The Case

An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home in addition to other medications. Before leaving the hospital, he was given written information sheets regarding his medications and received counseling from a nurse and a pharmacist. They did not notice that the patient was blind.

Several days after discharge, the patient called the primary care triage nurse and stated that he had been discharged with a bag of medications and some injections, but that he could not administer them because he could not read the instructions.

After retrieving his chart, the triage nurse noted that the patient was blind and, upon questioning, also learned that he lived alone. The patient was subsequently readmitted to the hospital for continuation of anticoagulation therapy.

The Commentary

More than 1 million persons age 40 and older living in the United States are legally blind (best corrected central visual acuity of ≤ 20/200 or a field of vision of ≤ 20 degrees).(1) Another 2.4 million have impaired vision (best corrected visual acuity ≤ 20/40). Most persons who are blind have some usable vision that allows them to navigate their environments and perform daily activities. After refractive error, the most common causes of impaired vision relate to aging, including diabetic retinopathy, aging-related macular degeneration, cataracts, and glaucoma. Given this association, the number of adult Americans with visual deficits will likely double over the next 30 years.(1) Clinicians treating elderly individuals should routinely ask patients about their vision. In addition to its importance for reading printed material and performing tasks requiring manual dexterity (eg, self-administering injections), vision is crucial for other activities, such as safe ambulation and driving.

Blindness and low vision affect health care quality and access in many specific ways.(2,3) In 2001, 21.4% of working-age persons reporting blindness or major vision problems lacked health insurance, compared with 15.0% of those without sensory or physical disabilities.(2) Persons who do not drive and rely exclusively on public transportation and taxis may face challenges finding local providers, especially in suburban and rural areas with few transportation options. Once inside facilities, persons can have difficulties independently navigating spaces if signage is not readily visible in large, braille, or raised print, and if audible direction and floor indicators in elevators are not provided. Untrained staff can present a range of problems, including failing to convey respect (eg, not introducing themselves, speaking excessively loudly, addressing patients’ companions rather than patients), compromising patient privacy (eg, by helping patients to complete written forms in public settings, like waiting rooms), inappropriately assisting patients (eg, grabbing elbows to maneuver patients to examining rooms), and not informing patients before touching them. Patients report rarely obtaining written information—ranging from discharge instructions to labels on medication bottles—in accessible formats.(2,3) Patients are therefore often ill informed, risking both their safety (eg, from misidentifying medications) and well-being (eg, from being unaware of medication side effects).

Training staff—at all levels—about interacting and communicating effectively and respectfully with persons with blindness and low vision is essential.(4) Many recommendations reflect simple “common sense,” such as introducing oneself upon entering rooms, asking patients what types of assistance they desire, not touching or interfering with white canes or guide dogs, describing procedures verbally before starting, and informing patients before touching them. Staff should provide written and instructional materials in patients’ preferred accessible formats, including large print, braille, audiotape, computer diskette, or CD ROM. Some patients also wish to audiotape discussions with clinicians to replay later.

In this case, counseling provided by a nurse and a pharmacist was ineffective because they did not realize that the patient was blind. Preventing this error simply required asking the patient respectfully about his eyesight and ability to read, understand, and follow written instructions. (His medical record apparently noted his blindness; reading records is also always a good idea!) Many blind persons live alone, as did this patient, leading independent lives. Their vision deficits may not be noticed simply by observing them seated and at rest. Clinicians should always assess patients’ ability to see, especially when expecting persons to perform complex tasks such as self-injecting medications. Such assessments are especially crucial for elderly persons, who have high rates of vision loss. Giving the patient written information—in an inaccessible format and without actually showing him how to perform the injections—was clearly insufficient. At a minimum, the clinicians should have asked the patient to verbally repeat (“teach back”) their instructions to make sure he understood them. Even better, after explicitly training him in injection techniques, the clinicians should have watched the patient repeat the task independently, without coaching or assistance. Observing patients carefully during this process should generally identify potential problems.

When teaching needs to be reinforced, clinicians should offer written and instructional materials to patients in their preferred accessible formats, such as large print (14-point font or larger), braille, audiotape, computer diskette, or CD ROM. Numerous devices now exist to help patients with vision impairments accomplish self-care activities, such as insulin delivery equipment, glucose monitoring devices, pill minders, talking watches, various magnification devices, and computers with voice capabilities.(5) Physical and occupational therapists who specialize in visual disabilities can work with persons who are blind or low vision to devise ways to perform care-related tasks. Web sites of the American Foundation for the Blind (6), National Federation of the Blind (7), medical supply vendors, and other organizations (5,8) provide additional information about products and services.

Take-Home Points

• Clinicians must observe and proactively and respectfully ask patients about any factors that might affect their ability to perform self-care tasks. Clinicians should not assume that all patients can read, understand, and follow written instructions.
• When patients identify factors that might impede self-care, clinicians must ask patients about their preferences for accommodating their needs.
• Clinicians should observe patients performing manual tasks independently and without coaching before completing initial training.
• Clinicians should follow up with patients shortly after discharge, to determine whether they are successfully performing self-care activities and to identify any questions or problems.

Lisa I. Iezzoni, MD, MSc Professor of Medicine Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center Department of Medicine, Harvard Medical School

References

1. Vision Impairment. National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/ncbddd/dd/ddvi.htm. Accessed October 20, 2005.

2. Iezzoni LI, O’Day BL. More than Ramps: A Guide to Improving Health Care Quality and Access for People with Disabilities. New York, NY: Oxford University Press; 2006.

3. O’Day BL, Killeen M, Iezzoni LI. Improving health care experiences of persons who are blind or low vision: suggestions from focus groups. Am J Med Qual. 2004;19:193-200. [ go to PubMed ]

4. Marshall S, Joffee E. ADA Checklist: Health Care Facilities and Service Providers. Ensuring Access to Services and Facilities by Patients Who Are Blind, Deaf-Blind, or Visually Impaired. American Foundation for the Blind Web site. Available at: http://www.afb.org/Section.asp?SectionID=3&TopicID=136&DocumentID=529. Accessed October 20, 2005.

5. Goldzweig CL, Rowe S, Wenger NS, MacLean CH, Shekelle PG. Preventing and managing visual disability in primary care: clinical applications. JAMA. 2004;291:1497-1502. [ go to PubMed ]

6. American Foundation for the Blind Web site. Available at: http://www.afb.org. Accessed October 20, 2005.

7. National Federation of the Blind Web site. Available at: http://www.nfb.org. Accessed October 20, 2005.

8. Lighthouse International Web site. Available at: http://www.lighthouse.org. Accessed October 20, 2005.