Another impediment to participation
in decision making is communication
difficulty, which in
the ICU is commonly the result of
orotracheal intubation or tracheostomy
placement. Although patients
may be awake and aware, the voicelessness
imposed by these treatment
modalities significantly impacts the
communication process (BergbomEngberg
& Haljamäe, 1989; Happ,
2000). Communication techniques
and assistive devices are available,
but the degree to which they are
used is unknown. Without successful
communication, patients are excluded
from the dialogue, and instead of
maximizing patient participation in
decision making, a lower standard of
decision making is accepted.