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Informed Consent and Informed Consent and Professional Interpretation ServicesProfessional Interpretation Services
Elizabeth Abraham, MA, MSc, C.Tran.Manager, Interpretation and Translation ServicesUniversity Health NetworkPresident, Healthcare Interpretation Network
Kyle Anstey, PhDBioethicist, University Health NetworkJoint Centre for Bioethics, University of Toronto
Why is professional interpretation an important and novel topic in bioethics?• Disproportionate attention relative to the demand for
and complexity of providing this service and the significant harm and costs resulting from a failure to provide professional (vs. ad hoc) interpretation
• Compromised informed consent in the absence of the required use of professional interpretation services for LEP patients
• Even if professional interpretation is required, these professionals will have to deal with issues like family dismissal, and there is no literature on how to manage these situations
1. Attention to professional interpretation in bioethics is disproportionate to:
- the demand for these services
- the complexity of providing them
- the harmful outcomes of not doing so
Small literature on ethical issues and professional interpretation
• Significant literature linking lack of professional interpretation to poor health care quality and outcomes
•• Very small literature on the importance of professional
interpretation for assuring informed consent and confidentiality for LEP patients
• This research is overwhelmingly found in medical vs. bioethics journals
Demand: size of LEP population in Toronto relative to rest of Canada 2006 Canadian census first official language spoken
Underreported demand for interpretation in the population
• Census figures do not capture people who are limited English or French proficient and need an interpreter
• The census itself is not translated into all languages
• The census does not capture persons living in the country illegally
Lack of requirements and funding for professional interpretation
• No explicit Federal or Provincial legislative requirement in Canada
• No dedicated Federal or Provincial funding• Certification qualifications for Community
Interpreters in Ontario under development• Varying Organizational Policy Requirements:
Trend: Encourage, but don’t require professional interpretationTrend: Discourage, but don’t prohibit ad hoc interpretation by staff or family members
Linking professional interpretation services and outcomes for LEP patients
Length of stayMisdiagnosis, drug errorPatient safety Patient adherence to treatment planPatient satisfaction
Linking professional interpretation services and outcomes for LEP patients
Reduced costsReduced length of stayReduction of unnecessary diagnostic tests, inappropriate admissions & readmissions, overuse of emergency services
Reduced liabilityFailure to provide interpretationCommunication errors
History of informed consent• Concept of requiring a patient’s consent to
treatment dates back to 18th c England• Stems from Latin adage Noli me tangere (do not
touch me) • France: jurisprudence established requirement
to obtain informed consent in 1910• Legal doctrine articulated in US in 1914• Lexicon evolved to “informed consent” (1957)• To treat a patient without his or her consent
is battery (nonconsensual touching that is harmful/offensive)
Obtaining informed consent from LEP patients
Family or bilingual staff (ad hoc interpreters) are not acceptable substitutes for medical interpreters when obtaining informed consent
2. Compromised informed consent in the absence of required professional interpretation for LEP patients
Documentation• Consent forms document a process vs.
being a substitute for it. That said…
- Evidence that LEP patients less likely to have documented informed consent, even where on-site medical interpreters are
available.
- More importantly, where there is documentation of informed consent, it suggests that there are differences in how
consent is obtained from LEP patients.
Improvements in documentation– Revised consent forms:
• Translation into more languagesAccommodate literacy levelInclude requirements and documentInvolvement of professional interpretation
– Beyond the consent form:• Other documentation of use of professional
interpretation for LEP patients (e.g. diagnosis, medication instructions)
Ad hoc interpretation: why are family or staff members used?
Convenience?• "It is easier for me to order a $1,400 CT scan
than a translator ... even though that information will be more valuable than a CT scan.” Dr. Jose Silveira, Chief of Psychiatry, St. Joseph’s Health Centre, Toronto
Avoiding conflict with family?• “In our country/culture this is not done”• “My mother/father will lose hope if you tell her
this”
Ad hoc interpretation: why are family or staff members used?
Cost of providing?• Less than the cost of an x-ray!• Ignores huge cost of not providing
Satisfaction with ad hoc skill and professionalism?• Not supported by little research done (Kuo and Fagan 1999; Mesa, 1997)
Compromised informed consent with ad hoc interpreters: Family
– Lack of proficiency in both languages– Lack of knowledge and training to competently interpret medical procedures and concepts– Tendency to significantly filter information– Failure to disclose serious diagnoses to patients due to family’s desire to protect patient from negative information
Related issues of ad hoc interpretation: Family
• Conflict of interest
• ConfidentialityRole, size of/membership in ethnic communities
Compromised informed consent with ad hoc interpreters: Staff
• Lack of training and evidence of proficiency, competencies
• Trust: janitor as member of the healthcare team
Related issues of ad hoc interpretation: Staff
• Involvement frequently not documented
• Accountability of many “pulled in staff” questionable given scope of their practice
• Role confusion and conflicts of interest
3. Dismissal of professional interpreter
Even if professional interpretation is mandated, these professionals will have to deal with issues like family or staff dismissal, and there is no literature on how to manage these situations
Case study• Professional interpreter booked with oncologist
for final appointment for Vietnamese-speaking patient
• Neither patient nor wife speak any English. Adult children had been interpreting all previous appointments
• Patient asks why he is not receiving his chemotherapy treatment
• Oncologist tells him he is at end stage cancer
Strategies for dealing with dismissal: Family
• Demonstrate appreciation of family’s views
• Determine if disclosure is really the issue
• e.g. Fears about confidentiality in small cultural communities
• Communicate why professional interpreters are needed
Strategies for dealing with dismissal: Family• Where a Substitute Decision-Maker is involved, explain their role and obligations (i.e., acting on expressed wishes or, where they are unknown or not applicable, in the patient’s best interests)
• Use additional mediation resources where necessary (e.g. Patient Relations, Bioethics)
• Possible compromise: involvement of family in interpreting with understanding that professional interpreter be present and can clarify and supplement family statements.
Strategies for dealing with dismissal: Staff
• Have a policy that backs up and empowers staff by requiring professional interpretation services for specific acts (e.g. obtaining informed consent from a patient)
• Educate unit staff of risks of providing or enabling informal interpretation
• Educate interpreters to empower them in raising concerns with members of the healthcare team
