

Auditory
stimulation by
familiar voices
may have an
effect on
promotion of
level of
consciousness
in comatose
patients.

Gorji et al.,
(2014)
LOE 2

Alasad J. &
Ahmad M.
(2005)
LOE 5

Wang,
Xiaoyan.,
Zhang, Hao.,
Zhang,
Xiaonian., Sun,
Xinting.,
Zhang, Tong.,
(2015)
LOE 4

Megha M.,
Harpreet S.,
Naveem Z.,
(2013)
LOE 2

N = 13,
traumatic
coma,
GCS less
than or
equal to
8,
admitted
in ICU

To investigate
the impact of
a familiar
voice to
consciousness
level in coma
patients

Familiar
voices and
comatose
patients

Glasgow
Coma Scale
used to
test
reliability/v
alidity

Duration to reach
GCS of 15 was
significantly shorter
in the experimental
group who received
15 minutes of
familiar auditory
stimulus twice a day

Comatose
patients who
receive some
sort of familiar
auditory
stimulus
recover better
than those who
dont.

N=28,
critical
care
nurses
from
three
hospitals,
experienc
e ranging
from 520 years

To investigate
the
experiences
of a group of
critical care
Jordanian
nurses
concerning
verbal
communicatio
n with
critically ill
patients.

Verbal
communicati
on and
critically ill
patients

N/A

Nurses generally
believe that
communication with
critically ill patients
is an important part
of good nursing care
however,
communication was
not effectively or
consistently given
and was seen as a
barrier to getting the
job done.

Lack of
communication
can have
negative
implications on
the patients
physical and
psychological
health, the care
of critically ill
patients should
include
communication
to contribute to
their recovery

N=1, 43
year old
man with
intracere
bral
hemorrha
ge with
persisten
ce VS for
8 months

To observe
changes in
mismatch
negativity and
P300 in a
patient
transitioning
from a
vegetative
state to a
minimally
conscious
state.

Mismatch
negativity
and P300
and
vegetative
states

EEG

MMN was generated

in the frontal and
temporal lobes,
whereas P300 was
generated in the
frontal, temporal,
and parietal lobes.
MMN and P300
might emerge earlier
than previously
believed and
continue in
persistent VS and
MCS.

Shows where
auditory
stimulation
does or does
not improve
the patients
LOF and
outcomes.

N=30,
comatose
patients
with
GCS less
than 8

To determine
whether
frequent
stimulation or
less
stimulation
was more

Stimulation
and
comatose
state

N/A

High frequency low

duration stimulation
tended to be more
beneficial

Demonstrates
the correlation
between
auditory
stimulation and
its benefits for
comatose

beneficial to
comatose
patients.
Pape TL,
Rosenow JM,
Harton B, Patil
V, Guernon A,
Parrish T,
Froehlich K,
Burress C,
McNamee S,
Herrold AA,
Weiss B,
Wang X.,
(2012)
LOE 2

N=25,
with a
TBI, 18
years or
older
from a
rehab
institutio
n

To determine
whether
familiar vocal
stimulation,
provided
during coma
recovery,
improves
outcomes for
persons who
are
unconscious
after severe
TBI.

patients.

Familiar
vocal
stimulation
and
comatose
state

FAST
protocol,
MRI

Individuals who
received familiar
voice stimulation
displayed more brain
activity than those
with non familiar
auditory stimulation.

Demonstrates
how familiar
voice auditory
stimulation is
more
beneficial to a
patient.

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