Like most medical students, Jay M. Brenner, MD, FACEP, learned about the ethical obligation to offer professional interpreters instead of “ad hoc” interpreters (untrained staff, family, or friends) to patients who are deaf or speak a foreign language primarily. “It was drilled into us that ad hoc interpreters were suboptimal,” says Brenner, now medical director of Upstate University Hospital Community Campus ED in Syracuse, NY.
Yet during his residency and as an attending physician, ad hoc interpreters were used routinely. ED providers often turned to whoever was at the bedside.
“This became even more concerning when access to professional interpreter services declined in my clinical setting temporarily,” Brenner recalls.
Brenner submitted the use of professional interpreters as a topic for the ACEP ethics committee to consider. Subsequently, he led a subcommittee group in authoring a paper on the topic.1 Language barriers during a medical emergency could compromise care, according to the case studies included in the analysis. “I was most surprised by the extent of consequences for not offering professional interpreters, including missed opportunities for recognizing human trafficking,” Brenner offers.
Not surprisingly, the analysis pointed to access, feasibility, and timeliness as top reasons for failure to offer professional interpreters in the ED setting. Although it is believed to be commonplace, data are lacking on how often ED providers use ad hoc interpreters. “Providers often do not document when they do not use a professional interpreter,” Brenner explains. Brenner and his colleagues recommended:
- improving physician education on policies and resources available in their clinical setting as well as awareness of the problems with ad hoc interpreters;
- partnering with organizations to identify and support specific local needs.
Some EDs serve special populations, such as refugee communities. “EDs should reach out to nonprofit organizations serving such populations to see what collaborations of providing interpreter services are possible,” Brenner says.
Brenner and colleagues described several ED cases in which lack of an interpreter resulted in misdiagnoses and medical errors. “Obviously, not obtaining an accurate history from a patient can lead to devastating outcomes,” Brenner says. He recalled one case in which ED providers wrongly believed a Spanish-speaking patient was intoxicated when he was showing signs of altered mental status. The patient died of a missed intracranial hemorrhage.2
“Not offering professional interpreters can not only contribute to medical malpractice but can also violate federal civil liberties and some state laws,” Brenner warns. Title VI of the Civil Rights Act of 1964 requires healthcare facilities to provide competent interpreter services to patients with limited English proficiency. “Emergency physicians should be aware of the state laws related to this federal statute in the states where they practice,” Brenner adds.
In terms of legal risks for EDs, missing relevant information “is the major theme that comes up over and over again,” says Ken Marshall, MD, assistant professor in the department of emergency medicine at University of Kansas Medical Center. Marshall says that ED documentation should make it abundantly clear that a qualified interpreter with relevant training and expertise to communicate the medical intricacies of the case was used. Further, documentation should show that appropriate steps were taken if a translator is unavailable for any reason, such as the patient speaking a rare language. Legally protective documentation in cases like that could include a note that indicates an EP called whatever interpreter services were available at his or her hospital, or that an EP managed to find a translator for the closest available dialect. In general, the ED chart should paint a clear picture of “a good faith effort to do right by the patient, as much as possible,” Marshall advises.
ED patients sometimes appear to prefer a family member interpret on their behalf.
“If possible, EDs should have someone who speaks the patient’s primary language convey that providers might miss something important for their care,” Marshall explains. Ideally, the ED chart indicates that the patient was informed of this and was offered a qualified interpreter.
Also important: The use of an interpreter is documented in all the important places in the ED chart, not just the history and physical. “It’s crucial to document it specifically on the consent,” Marshall stresses. Otherwise, it could appear as though no interpreter was used when the patient was informed of risks of an invasive procedure such as a lumbar puncture.
The same is true for discharge instructions. Some malpractice claims revolve around the fact that these instructions were given only in English.
“Even in cases where the ED provider did everything right and used a qualified interpreter, the plaintiff attorney could claim no translation was provided for the discharge summary,” Marshall notes.
Putting discharge instructions in the patient’s preferred language is best, Marshall says. If this is not feasible, another option is for the interpreter to review these instructions with the patient. The chart also should show that the ED provider reviewed the discharge instructions with the interpreter.
“If there’s any kind of bad outcome, any kind of deviation from best practices — it is going to look suspicious even if it wouldn’t have materially changed the care provided,” Marshall adds.
REFERENCES
- Brenner JM, Baker EF, Iserson KV, et al. Use of interpreter services in the emergency department. Ann Emerg Med 2018;72:432-437.
- Johnstone MJ, Kanitsaki O. Culture, language, and patient safety: Making the link. Int J Qual Health Care 2006;18:383-388.
Despite state and federal laws requiring professional interpreters be offered to patients with language barriers, many EDs still rely on family members, friends, or untrained staff. The ED chart should show that an interpreter informed the patient of risks of invasive procedures, the ED provider reviewed discharge instructions with the interpreter, and the patient was informed of risks of ad hoc interpreters.
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