English, Spanish and varieties of Chinese are the most popular of the 6,900 spoken and written languages worldwide, any of which can be an effective communication method for those that can hear and speak. But for people who are deaf, hard-of-hearing, or late-deafened, effective communication requires more.
For example, deaf people may prefer sign language, hard-of-hearing people may prefer lip-reading and writing, and late-deafened people may prefer texting. Additionally, sign languages are not mutually translatable. In the United States alone, American Sign Language, Pidgin Signed English and Signing Exact English are the most popular of the 300 different sign languages worldwide, but knowing one does not mean knowing the others.
What is Effective Communication under the ADA?
The law generally requires hospitals and healthcare practices to provide reasonable accommodations to patients with disabilities. This means that providing effective communication to deaf and hard-of-hearing patients is necessary and a part of reasonable accommodations. Furthermore, effective communication leads to better care and reduces the risk of medical liability.
Here are three sample scenarios that a practice treating deaf patients may encounter. Pretend you are Hypothetical Medical Center (HMC) and decide whether your practice or facility can make a reasonable accommodation as required by the law.
Scenario 1: The “Advance Notice” Patient
Alex, a deaf man, used the free video relay service to schedule an appointment at HMC. Receptionist Reece correctly asked about Alex’s preferred methods of communication. Alex said he only uses American Sign Language and prefers a live interpreter. Reece incorrectly informed Alex that HMC can hire a translator on his behalf, at Alex’s cost. Alex agreed anyway. Receptionist Reece then scheduled Alex and the interpreter for the appointment. The following week, the interpreter arrived and provided excellent translation service for Alex. However, the appointment took longer than expected. Alex was nonetheless satisfied with the interpreter and felt included in his own care. A week later, HMC billed Alex for the $1,500 interpreter fee. He was shocked at the cost but ultimately paid the invoice in full. After consulting a lawyer, HMC apologized to Alex and waived the interpreter fee.
Discussion: Was there a problem here? No, yes and maybe. A practice must reasonably accommodate a deaf patient, and HMC did. The problem is that HMC may not charge the patient (except under very specific and rare circumstances). Charging a translation fee to deaf patients has a discriminatory effect against deaf patients, which is prohibited under the Americans with Disabilities Act and several other state and federal laws. Recognizing the mistake and correcting it as HMC did would provide a strong defense and mitigation if Alex complained to a federal agency about the interpreter charge. The long appointment time is not necessarily a problem, as long as the patient was treated in a timely manner.
Takeaway: Determine the deaf patient’s preferred and other effective methods of communication as soon as possible. Develop resources like printed materials or video clips for staff to use in order to obtain this information quickly and efficiently. Refusing to schedule the patient because of the patient’s disability is likely discriminatory under the law.
Did you know? In addition to traditional sign language interpreters, some patients may prefer an oral interpreter, a person trained to articulate speech silently and clearly so that the deaf patient can read the interpreters words. Or, they may prefer a cued-speech interpreter who uses hand codes or cues to represent each sound.
Scenario 2: The “Sudden Need for More Accommodations” Patient
Oliver is a 50-year-old dual British-American citizen who is hard-of-hearing but known in previous visits to write and lip-read American-English expertly and accurately. Doctors at HMC have been effectively and successfully communicating with Oliver using this preferred communication method.
One day, Oliver returned for a routine checkup. He abruptly asked for a British Sign Language (BSL) interpreter. Though surprised at this first-time request, HMC decided instead to use the newly-purchased video remote interpreting (VRI) device, because no interpreters were scheduled for that day. A nurse assistant was able to quickly and efficiently turn on the device, which provided a perfect connection to a remote BSL interpreter. However, Oliver was unsatisfied, citing that the minimal lag inherent in VRI was unbearable and demanded a live interpreter. After two hours, HMC was able to locate an emergency translator. The rest of the appointment went well with no other complaints.
Discussion: Was it necessary (for legal compliance) that HMC found the emergency translator based on Oliver’s new demands, despite the fully functioning VRI? It depends. Primary consideration of a patient’s preference is the first but not the only consideration when choosing reasonable accommodations. Here, the facts indicated that reasonable accommodation for Oliver was possible through lip-reading and writing, VRI, or live interpreter. The problem was the sudden need for more accommodations. Such instances require specific, individualized evaluations by the practitioners in order to determine how best to provide effective communication based on the unique circumstances.
Takeaway: When a long-time patient abruptly requires new or different accommodations, practitioners should understand why. For deaf patients, it may be due to other health problems preventing them from effectively lip-reading or writing (thus becoming ineffective communication). Or, providers’ perception of patient satisfaction was skewed, and the patient never received effective communication in the first place. More nefariously, it could also mean that a patient is being used as a test case for a plaintiff’s lawsuit. Whatever the circumstances, it’s a good idea to report this as an incident to your medical malpractice provider, carefully documenting the incident and the steps taken to provide reasonable accommodations.
Did you know? VRI is a fee-based service that is generally less expensive than having live interpreters. To be an effective choice, however, the VRI should have the following performance standards:
- Real-time, full-motion video and audio over a dedicated high-speed, wide bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication;
- Sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the face, arms, hands and fingers of the person using sign language, regardless of his or her body position;
- Clear, audible transmission of voices; and
- Adequate staff training to ensure quick, efficient set-up and proper operation.
Scenario 3: The “Isolated” Patient
Clara, a 30-year-old, late-deafened patient was referred to HMC for its incredible service to deaf patients. Because Clara only recently lost her hearing, she was constantly adjusting to the silence. She did not know any sign language but could read and write in English. During her first visit, she was treated well and professionally by everyone, but a series of mishaps made her feel isolated:
- When it was Clara’s turn, new intern Iris called out Clara’s name repeatedly instead of approaching her. Clara eventually figured they were looking for her, but she was not sure until she approached Iris.
- Iris realized Clara was late-deafened while looking at her chart, and then verbally apologized, exaggerating and speaking very slowly to Clara. Clara found this demeaning and asked that Iris write what she wants to say.
- Iris left Clara to wait in the exam room, communicating on paper that Doctor Dan would come in for the exam shortly. Iris then taped the note outside the door that read, “Disabled Patient - Deaf. Enter Cautiously.” Doctor Dan entered cautiously into the room, revealing the note Iris left. Clara felt degraded upon seeing the note, despite the excellent care that followed.
At checkout, Clara expressed content with her visit but felt left out, despite the good medical care.
Discussion: What else could HMC have done? A provider may do everything medically and legally correct, but unintentionally socially isolate the patient. Here Iris should have known that Clara was late-deafened and walked up to her, face-to-face, instead of calling her name. Iris also did not know that speaking slowly could feel demeaning. Finally, Iris could have asked Clara if putting the note on the door was acceptable to Clara. These mistakes were not legal violations, but can be a barrier to patient trust and reliance on the healthcare providers.
Takeaway: Don’t get complacent. Regularly train the staff on the cultural, medical and legal care of deaf or hard-of-hearing patients. Approach patients from the front, and ask how they would like to be identified. Give patients an opportunity to express their comments at checkout. Alternatively, consider a follow-up call if preferred by the patient, using one of his or her preferred telecommunication relay service.
Did you know? People with any hearing loss often struggle with communication, leading to stress and social isolation. The National Institute on Deafness and Other Communication Disorders found that people with hearing loss are at greater risk of depression when compared to those without hearing loss. Recognizing this, providers can make their practices more inclusive by being culturally aware and looking for signs a patient may be dissatisfied or distant.
Other Risk Management Considerations
Consider scheduling deaf patients on select days when the accommodation is available. Shop around for professional interpreters or signing services, comparing each for price and flexibility. There are a variety of resources: nonprofits, profit-making companies, and state and federal information sources. Video Remote Interpretation devices are less expensive than live, with a predictable monthly cost. However, they have significant limitations and require technical training regularly to avoid interruptions.
For more practical tips, deaf etiquette, and best practices for the medical care of the deaf, read LAMMICO’s article "Deaf Patients: Talking with the Hands, Hearing with the Eyes". For more information, please contact the LAMMICO Risk Management and Patient Safety Department at 504.841.5211.
- "What We’ve Got Here is a Failure to Communicate"
- "New ACA Rule Regarding Language Interpreters"
- Laurent Clerc National Deaf Education Center’s Info to Go
- State Resources for Louisiana
- Louisiana Commission for the Deaf Registry of State-Certified Interpreters
- American Deaf Culture
- Multi-Cultural Considerations (Hispanics, Chinese, Spanish, Black, Asian, etc.)
- Assistive Tools for the Deaf and Hard of Hearing