Elizabeth Abraham, MA, MSc, C.Tran.Manager, Interpretation and Translation Services

Kyle Anstey, Ph.D.Bioethicist, University Health NetworkJoint Centre for Bioethics, University of Toronto

Informed Consent

and Professional Interpretation Services

Why is professional interpretation an Why is professional interpretation an important and novel topic in bioethics?important and novel topic in bioethics?

1. 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

Why is professional interpretation an Why is professional interpretation an important and novel topic in bioethics? (cont.)important and novel topic in bioethics? (cont.)

2. Compromised informed consent in the absence of the required use of professional interpretation services for LEP patients

3. 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 1. Attention to professional interpretation in bioethics is disproportionate to: 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 Small literature on ethical issues and professional interpretationprofessional 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

Estimated LEP Population in TorontoEstimated LEP Population in Toronto

• 213,000 “no knowledge” of English or French

• Census figures do not capture people who need an interpreter

• Estimated LEP population: 450,000

• The census itself is not translated into all languages

• The census does not capture persons living in the country illegally

Lack of explicit requirements and funding for Lack of explicit requirements and funding for professional interpretationprofessional interpretation

• No explicit Federal or Provincial legislative requirement in Canada

• No dedicated Federal or Provincial funding

• Certification for Community Interpreters in Ontario under development

• Varying Organizational Policy Requirements:• Trend: Encourage, but don’t require professional

interpretation

• Trend: Discourage, but don’t prohibit ad hoc interpretation by staff or family members

Linking professional interpretation services Linking professional interpretation services and outcomes for LEP patientsand outcomes for LEP patients

Length of stay

Misdiagnosis, drug error

Patient safety

Patient adherence to treatment plan

Patient satisfaction

Linking professional interpretation services Linking professional interpretation services and outcomes for LEP patientsand outcomes for LEP patients

Reduced costs Reduced length of stay Reduction of unnecessary diagnostic tests,

inappropriate admissions & readmissions, overuse of emergency services

Reduced liability Failure to provide interpretation Communication errors

History of informed consentHistory 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 Obtaining informed consent from LEP patientspatients

Family and untrained bilingual staff (ad hoc interpreters) are not acceptable substitutes for medical interpreters when obtaining informed consent

2. Compromised informed consent in the absence of professional

interpretation for LEP patients

DocumentationDocumentation

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 DocumentationImprovements in Documentation

• Revised consent forms:• Accommodate literacy level• Include requirements and document• Involvement 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: Ad hoc interpretation: why are family or staff members used?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, this is not done”• “My mother will lose hope if you tell her this”

Ad hoc interpretation: Ad hoc interpretation: why are family or staff members used?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 Compromised informed consent with ad hoc interpreters: interpreters: FamilyFamily

•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:Related issues of ad hoc interpretation:FamilyFamily

• Conflict of interest

• Confidentiality Role, size of/membership in ethnic

communities

Compromised informed consent with ad hoc Compromised informed consent with ad hoc interpreters: interpreters: StaffStaff

• Lack of training and evidence of proficiency, competencies

• Trust: janitor as member of the healthcare team

Related issues of ad hoc interpretation:Related issues of ad hoc interpretation:StaffStaff

• 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 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

Strategies for dealing with dismissal: FamilyStrategies 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: FamilyStrategies 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: StaffStrategies 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

Questions?Questions?

Contact: Elizabeth Abrahamelizabeth.abraham@uhn.on.caKyle Ansteykyle.anstey@uhn.on.ca