U.S. Department of Justice

Civil Rights Division

Disability Rights Section

Americans with Disabilities Act

Communicating with People Who Are Deafor Hard of Hearing in Hospital Settings

ADA Business BRIEF:

People who are deaf or hard of hearing use a variety of ways tocommunicate. Some rely on sign language interpreters or assistivelistening devices; some rely primarily on written messages. Manycan speak even though they cannot hear. The method ofcommunication and the services or aids the hospital must provide willvary depending upon the abilities of the person who is deaf or hard ofhearing and on the complexity and nature of the communications thatare required. Effective communication is particularly critical in healthcare settings where miscommunication may lead to misdiagnosis andimproper or delayed medical treatment.

Under the Americans withDisabilities Act (ADA), hospitalsmust provide effective means ofcommunication for patients,family members, and hospitalvisitors who are deaf or hard ofhearing.

The ADA applies to all hospitalprograms and services, such asemergency room care, inpatientand outpatient services, surgery,clinics, educational classes, andcafeteria and gift shop services.Wherever patients, their familymembers, companions, ormembers of the public areinteracting with hospital staff, thehospital is obligated to provideeffective communication.

Exchanging written notes orpointing to items for purchase willlikely be effective communicationfor brief and relatively simple

face-to-face conversations, such asa visitor’s inquiry about a patient’sroom number or a purchase in thegift shop or cafeteria.

Written forms or informationsheets may provide effectivecommunication in situations wherethere is little call for interactivecommunication, such as providingbilling and insurance informationor filling out admission forms andmedical history inquiries.

For more complicated andinteractive communications, suchas a patient’s discussion ofsymptoms with medical personnel,a physician’s presentation ofdiagnosis and treatment options topatients or family members, or agroup therapy session, it may benecessary to provide a qualifiedsign language interpreter or otherinterpreter.

Sign language interpreters

Sign language is used by manypeople who are deaf or hard ofhearing. It is a visuallyinteractive language that usesa combination of handmotions, body gestures, andfacial expressions. There areseveral different types of signlanguage, including AmericanSign Language (ASL) andSigned English.

Oral interpreters

Not all people who are deaf orhard of hearing are trained insign language. Some individu-als with hearing disabilities aretrained in speech reading (lipreading) and can understandspoken words fairly well withassistance from an oral inter-preter. Oral interpreters arespecially trained toarticulate speech silently andclearly, sometimes rephrasingwords or phrases to givehigher visibility on the lips.Natural body language andgestures are also used.

Cued speech interpreters

A cued speech interpreterfunctions in the same manneras an oral interpreter exceptthat he or she also uses a handcode, or cue, to represent eachspeech sound.

Computer Assisted Real-time

Transcription (CART)

Many people who are deaf orhard of hearing are not trainedin either sign language orspeech reading. CART is aservice in which an operatortypes what is said into acomputer that displays thetyped words on a screen.

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Situations where an interpretermay be required for effectivecommunication:

• discussing a patient’ssymptoms and medicalcondition, medications, andmedical history

• explaining and describingmedical conditions, tests,treatment options,medications, surgery andother procedures

• providing a diagnosis,prognosis, andrecommendation fortreatment

• obtaining informed consentfor treatment

• communicating with apatient during treatment ,testing procedures, andduring physician’s rounds

• providing instructions formedications, post-treatmentactivities, and follow-uptreatments

• providing mental healthservices, including group orindividual therapy, orcounseling for patients andfamily members

• providing information aboutblood or organ donations

• explaining living wills andpowers of attorney

• discussing complex billing orinsurance matters

• making educationalpresentations, such asbirthing and new parentclasses, nutrition and weightmanagement counseling,and CPR and first aid training

Hospitals may need to provide aninterpreter or other assistiveservice in a variety of situationswhere it is a family member orcompanion rather than the patientwho is deaf or hard of hearing.For example, an interpreter may benecessary to communicate wherethe guardian of a minor patient isdeaf, to discuss prognosis andtreatment options with a patient’sspouse or partner who is hard ofhearing, or to allow meaningfulparticipation in a birthing class fora prospective new father who isdeaf.

Individuals with hearingdisabilities have differentcommunication skills and thehospital should consult with eachindividual to determine what aidsor services are necessary toprovide effective communicationin particular situations.

It is inappropriate to ask familymembers or other companions tointerpret for a person who is deafor hard of hearing. Familymembers may be unable tointerpret accurately in theemotional situation that oftenexists in a medical emergency.

Hospitals should havearrangements in place to ensurethat qualified interpreters arereadily available on a scheduledbasis and on an unscheduled basiswith minimal delay, includingon-call arrangements forafter-hours emergencies. Largerfacilities may choose to haveinterpreters on staff.

Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings (continued)

A doctor uses a sign language interpreter tocommunicate with a patient who is deaf.

Sign language or otherinterpreters must bequalified. An interpreteris qualified if he or shecan interpretcompetently, accurately,and impartially. In thehospital setting, theinterpreter must befamiliar with anyspecialized vocabularyused and must be able tointerpret medical termsand concepts. Hospitalpersonnel who have alimited familiarity withsign language shouldinterpret only inemergency situations fora brief time until aqualified interpreter canbe present.

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For training or other educationalservices offered to patients ormembers of the public, additionalaids and services such as notetakers, captioned videos, andassistive listening systems may benecessary for effectivecommunication.

Hospitals should developprotocols and provide training toensure that staff know how toobtain interpreter services andother communication aids andservices when needed by personswho are deaf or hard of hearing.

It is helpful to have signs andother types of notices to advisepersons with disabilities thatservices and assistance areavailable and what they need to doto obtain them. It is most useful to

post signs at locations wherepatients or visitors typically seekinformation or assistance and toinclude information in generalinformation packets.

Hospitals cannot charge patients orother persons with hearingdisabilities an extra fee forinterpreter services or othercommunication aids and services.

For telephone communications,many people who are deaf or hardof hearing use a teletypewriter(TTY, also known as a TDD)rather than a standard telephone.These devices have a keyboardand a visual display forexchanging written messages overthe telephone.

The ADA established a freenationwide relay network tohandle voice-to-TTY and TTY-to-voice calls. Individuals may usethis network to call the hospitalfrom a TTY. The relay consists ofan operator with a TTY whoreceives the call from a TTY userand then places the call to thehospital. The caller types themessage into the TTY and theoperator relays the message byvoice to the hospital staff person,listens to the staff person’sresponse, and types the responseback to the caller. The hospitalmust be prepared to make andreceive relay system calls, whichmay take a little longer than voicecalls. For outgoing calls to a TTYuser, simply dial 7-1-1 to reach arelay operator.

If telephones and televisions areprovided in patient rooms, thehospital must provide patients whoare deaf or hard of hearingcomparable accessible equipmentupon request, including TTY’s,telephones that are hearing-aidcompatible and have volumecontrol, and televisions withclosed captioning or decoders.

Visual alarms are not required inpatient rooms. However, hospitalevacuation procedures shouldinclude specific measures toensure the safety of patients andvisitors who are deaf or hard ofhearing.

A hospital need not providecommunication aids or services ifdoing so would fundamentallyalter the nature of the goods orservices offered or would result inan undue burden.A hospital patient uses a TTY in his hospital room.

Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings (continued)

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Certain built-in communicationfeatures are required for hospitalsbuilt or altered after the effectivedate of the ADA:

• Visual alarms must be providedin all public and common-useareas, including restrooms,where audible alarms areprovided.

• TTY’s must be provided atpublic pay phones servingemergency, recovery, or waitingrooms and at least one TTYmust be provided at otherlocations where there are fouror more pay phones.

• A certain percentage of publicphones must have otherfeatures, such as TTY plug-incapability, volume controls, andhearing-aid compatibility.Consult the ADA Standards forAccessible Design for morespecific information. [ADAStandards 4.1.3(17), 4.31]

ADA InformationYou may view or download ADAinformation on the ADA website.This website provides access to theADA Business Connection, ADAdesign standards, regulations,policy letters, technical assistancematerials, and general ADAinformation. It also provides linksto other Federal agencies and newsabout new ADA requirements andenforcement efforts.

www.ada.gov

If you have specific questionsconcerning the ADA, call theDepartment of Justice ADAInformation Line.

(800) 514-0301 (voice)

(800) 514-0383 (TTY)

A man uses a TTY that is connected to a pay telephonein a hospital emergency room waiting area.

Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings (continued)

Duplication is encouragedOctober 2003