Maintaining Our Humanity Through the Mask: Mindful Communication During COVID-19.

To the Editor:

When it comes to communication, we rely on language at the expense of the rest of our communication toolbox. However, nonverbal communication is just as important as the words we use.1 In times of the coronavirus disease 2019 (COVID‐19) pandemic, the use of face masks has become ubiquitous in many countries.2 Many facial expressions are the same across cultures, like happiness, sadness, anger, and fear, and our faces can express emotions without saying a word. Given widespread masking, this nonverbal communication has become increasingly difficult.

The COVID‐19 pandemic for older, frail, and cognitively impaired patients in particular is challenging.3 For example, it must be jarring for older people to discuss serious challenges, such as the importance of advance care planning or decisions about do‐not‐resuscitate orders, with a physician wearing a face mask.4

Nonverbal communication is thought by many to be the most effective element of communication to connect with a person who has dementia.5 Though people with dementia increasingly lose the ability to communicate verbally, body language skills are retained longer than verbal skills in the vast majority of forms of dementia. People with dementia are usually able to interpret facial signals correctly: they interpret a smile as a sign of joy and compressed lips as a sign of anger. They can tell from the sound of our voice, our posture, and our speed whether we are relaxed or stressed, in a good mood or angry. A lot of this is missing right now—and many of us do not even realize it!

Physicians and nurses who are more sensitive to nonverbal cues reinforce the perception of sincerity, dedication, and competence, which, in turn, improves measures around utilization of health services, functional status, and the overall provider‐patient relationship.6 Nonverbal communication is a unique opportunity to connect. Therefore, it is important that we take intentional control of our nonverbal communication in this time of social distancing and masked faces.

The following three steps, based on our ABC mnemonic, can, when embraced with intentionality, positively impact healthcare providers' interactions with older patients.

Attend Mindfully

Create a ritual to focus your attention before a visit1 and reflect on the many asymmetries in communication with older patients: expert‐layperson, healthy‐sick, independent‐dependent, cognitively healthy–cognitively impaired, young‐old.7 It is important that we think about the ways that we typically communicate, in gesture and tone, when not constrained by distance and personal protective equipment. Once we become more aware of our characteristic gestures and body language, we can then go about aligning our nonverbal signaling with our spoken message. If we do not practice the habit of underlining everything we say with gestures and pantomime, the message we convey might be harder to interpret.

Behave Calmly

People, especially those with functional or cognitive limitations, will become more familiar with you when they feel like they are being respected. By approaching them from the front, you will give older people a chance to process who you are and what you are asking. Respect the person's personal space but make sure to drop down to eye level; this will allow the individual to feel more comfortable and in control of the situation. Since a person with dementia will be able to detect your body language, sudden movements can cause distress on the person and can make it hard to communicate. Therefore, project a positive, calm attitude and avoid body language that shows frustration, anger, or impatience, while trying not to interrupt them and give them your full attention.

Communicate Clearly

Avoid noise and overwhelming stimulus and make sure the older person is wearing glasses or hearing aids, if needed, then slowly communicate one point at a time. Use short, simple sentences and underline your words with gestures. Make your statement or ask your question and then pause. Keep your voice even, tone gentle, and speech slow. Speak louder, if needed, because the lip‐reading cues that many with hearing disabilities use to compensate will be absent. Sometimes, it might be helpful subtly matching the gestures and tone of the older adult to help them feel understood. Observe first, then try mirroring the person’s mood or tone, or using a quieter approach.

Greater training efforts are necessary to improve perception and interpretation of patients' nonverbal communication and to enhance clinicians' awareness of their own displays of nonverbal behavior. Let us use the pandemic to remember why we have chosen the beautiful field of medicine and, as E. M. Forster said many years ago in Howards End, “Only connect…!”