Patient Stories

Medical issues: Hospital admission for a scheduled hysterectomy.  She has severe hearing, speech, language impairments secondary to TBI at age 4 years.
Background: Ms. D. lives with her family in a Vietnamese community. She doesn't speak or understand spoken English or Vietnamese. She had no education or rehabilitation opportunities as a child.  

Ms. D grew up in South Vietnam during the Vietnam War. At age four, she sustained a traumatic brain injury and had rudimentary brain surgery. She was also given antibiotics that were ototoxic and resulted in a severe hearing loss. She currently has speech, language and cognitive disabilities as a result. After her injury, Ms. D did not attend school or receive any rehabilitation services. She immigrated to the United States as an adult. At age 54, her speech is unintelligible and she is illiterate in both English and Vietnamese. She communicates with familiar people using idiosyncratic gestures.

Ms. D. was admitted to the hospital for a scheduled hysterectomy. Unfortunately, her brother, who typically accompanies her to appointments and acts as a communication assistant/interpreter was ill, so her teen-aged nephew drove her to the hospital. He was unfamiliar with medical procedures and could not legally provide consent. The hospital staff were unable to explain the purpose or procedures related to her surgery and did not obtain informed consent. A hospital interpreter was unsuccessful in helping because of Ms. D's significant hearing and speech problems. During the interview, Ms. D. became confused and began to cry. Surgery was delayed and she was sent home.

Ms. D's multiple communication difficulties significantly interfere with her ability to access appropriate healthcare. For example, without informed consent, surgery cannot be performed and without surgery, her long-term health is at risk. She faces multiple barriers, which include:

Hearing. A severe hearing impairment and inability to understand spoken English or Vietnamese. She never learned to use a formal sign language system. Also, fine motor difficulties make her idiosyncratic signs/gestures difficult to understand.
Speech, language and communication impairments. Ms. D is unable to produce intelligible speech because of oral motor problems. She relies on a few family members to interpret her communication efforts and explain things to her.
Health literacy. Ms. D is easily overwhelmed by unfamiliar situations and has limited experience dealing with the healthcare system and hospital procedures.
Cultural and linguistic supports. She is highly dependent on others to negotiate her interactions, as her communication is quite idiosyncratic. She needs to identify a support person who understands her idiosyncratic way of communicating and materials that help her understand  procedures, as well as express her needs and feelings and answer medical staff questions.

New Standards: Effective Communication, Cultural Competence, and Patient- and Family-Centered Care

The new Joint Commission standards can help remove barriers to successful patient-provider communication.
The hospital effectively communicates with patients when providing care, treatment, and services (Standard PC.02.01.21) means that hospitals identify and address oral and written communication needs—including cognitive, speech, hearing and vision issues, preferred language, and health literacy—throughout the "course of care."  Since Ms. D.'s communication challenges pre-exist her pre-scheduled surgery, the speech-language pathology and audiology departments could identify her communication needs and how to meet them prior to her admission and throughout her stay. For example, the SLP department could provide nursing staff with a low-tech, pictographic-based communication board containing needs-based messages. The audiologist might provide a temporary amplification device, marking the on/off switch and posting a chart explaining its operation. Medical instructions (consents, explanations of the surgery) could be given with pictures to increase comprehension.

The medical record contains information that reflects the patient's care, treatment, and services(Standard RC.02.01.01). According to this standard, speech, language and hearing issues must be identified at admission and documented in the medical record. It also states that if the patient is "incapacitated, the communication needs of the parent or legal guardian, surrogate decision-maker or legally authorized representative is documented in the medical record. Ms. D.'s medical record documents her significant communication needs, which not only generates referrals to audiology and speech-language pathology for assessment and treatment recommendations, but also could alert hospital staff to the need for communication displays and the presence of a competent support person.  

The hospital respects, protects, and promotes patient rights(Standard RI.01.01.01).This standard indicates that hospitals will allow for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights or safety or is medically or therapeutically contraindicated. Ms. D. needs to come to the hospital with a family member who will help her talk to admission personnel, doctors and nurses.

The hospital respects the patient right to receive information in a manner he or she understands(Standard RI.01.01.03). This includes proving language interpreting and translation services, as well as information to patients who have vision, speech, hearing or cognitive impairments in a matter that meets the patient's needs. For example, Ms. D is able to communicate with her family, but does so idiosyncratically. She has no education and limited connection to people outside the Vietnamese community. Her limited communication abilities, poor health literacy skills and cultural issues affect communication between Ms. D and hospital staff and ultimately, the quality of her care and outcomes.