Rod Sterling famously said, "Imagine, if you will…an alternative universe." Imagine that the vast majority of the world is deaf, but you can hear. Your hearing family has rushed you to the hospital for a snakebite. All around you in the emergency department, the doctors are signing to you in American Sign Language, and you don't understand a thing. Everyone looks irritated with you. Frowning faces all around. Your wife gasps at you panicked. Your children are crying. All you know is that you could die within the hour if you cannot tell them what happened.
Let's refocus. In reality, almost 4 percent of the U.S. population is deaf or has a significant hearing difficulty. They live in a mostly hearing world, and they go to hospitals that may not understand them. Several federal and state laws have long governed how hospitals should treat a deaf patient.
In short, since 1973, deaf patients have had at least some level of protection from discrimination to ensure that the deaf patient is not treated differently than others. Patient claims based on the violation of these laws are increasingly common and can be expensive. Remember that the touchstone for compliance is effective communication. Some requirements for deaf accommodation to enhance communication may extend to a hearing patient’s deaf companion, spouse, or parent.
Cost of Doing Business
When possible, and when preferred by the patient, professional interpreters are the best accommodation. When providing this accommodation, however, the facility cannot charge the patient for the costs of the services.
Some smaller hospitals and medical practices find the obligation to provide deaf accommodations burdensome and expensive, and sometimes costing more than the patient visit’s reimbursement. The federal law requiring accommodation also provides certain exceptions for certain types of facilities or for certain very fact-specific circumstances. These smaller facilities should be wary of relying on the narrowly limited exceptions to these laws, however. Even if justified, such an exception does not shield the practice from the associated costs of a deaf patient’s legal claim. A prominent New Orleans defense attorney advised, “Even if the physician has a good argument that his practice is too small, or the cost [is] too high and the patient [impairment is] too rare to justify the expense, legal fees defending such claims, even if won, make the failure to comply with [accommodation] requirements prohibitively expensive.”
The facility has the ultimate responsibility to decide the best way to accommodate the deaf patient’s communication needs. It may not require the patient to bring their interpreter or signer. If the deaf patient prefers to use a family member or friend, it is the responsibility of the hospital to evaluate whether or not the person chosen is qualified to accurately facilitate communication. Emotional personal involvement and confidentiality considerations may impair the ability of a friend or family member to interpret impartially. In short, not just anyone will do. Just because you know the guy who works in the kitchen is handy and can sign doesn’t make him the best choice for a complicated medical conversation.
When accommodating deaf patients in clinics, consider scheduling them on days when your interpreter is available. Shop around for professional interpreter or signing services, comparing each for price and flexibility. There are a variety of resources: non-profits, profit-making companies, and state and federal information sources. Video remote interpretation devices can be less expensive than live webcam interpretation via videophones, and are often available to healthcare facilities with a predicable monthly cost. However, these services have significant limitations. Staff often are not familiar with the most effective means to use them, and patients cannot see them if the patient is flat on his or her back.
Practical Tips and Deaf Etiquette
Deaf communities have their own language, customs and culture. Hearing caregivers may unintentionally insult, stigmatize or demean a deaf patient. For effective, respectful communication:
- Do be sensitive to cues your patient gives you. Don’t assume your deaf patient cannot understand you or doesn’t have autonomy.
- Do follow your patient’s preference for communication; e.g., some younger deaf patients accustomed to smart phones may request and prefer typing into their phone and then displaying the phone to you.
- Don’t yell or appear irritated.
- Do be cautious of depending on written notes for communication. Written English is likely a second language for those that can sign. For that reason, many deaf individuals have limited reading comprehension.
- Don’t assume the deaf patient can sign in American Sign Language, or sign at all.
- Do talk to the patient, not the translator. Don’t cover your mouth or turn away to type into the computer or make an entry in the record.
- Do make eye contact. Don’t “over-mouth” or overly enunciate.
- Do address the patient in the first person. Don’t say, “Tell her X.”
- Do speak at a moderate pace and volume to make sure the lip reader or the signing language interpreter understands and can keep pace. Don’t assume the deaf patient can read lips. Even the best lip readers only understand 60% of what is said.
- Do make sure the American Sign Language translator can see everything that is relevant, e.g. the X-ray you are discussing or the others in the room. Don’t make extraneous comments or asides only to the translator.
- Carefully consider your word choices. In deaf culture etiquette, calling deafness a disability or a handicap may be perceived as derogatory. Generally, a “person with a disability” may be preferred. Don’t be condescending or express frustration with accommodating a hearing-impaired patient.
- Do use common sense. e.g., don’t grin when you are about to give bad news.
Best Practices for the Medical Care of the Deaf
- Have a policy and follow it. Although it may seem obvious, many smaller entities may not have any deaf policy at all. Given how longstanding disability laws are, the absence of a policy may be severely frowned upon by regulatory agencies and judges.
- Educate your staff on the practical mechanisms of implementing the policy. Do they know what number to call? Can they troubleshoot the devices used to accommodate the Deaf?
- Be reasonable. Most deaf patients that arrive expectantly understand that translators may not be instantaneously available.
- Do what needs to be done and as quickly as possible. Your patient needs to communicate with you.
- Don’t give up if there is a barrier to accommodation (e.g., translator or signer isn’t available, video remote interpreter doesn’t work). Your patient needs to communicate with you.
- Use your assessment skills. Does your patient really understand what you are trying to convey?
- Ask your patient what they want once communication is established.
- Ask before you use a special armband or a sign posted in the room to indicate their communication problems to your staff. Deaf patients also have a right not to be labeled.
- Time the availability of the translator, signer or accommodation device to when the patient’s doctor is making rounds.
- There is no alternative to making a physical trip to the bedside if a hospitalized deaf patient rings the call button.
References and Resources
- Information about Louisiana Deaf resources:http://www3.gallaudet.edu/clerc-center/info-to-go/national-resources-and-directories/state-by-state-resources/state-resources-louisiana.html
- American Deaf Culture (values, behaviors, and traditions):http://www3.gallaudet.edu/clerc-center/info-to-go/deaf-culture/american-deaf-culture.html