“It seems like I am going to die in a moment when I felt I can only breathe on a machine, people trying to resuscitate me, hearing the alarms, noise of so many instruments, people coming and going out of my room, opening and closing the door. Suddenly I heard a voice telling me what's going on with me. When God gave me another chance of living my life, I was so desperate to meet and listen to that voice which every day was assuring me courage and strength of fighting for my life. Finally, one day when I was cured, with the sense of her touch and voice, I was able to recall and recognize her.”

Communication with critically ill patients has an essential significance and it is very challenging, especially when the patient is sedated, ventilated and unable to speak. Therefore, in this extremely difficult situation, verbal communication and touch is a measurable means of conveying messages ( Reed, Rrineck, Fonseca, 2011). Effective communication is a keystone of the nurse patient relationship. It takes many forms and it is more than just talking and listening. Communication is a process which can enable the nurse to establish a human to human relationship and thereby fulfill the purpose of nursing. Health care professionals deal with a human being who needs respect and care which can be done by effective communication. The importance of communication and its impact on patient outcomes are also recognized by several entities, including The Joint Commission, American Association of Critical-Care Nurses (AACN), Society of Critical Care Medicine (SCCM), and the National institute of Health (NIH). Recent recommendations from the American College of Chest Physicians and the AACN focuses on the importance of skilled communication as an essential element of providing care for acute and critically ill patients ( Joint Commission guide to improving staff communication, 2009).

It has been frequently observed that health care professionals do communicate with conscious patients regarding their diagnosis, treatment, discharge teaching and care related aspects. However, when it comes to communicate with an unconscious patient, healthcare professionals assume that patients are not in their senses to understand; therefore, they do not communicate with patients. Healthcare professionals often face exceptional challenges in dealing with patients who are vented and lack good communication ( Puggina, Silva, Schnakers, & Laureys, 2012 ). Critically ill patients who require mechanical ventilation are frequently treated with sedatives and analgesics because pain and agitation are common experiences for most ICU patients; mostly they remain unconscious for a specific period of time until they recover from their illnesses ( Ruth et.al., 2008). Surgical incisions, indwelling vascular catheters, endotracheal suctioning, and mechanical ventilation are all potential sources of pain for patients. These interventions require sedation and analgesia, however, majority of the doctors and nurses do not communicate with patients during care or while providing any interventions especially when they are unconscious. A study conducted by Cardim, Costa, Nascimento, and Figueiredo (2004) revealed that 90% of the care for the unconscious patients were performed by healthcare professionals in silence and interaction with the patients in a coma were rare. Communication is not only the way to give respect to the patients, but also their right to be known about the interventions taking place with them. Health care professionals assume that the patient is unable to hear, but it is not necessary that they do not understand. Unconscious patients have no control over themselves or their environment and thus are highly dependent. Mostly it has been noticed that doctors and nurses do communicate in assessing neurological status, however while giving care, they don't interact that provides orienting and meaningful sensory input to the patients.

Literature reveals nursing unconscious patients as a challenging experience. On the other hand, patients do recall their experience after regaining consciousness. According to Baker and Meley (1996), the last sense of a human being to go is hearing becomes unconscious. A number of studies have reported that patients do hear and understand healthcare professionals' conversation when they regain their consciousness while they were unconscious ( Tosch, 1988; Podurgiel, 1990).

There are two ways of communication: verbal and nonverbal communication. Helwick (1994) stated that verbal communication helps to stimulate the brain's reticular activating system, and maintains a person's conscious state. According to Alasad and Ahmad (2005), unconscious patients could hear and respond emotionally to verbal communication. One patient, when being neurologically assessed, “understood the nurse's request tso squeeze her hand but was unable to move”. Another stated: “I could think and I could hear, but I could not move and I could not talk or open my eyes”. Unconscious patients may have a normal auditory response. If one stops talking to them, they may not be likely to recover early which increases their sense of vulnerability. On the other hand, nonverbal communication such as eye contact, facial expression, posture, bodily contact and personal space is important in nurse-patient interaction. Touch with comforting words can be a significant means of providing reassurance. However, touch can be perceived as threatening or invasive in some aspects of care. It is essential that nurses should communicate gently to unconscious patients, explaining all procedures and maintaining dignity at all times even when family is not present (Leigh, 2001).

There are many factors facilitating communication with unconscious patients. It is important to inform unconscious patients regarding their presentation, identification and orientation to time, place and person. Moreover, patients have a right to be informed about current affairs, diagnosis, treatments, medical and nursing interventions, and about important events that they are experiencing. Working with unconscious clients and not making them aware of the surroundings is questioned on moral and ethical grounds. Another facilitating factor is that, communicating with unconscious clients help to assess their functional capacity and provide strong verbal stimulation (Jesus, Simoes & Voegeli, 2013) . Communication does facilitate in reducing stress and psychological anxiety among patients when nurses personalize their care by even addressing the patient's name, using alternative communication methods and meeting his or her individual needs. Alternative communication methods always guide nurses through assessment of the patient's level of consciousness, cognitive level, language ability, fine and gross motor skills. It is also recommended that orientation, touch, and reassurance strike the balance in providing physical and psychological needs. Moreover, it prevents unnecessary distress which can lead to remarkable recovery. On the other hand, factors which contribute in limiting communication are work overload, unstable condition of the patient, personal problems and worries of the health care providers.

Communicating with unconscious patients or comatose patients is always challenging for healthcare professionals. However, verbal and non-verbal communication is considered to be an integral part of health care practice. It requires skills and continuous interaction with clients to produce a strong verbal response. It is the right of every client to be informed about their condition at all times. Therefore, it is important to educate healthcare professionals about the benefits of verbal communication with unconscious patients.