Administration and Leadership, Columns

Pro Bono: Dealing with Barriers to Patient Communication

Issue 9 and Volume 38.

There’s nothing more important than clear, concise and accurate communication between you and your patient. It’s the hallmark of good patient care. The patient needs to communicate complaints and concerns so that proper treatment can be initiated. From a legal standpoint, it’s essential the patient fully understand the extent of treatment to make an “informed decision” about their healthcare. This is a critical challenge when dealing with refusal of care cases, especially when there are barriers to effective communication. If the patient doesn’t fully understand the risks of refusing treatment, then the validity of a signed “refusal and release” may be called into question in court. 

There are many barriers to communication EMS providers face every day, such as barriers based on language and disabilities including blindness, hearing loss or impaired mental capacity. Communication barriers can cause significant anxiety, fear and frustration for the patient, so these issues demand our special attention. We can’t let the patient’s frustration cause us to be frustrated and short with the patient. We must accept the patient on their terms instead of ours. An outward display of frustration will only make the situation worse.

EMS providers are judged on whether they conduct themselves as other reasonable and prudent providers would given similar circumstances. In some states, EMS providers enjoy limited immunity from liability as long as they act in good faith within their scope of practice, and don’t commit “gross negligence” (which is more than a mistake and is often described as willful or wanton lack of regard for the patient). Can you be liable for harm to the patient caused in part by a lack of understanding between you and the patient? Yes. So the key to avoiding liability is to always act in good faith and with the patient’s best interests in mind. The bottom line is to be engaging and tolerant when confronted with communication barriers, and do the best you can to communicate with the patient.

Make careful note in your patient care documentation if there were communication issues that limited your ability to assess and treat the patient, or in obtaining the patient’s consent for treatment. Describe the steps you took to minimize those barriers, such as reliance on an interpreter like a family member, and clearly describe the patient’s response, such as the use of hand gestures, nodding of the head and other nonverbal cues. 

The following suggestions can help minimize communication barriers, improve your care in these sometimes difficult situations, and reduce your risk of liability:

Positive Attitude on Approach. How you approach the patient can make or break the communications process. Always be positive, courteous, look the patient in the eye and speak clearly and distinctly, especially when you first meet the patient. First impressions are important when setting the stage for effective communication throughout the patient encounter.

Use All Your Senses and Be Sensitive to Body Language. We sometimes rely too much on verbal communication and don’t pay enough attention to the nonverbal aspects of communication. Observe the patient’s surroundings, their body language, the look on their face, the movements and noises they make, the tone of their voice, and the gestures they make. These can help you synthesize what the patient is really trying to say and if they understand what you’re saying. Be careful not to judge the patient’s movements and gestures too quickly—use all your senses to interpret them.

Recognize Cultural Differences. Many cultures use different words or phrases to describe how we would describe the same things in English. Be respectful and sensitive of these differences, and try to ensure that you understand what the patient is trying to say before moving to the next point. It’s OK to rely on family members or others at the scene with better English skills who know the patient and who can help interpret.

Use Language Boards and Other Technology. Interpretive technology has advanced so much in recent years. Language boards can help communicate with a patient through simple phrases and images. Products like the Kwikpoint Medical Translator have boards specially designed for EMS. These “visual language translators” include pain scales as well as pictures for the patient to express common symptoms such as nausea, dizziness and other common maladies that may prompt a call to 9-1-1. There are also many smartphone applications that can be used such as iTranslate, a free app that takes short English phrases you speak and translates them into a wide range of other languages.

An excellent list of resources to help overcome communication barriers with patients can be found in an article by the Central Coast Children’s Foundation entitled “Overcoming Communication Barriers in Emergency Situations: Some Basic Tools.” (www.patientprovidercommunication.org/pdf/23.pdf). The authors list many software products, smartphone applications, and simple devices and charts to improve our ability to communicate with patients in the field.

We have become a more diverse society. We need to embrace this diversity and take positive steps to ensure that we are meeting the needs of those in our community who need our help, but who have a difficult time with that process of “simple conversation” we sometimes take for granted. This approach will not only improve the EMS experience for the patient, it can also help keep you out of legal trouble down the road since “miscommunication” is one of the key drivers of lawsuits against EMS providers and their EMS agencies.