Providers don’t always meet ethical obligations for patients with limited English proficiency
Problem is ongoing but "has gotten harder"
Approximately 62 million Americans speak a language other than English at home, and 25 million have limited English proficiency (LEP), notes Glenn Flores, MD, FAAP, director of the Division of General Pediatrics at University of Texas (UT) Southwestern and Children’s Medical Center Dallas (TX). Flores is director of the American Pediatric Association’s Research in Academic Pediatrics Initiative on Diversity.
"A substantial body of literature, from decades of research, documents the often profound adverse impact of language barriers on health and health care," says Flores. These include access to care, health status, use of health services, quality of care, patient-physician communication, satisfaction with care, and patient safety.1,2
"Language barriers are associated with significantly higher odds of prolonged lengths of stay for hospitalizations, and serious medical events during hospitalizations," notes Flores.
Many studies, however, link the use of trained professional interpreters and bilingual clinicians with optimal communication, patient satisfaction, and quality of care for LEP patients and their families.3
"Therefore, one of the most important ethical obligations is to ensure that every LEP patient is provided with a trained professional medical interpreter or bilingual clinician," underscores Flores.
Many providers are still unclear that the onus of providing effective care across a language barrier is on them, says Alicia Fernandez, MD, a professor of clinical medicine at University of California, San Francisco.
"We need to ensure we use professional interpreters, and that we do not cut corners in care because of the hassle factor involved in obtaining and working with interpreters," she emphasizes.
"Huge ethical challenges"
Providers not meeting their ethical obligations to communicate with LEP patients is "not a new problem," says Elizabeth Heitman, PhD, a faculty member of Vanderbilt University Medical Center’s Center for Biomedical Ethics and Society in Nashville, TN, noting that her 1988 dissertation addressed this topic.4
"It is an old problem that still poses huge ethical challenges, and it has gotten harder," she says. This is not just due to increased numbers of immigrants, but also because of the increased diversity of languages used by immigrant and refugee populations.
"There are probably lots of unrecognized ethical problems in the care of patients who don’t speak English," says Heitman. All the same ethical challenges that exist for English-speaking patients are there for LEP patients, she says, but are further complicated by miscommunications and cultural barriers, particularly with end-of-life care.
Here are some potential obstacles in providers’ meeting their ethical obligations to LEP patients:
- It is difficult for providers to communicate at the same level with an LEP patient as they would with an English-speaking patient.
"This is horrifically hard to do in a lot of contexts," says Heitman. "Even the best communication through an interpreter takes longer and may be less complete." There is no getting around the fact that having patients participate in discussions about their care is logistically much harder when they don’t speak the same language as the provider, she adds.
Providers often view access to qualified interpreters solely as a patient’s right, adds Heitman, but "providers themselves have an ethical and legal responsibility to make sure that they understand their patients fully."
- Hospitals struggle with financing of interpreter services.
Skilled interpreting can be expensive, and is rarely covered by insurance. Hospitals that can’t afford to have in-house interpreters typically contract with off-site telephone interpreting services, says Heitman. Another option is for hospitals to certify bilingual staff to serve as medical interpreters, but staff may be reluctant to do so if their additional work is not recognized and if no additional compensation is offered.
"A lot of hospitals don’t recognize that the ability to communicate professionally in another language is a skill," says Heitman. If a hospital relies on bilingual staff to work with LEP patients, the institution should certify that the staff member can actually work at a professional level in that additional language, and pay them for that skill, she advises.
- Some facilities use "ad hoc" interpreters to provide language assistance, including children, family members, friends, or un-trained medical staff.
"Despite the number of LEP Americans and federal policy requiring providing adequate language assistance to LEP patients, many LEP patients do not receive professional medical interpretation," says Flores.
Although family members and friends may know the patient well, they are put in an "awkward and unfair" position when pressed into service as interpreters, says Margaret R. McLean, PhD, director of bioethics at Markkula Center for Applied Ethics at Santa Clara (CA) University.
Family members usually lack an understanding of the language of medicine, she explains, and often have a large emotional stake in the situation.
"There are a lot of problems with using uncertified translators," says Heitman. There is no way for providers to determine how well the family member speaks the patient’s language, or if he or she understands the medical information or is translating it accurately.
Some institutions have patients sign a waiver if they request that a family member translate for them instead of an interpreter. "Waivers don’t eliminate the providers’ responsibility to gather and convey accurate health information," says Heitman.
If the patient wants to rely on a family member to translate, says Heitman, the caregiver should still have a qualified interpreter present to ensure that the appropriate information is being communicated.
- Language barriers can cause confusion during ethics consults.
Ethics consultants are typically not accustomed to working with interpreters, but need to learn how to do so, advises Heitman. A member of Vanderbilt’s interpreter services staff sits on the hospital’s ethics committee.
"We have had several consults where we had to bring in an interpreter," says Heitman. Under medical interpreters’ own ethical standards, she notes, interpreters should convey the words being spoken, rather than using their own words to explain the concepts being discussed.
Adding explanatory or editorial comments can be perceived as interfering. "An interpreter can say, Stop, I need an explanation of this concept,’ to be sure that they understand what the clinician means." Likewise, the ethicist needs to recognize where there may be a cultural issue that needs to be spelled out for the patient or provider.
- Some clinicians believe their ethical duty to provide adequate language services to LEP patients and their families ends after the office visit, hospital encounter, or procedure is completed.
"A key ethical consideration is that LEP patients and their families have comprehensive, door-to-door’ language access," underscores Flores. He recommends these practices to ensure ethical care:
- Facilities should have multilingual operators and phone trees for making appointments; and provide multilingual signage, consent forms, and patient information materials.
- Clinicians should have interpreters write discharge instructions for patients and their family in their primary language.
- Pharmacists should print prescription instructions in the patient/family’s primary language.
- Interpreters should accompany the patient to procedures, imaging, lab procedures, and to schedule follow-up appointments and referrals.
"A professional medical interpreter also should always be present for discussions regarding end-of-life care, advance directives, palliative care, and life-support decisions," says Flores.
Providers need to ensure that other areas of the health system also provide language access services so that LEP patients can, for example, make an urgent care appointment or obtain interpretation of a complex radiology procedure.
"Our ethical obligation to provide language access services transcends our encounter with the patient, and encompasses other essential health services," says Fernandez.
- Flores G, Abreu M, Barone CP, et al. Errors of medical interpretation and their potential clinical consequences: A comparison of professional vs. ad hoc vs. no interpreters. Ann Emerg Med. 2012;60:545-53.
- Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 2003;111:6-14.
- Flores G. The impact of medical interpreter services on the quality of health care: A systematic review. Med Care Res Rev 2005;62:255-299.
- Heitman, Elizabeth. (1988) Caring for the silent stranger: Ethical hospital care for non-English speaking patients. Doctoral Thesis, Rice University. http://hdl.handle.net/1911/16151.
- Alicia Fernandez, MD, Professor of Clinical Medicine, University of California, San Francisco. Phone: (415) 206-5394. E-mail: firstname.lastname@example.org.
- Glenn Flores, MD, FAAP, Director, Division of General Pediatrics, UT Southwestern and Children’s Medical Center Dallas (TX). Phone: (214) 648-3405 Fax: (214) 648-3220. E-mail: Glenn.Flores@UTSouthwestern.edu.
- Elizabeth Heitman, PhD, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 936-2686. Fax: (615) 936-3800. E-mail: email@example.com.
- Margaret R. McLean, PhD, Director of Bioethics, Markkula Center for Applied Ethics, Santa Clara (CA) University. E-mail: firstname.lastname@example.org.