Informed consent and language barrier

[leaverus]

So at my new gig a high percent of the population speaks no english - it's either spanish or occasionally polish. I speak no spanish and there is no interpreter readily available to translate for me. Technically, there is an interpreter in house but if i requested one every time, i'd be delaying many cases; and as the new guy who is not familiar with most of the surgeons yet, i don't want to make a bad impression either. yet, getting a proper informed consent is important to me - i usually explain everything in detail to my patients and make sure they understand and have opportunity to ask questions. anyone else in a similar situation - what are you doing? anyone using any of the android/ios translation tools that are available? is that an acceptable (medicolegally) way to obtain consent? i'm not really sure what my colleagues are doing - some of them appear to speak rudimentary spanish and i assume the others simply don't care. oh, a few times i've asked the patient transporters who speak fluent spanish but i hate to use them - it's not their job function.

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[WholeLottaGame7]

So at my new gig a high percent of the population speaks no english - it's either spanish or occasionally polish. I speak no spanish and there is no interpreter readily available to translate for me. Technically, there is an interpreter in house but if i requested one every time, i'd be delaying many cases; and as the new guy who is not familiar with most of the surgeons yet, i don't want to make a bad impression either. yet, getting a proper informed consent is important to me - i usually explain everything in detail to my patients and make sure they understand and have opportunity to ask questions. anyone else in a similar situation - what are you doing? anyone using any of the android/ios translation tools that are available? is that an acceptable (medicolegally) way to obtain consent? i'm not really sure what my colleagues are doing - some of them appear to speak rudimentary spanish and i assume the others simply don't care. oh, a few times i've asked the patient transporters who speak fluent spanish but i hate to use them - it's not their job function.

With no in-house interpreter, I'd use one of the telephone interpreting services. We have a "blue phone" system that connects to an interpreting service. Even though we have in-house interpreters, I'll still use that occasionally because sometimes the live person is trapped in the ED. If I recall, many of the major telephone providers (AT&T, etc) provide interpreting services, though you'd have to look into that.

I think using a non-official means of interpreting is asking for trouble. Patient transporters, family members, your high school Spanish, all could come back and bite you in the ass.

I've also found that it's not just the language barrier you have to overcome, it's an educational barrier, especially those patients that come from the sticks of Latin America. I'm on L&D right now, and I'll end up spending 15 minutes just trying to explain an epidural (in as simple terms as I can imagine), and I'm not convinced they understand the concept or the process.

 

[leaverus]

With no in-house interpreter, I'd use one of the telephone interpreting services. We have a "blue phone" system that connects to an interpreting service. Even though we have in-house interpreters, I'll still use that occasionally because sometimes the live person is trapped in the ED. If I recall, many of the major telephone providers (AT&T, etc) provide interpreting services, though you'd have to look into that.

I think using a non-official means of interpreting is asking for trouble. Patient transporters, family members, your high school Spanish, all could come back and bite you in the ass.

I've also found that it's not just the language barrier you have to overcome, it's an educational barrier, especially those patients that come from the sticks of Latin America. I'm on L&D right now, and I'll end up spending 15 minutes just trying to explain an epidural (in as simple terms as I can imagine), and I'm not convinced they understand the concept or the process.

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

 

[deleted9493]

If you've got your consent form in the native language of the patient, they can read it and sign it. If they have questions, you're obligated to get an interpreter's assistance but I'd suspect that the majority of adults won't. If they're illiterate in their native tongue, again, I think from an ethical standpoint it is on you to describe what is at hand in terms that they can understand.

Documented informed consent does seem to reduce litigation--or at least you're not dinged for a lack of it when being litigated for something else: http://ppmrrg.com/FileUploads/Issue16.pdf

The last page of that pdf shows a pretty thorough example of form that you could have translated, if your hospital doesn't have an institutional form in Spanish.

 

[WholeLottaGame7]

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

We do have in-house translators, but overnight there is only one and they are oftentimes stuck in the ED for hours on-end. Thus, it is occasionally quicker to use the phone system. It's a two-phone system, which is nice, and really doesn't take any longer than having an interpreter in the room.

And I'm curious as to what I don't understand? That time pressures in private practice outweigh the importance of informed consent?

It kind of sounds like you just want people to reply back with "yeah man, just go with whatever's fastest and most convenient, that's what we do."

 

[pgg]

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

If there are that many patients who require an interpreter and there's no mechanism in the hospital to make it easy and efficient, the problem is the institution, not you.

I don't have much else constructive to say, except to sympathize that you wound up at a place that seems to practice in a substandard way. You can try to change that culture (maybe get risk management involved - the HOSPITAL should make translation services available). Or you can do the right thing and take your time.


I feel your pain, my moonlighting job has a high % of non-English speaking patients, many poorly/non educated. We have a number of preop and periop nurses who speak Spanish and 24/7 phone translation service. No one ever gives me crap about short delays for consent.

I don't speak Spanish. Grew up in southern California and still haven't forgiven my parents for allowing me to take German in high school. I've got a copy of Rosetta Stone and some time on my hands now though.

 

[Mman]

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

I'm in PP and use a "blue phone" when an interpreter isn't available. It doesn't slow down anything if the nurses know to have it ready. Besides, it should be one with 2 handsets so there is no passing back and forth.

Legally you have no ground to stand on if a qualified interpreter isn't available for your informed consent. I mean if you can't inform them and can't answer questions, you haven't obtained consent.

 

[ssmallz]

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

Lack of time is no reason to miss the informed consent. If you feel there is something pertinent that your pt is missing then it is your duty to make sure IC is obtained. A malpractice lawyer will love to hear how you are too busy to explain the details for informed consent. Your surgeon and hospital certainly won't support you and you'll be paying out quite a settlement with no ground to stand on.

 

[IlDestriero]

I'm in PP and use a "blue phone" when an interpreter isn't available. It doesn't slow down anything if the nurses know to have it ready. Besides, it should be one with 2 handsets so there is no passing back and forth.

Legally you have no ground to stand on if a qualified interpreter isn't available for your informed consent. I mean if you can't inform them and can't answer questions, you haven't obtained consent.

This.
You are obligated to get informed consent. If it takes a few extra minutes it takes a few extra minutes. The "language line" and two handset phone are no slower than an interpreter, and sometimes faster when the interpreter is delayed.
They have every language you can ask for and it only takes a minute to get it going.
The hospital should provide this service and the phones. We have a set on every unit, asc, and several in pre op. They augment the army of translators.

 

[soorg]

Simple solution: no English = no surgery.

 

[jwk]

if you're a resident as your avatar indicates, then you wouldn't understand - using the phone system isn't an option; i'm in pp and getting an interpreter on the phone and passing it back and forth for every other patient would cause signifcant delays in the OR schedule and quickly get me fired. i'm a little surprised you're in an academic setting and they don't provide in-house translators??

Although I'm a Neil Boortz "if you live in this country speak English" kinda guy, it's not that simple for hospitals and providers. I would think most would understand this, attending or otherwise, even if you don't like it.

Interpreters and/or interpretation services is a requirement of The Joint Commission. Like it or not, agree or not, you're stuck.

http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/24954

You can't possibly have enough interpreters in-house to satisfy that requirement. Sure, you might have a Spanish interpreter (the most common) but how many other languages are spoken by patients that come to your hospital? And even then, do you have an interpreter available 24/7? We're a big hospital - we don't.

Language lines (by whatever name) are the only way you can manage these requirements. I don't know the cost, but apparently they're not cheap - I assume they charge by the minute or some other timed interval. I hear private practice docs complain because the cost of interpretation services for a patient visit can exceed the cost of a patient visit. Unfortunately, if you're on a managed care plan or a preferred provider for a given insurance company, you don't get the option of turning down patients because of a language barrier - you're expected to take anyone and everyone if they're covered.

For the OR and anesthesia, we try and get the pre-op nurse, circulator, and anesthesia together at one time and make a single call and get all the info and consents needed in that one call. Is it a pain? Absolutely. But it's necessary.

And c'mon - informed consent (although you can debate it's value) is truly worthless if the patient doesn't speak or read the language in which you offer it.

 

[Consigliere]

I'm gonna give you some useful advice, leaverus:

Do what the more senior partners do - it's that simple. If they are blasting through the consent, then you do the same. If they are taking 15 minutes going over it for every non-English speaking pt, you do the same. Bottom line: you're the new guy, do what the "old guys" do. Simple as that.

 

[Arch Guillotti]

I'm gonna give you some useful advice, leaverus:

Do what the more senior partners do - it's that simple. If they are blasting through the consent, then you do the same. If they are taking 15 minutes going over it for every non-English speaking pt, you do the same. Bottom line: you're the new guy, do what the "old guys" do. Simple as that.

Have to agree here. If I spent too much time on really getting a true informed consent for most cases I would be crushed otherwise by the workload.

 

[IlDestriero]

I'm gonna give you some useful advice, leaverus:

Do what the more senior partners do - it's that simple. If they are blasting through the consent, then you do the same. If they are taking 15 minutes going over it for every non-English speaking pt, you do the same. Bottom line: you're the new guy, do what the "old guys" do. Simple as that.

If "you sleep, they cut, you wake up again" is the standard at your shop, good luck with the nuisance suits. Suddenly no informed consent is the centerpiece of the jury trial instead of a dismissal or a quick simple (low $$$) settlement for the broken tooth or whatever.
If production pressure is so high that you can't take 5 minutes to get informed consent (and make a great impression on the family as a caring and competent physician) you have serous problems.

 

[WholeLottaGame7]

WWUTSWD? (What would UTSW do?)

 

[leaverus]

If "you sleep, they cut, you wake up again" is the standard at your shop, good luck with the nuisance suits. Suddenly no informed consent is the centerpiece of the jury trial instead of a dismissal or a quick simple (low $$$) settlement for the broken tooth or whatever.
If production pressure is so high that you can't take 5 minutes to get informed consent (and make a great impression on the family as a caring and competent physician) you have serous problems.

i'm confused. why would there be lawsuits for lack of "informed consent?" i never said anything about there being a lack of consent altogether. the paper consent form is always signed by patient, surgeon, and anesthesiologist. i could simply take the easy way out: sign the form, never even talk to the patient, and just proceed with the cases. who's to say that a discussion of anesthetic risks, etc never took place? but i have a moral obligation to discuss that stuff with my patient so my question is how do i do that and still "go with the flow" they've established here for the past 50 years?

pgg: i'm sure your german is FAR more useful than the 4 years of french i completely wasted my time with in HS. hasn't even helped me pick up any french girls...

 

[Mman]

Have to agree here. If I spent too much time on really getting a true informed consent for most cases I would be crushed otherwise by the workload.

I'm not sure how it's possible to be too busy with workload to be bothered with getting informed consent. It doesn't take that long and you can't be that busy doing something else. I mean I can supervise 4 rooms and go place some labor epidurals, be present for every induction, trouble shoot in PACU, place a-lines and CVPs as needed, and still get informed consent on 100% of cases. It's not that hard.

 

[Monty Python]

So at my new gig a high percent of the population speaks no english - it's either spanish or occasionally polish. I speak no spanish and there is no interpreter readily available to translate for me. Technically, there is an interpreter in house but if i requested one every time, i'd be delaying many cases; and as the new guy who is not familiar with most of the surgeons yet, i don't want to make a bad impression either. yet, getting a proper informed consent is important to me - i usually explain everything in detail to my patients and make sure they understand and have opportunity to ask questions. anyone else in a similar situation - what are you doing? anyone using any of the android/ios translation tools that are available? is that an acceptable (medicolegally) way to obtain consent? i'm not really sure what my colleagues are doing - some of them appear to speak rudimentary spanish and i assume the others simply don't care. oh, a few times i've asked the patient transporters who speak fluent spanish but i hate to use them - it's not their job function.

Currently working on dual MHA and MBA degrees, and we discussed this very topic at length during last semester's healthcare jurisprudence course. The three instructors were all lawyers, all with certification in healthcare law, and with about a century of experience between them. The gist of their comments:

As JWK stated, interpretative functions are a requirement of JCAHO. No ifs, ands, or buts about it.

Informed consent primarily just protects you against an unfounded charge of battery. It won't protect you from getting sued.

Absent a true emergency you must get informed consent before touching a patient. That means the patient must be able to hear, understand, and ask questions relative to the information you're providing in a language they comprehend. Do not under any circumstances rely on a family member to act as interpreter.

More times than not I would predominantly run into this situation on L+D at 0200 with a non-English speaking patient who had never visited the anesthesia clinic for a preop visit. The patient would be completely unknown to us -- no H+P, no consent, nothing. Our by-the-book chief had a strict rule in situations such as this: no ability to communicate via hospital-provided interpreter = no consent = no epidural. We tried consents pre printed in several common languages, but the sticking point was the ability to answer patient questions lacking an interpreter.

This may sound harsh, and may resemble ivory tower academic trite, but an informed consent is absolutely necessary. Everything else is secondary. And informed consent means one obtained via unimpaired communication between patient and provider through an official interpreter. Will you get away with cutting corners? Most likely, 99.9% of the time. The 0.1% of the time you won't have a legal leg to stand on unfortunately.

The foundational case in US law is Schloendorff vs Society of New York Hospital.

 

[Idiopathic]

Schloendorff is a very interesting case, and not terribly applicable here, although it does set a precedent for informed consent, its also more a case of true battery in that the patient expressly forbid the surgeon from removing a tumor during diagnostic surgery prior to going under ether...a tumor which the surgeon then removed.

at the end of the day, you have to have a way to maintain an open line of communication with your patient, whose care is not over once the catheter is in (or the baby is out). if you dont have a mechanism in place for this, then i think its only a matter of time before something becomes an issue

 

[BobBarker]

Absent a true emergency you must get informed consent before touching a patient. That means the patient must be able to hear, understand, and ask questions relative to the information you're providing in a language they comprehend. Do not under any circumstances rely on a family member to act as interpreter.

More times than not I would predominantly run into this situation on L+D at 0200 with a non-English speaking patient who had never visited the anesthesia clinic for a preop visit. The patient would be completely unknown to us -- no H+P, no consent, nothing. Our by-the-book chief had a strict rule in situations such as this: no ability to communicate via hospital-provided interpreter = no consent = no epidural. We tried consents pre printed in several common languages, but the sticking point was the ability to answer patient questions lacking an interpreter.

This may sound harsh, and may resemble ivory tower academic trite, but an informed consent is absolutely necessary. Everything else is secondary. And informed consent means one obtained via unimpaired communication between patient and provider through an official interpreter. Will you get away with cutting corners? Most likely, 99.9% of the time. The 0.1% of the time you won't have a legal leg to stand on unfortunately.

The foundational case in US law is Schloendorff vs Society of New York Hospital.

Did your obstetricians follow the same rule? Routine vag delivery not an emergency, besides if you can't touch a patient without such a high standard of consent then no monitors, IV, or lab work could be done. Back to your mud hut you go!

 

[Mman]

Did your obstetricians follow the same rule? Routine vag delivery not an emergency, besides if you can't touch a patient without such a high standard of consent then no monitors, IV, or lab work could be done. Back to your mud hut you go!

I'm assuming that if a pregnant lady shows up to a hospital in labor, it's kind of assumed she is requesting medical assistance with the delivery. Sort of implied consent if the OB couldn't get an interpreter. That would also go along with the things like monitors, IVs, and labs that are part of the standard L/D admission.

 

[Monty Python]

I'm assuming that if a pregnant lady shows up to a hospital in labor, it's kind of assumed she is requesting medical assistance with the delivery. Sort of implied consent if the OB couldn't get an interpreter. That would also go along with the things like monitors, IVs, and labs that are part of the standard L/D admission.

Obstetrical consents are not needed in emergent conditions, as in the above situation with imminent vag delivery. Epidural consent would still be needed however.

 

[BobBarker]

So it can be assumed that she consents to modern obstetrical care, which includes an epidural, especially when she intertermittently shouts "EPIDURALLL!!!" between expletives in her native tongue, even though she is unable to ask questions.

 

[Monty Python]

So it can be assumed that she consents to modern obstetrical care, which includes an epidural, especially when she intertermittently shouts "EPIDURALLL!!!" between expletives in her native tongue, even though she is unable to ask questions.

I asked that precise, exact-same question last semester to the lawyers. Their contention was that "modern OB care" can easily include "all natural" births, doolas (no epidural), IV meds, etc. Thus, epidurals cannot automatically be assumed as part of modern OB care as there are alternate pain-control methods employed in US hospitals.

An epidural is not a requirement (medical necessity) for vag delivery. It is not life/limb/eyesight-saving. It is a comfort measure. Thus a consent is needed. Her screaming "Epidural" in and of itself does not meet the legal standard for consent.

Obstetrical attendance for someone who shows up crowning, no consent, no labs, no H+P, no speaky-the-English, is different. That falls under the realm of emergent treatment and the OB does not need consent to attend the delivery. We do, before picking up the Tuohy.

 

[Arch Guillotti]

I'm not sure how it's possible to be too busy with workload to be bothered with getting informed consent. It doesn't take that long and you can't be that busy doing something else. I mean I can supervise 4 rooms and go place some labor epidurals, be present for every induction, trouble shoot in PACU, place a-lines and CVPs as needed, and still get informed consent on 100% of cases. It's not that hard.

I can do it too, plus bail out the nurses when they screw up.

What I can't do is have a lengthy truly informed discussion about risks 15 times a day for every EGD/colonoscopy patient.

 

[Idiopathic]

I asked that precise, exact-same question last semester to the lawyers. Their contention was that "modern OB care" can easily include "all natural" births, doolas (no epidural), IV meds, etc. Thus, epidurals cannot automatically be assumed as part of modern OB care as there are alternate pain-control methods employed in US hospitals.

An epidural is not a requirement (medical necessity) for vag delivery. It is not life/limb/eyesight-saving. It is a comfort measure. Thus a consent is needed. Her screaming "Epidural" in and of itself does not meet the legal standard for consent.

Obstetrical attendance for someone who shows up crowning, no consent, no labs, no H+P, no speaky-the-English, is different. That falls under the realm of emergent treatment and the OB does not need consent to attend the delivery. We do, before picking up the Tuohy.

Neither is an IV, monitors, oxygen or physician assistance. This debate is about semantics, pure and simple, and the perception of risk. many more people have inadvertent perineal lacerations, nerve injury, and bleeding with "unnecessary" procedures than have any complications with epidural analgesia.

 

[leaverus]

Neither is an IV, monitors, oxygen or physician assistance. This debate is about semantics, pure and simple, and the perception of risk. many more people have inadvertent perineal lacerations, nerve injury, and bleeding with "unnecessary" procedures than have any complications with epidural analgesia.

Pregnancy is a pathology - didn't you know?

 

[Monty Python]

Neither is an IV, monitors, oxygen or physician assistance. This debate is about semantics, pure and simple, and the perception of risk. many more people have inadvertent perineal lacerations, nerve injury, and bleeding with "unnecessary" procedures than have any complications with epidural analgesia.

No argument from me. I'm posting here what I (as an MBA student sitting in a graduate healthcare jurisprudence class) heard from our expert attorney-instructors. Attorneys spend three years in law school becoming masters of semantics.

In the context of a woman showing up crowning, completely unknown to either the hospital or staff, the fact that she showed up is implied consent that she wants immediate attention to her emerging delivery. The modern litigation-conscious US hospital will immediately institute what it considers necessary to support the delivery process to ensure maximum patient and baby safety. She could have just as easily had the baby in a field by herself. But since she showed up on a hospital's doorstep in an emerging condition, that implies her consent and expectation for all that modern medicine should provide to care for that condition. To treat the mother's imminent delivery and potential complications in the context of our current US litigious society that means FHR, IV, maybe O2, etc. An epidural remains below that as a nice-to-have, not as an absolute requirement. An invasive procedure to institute a non-absolute requires proper consent, the standard for which is not met by a woman screaming "epidural!" in the only English word she knows.

Again I'm not trying to split hairs nor argue how many angels can dance on the head of a pin. I'm merely relaying what the expert opinionators said.

 

[Mman]

I can do it too, plus bail out the nurses when they screw up.

What I can't do is have a lengthy truly informed discussion about risks 15 times a day for every EGD/colonoscopy patient.

Yes you can. It's a legal requirement. If you choose to not obtain informed consent from a patient that isn't the wisest decision. Besides, informed consent usually isn't a prolonged Q&A session. You need not disclose every possible risk to a procedure. Merely go over the basics including risks and answer some questions. The majority of patients trust a physician and don't get into lengthy debates over consent.