When your patient doesn’t speak English, you may be in more trouble than you realize.

I was talking to a professional medical interpreter at Children’s Hospital and she was telling me about the different ways a healthcare professional can get into trouble when they use the family as the interpreter. She told me that in one language, the words you might say when a patient has died, “I am so sorry your sister has died” don’t translate very well. “I’m sorry” in that language means, “I’m responsible. I killed your sister.” Oops. If you had used a professional translator in that situation, they could have stopped and asked you, “Is that what you meant to say?” And of course when you said no, you could then ask for their help in putting the words into terms that would be acceptable. The translator in this instance will tell you that you should say, “I’m so sad. Your sister has died.”

This is just one reason you should be using a professional translator. There are other reasons as well. The family may not be able to translate some of the terminology because they’re medically illiterate. Or they may have an agenda and only translate some of the information to the patient. Or they may be following their cultural rules about what can be spoken to an elder. Or there may not be a word for what you are trying to say in their language. Did you know that in one language there is not a separate word for bacteria and virus? There is only one word to describe both. How are you going to explain something when they don’t even have a word for it? Good luck without a professional interpreter.

Here are a couple tips to make working with a medical interpreter more effective:

1. If you can, arrive a few minutes early to speak with the interpreter and let them know the types of things you’ll be discussing. This way they can give you insight into the linguistic and cultural rules and how they might affect the interaction.
2. Try to not talk for more than one to two minutes. The interpreter is having to remember everything you say, and then has to translate it into culturally appropriate language. Allow the interpreter thought time.
3. Once the interpreter begins translating. Do not interrupt. Patients may think that you don’t trust the interpreter if you interrupt and the interpreter will lose face. I know this takes patience.
4. The other thing that takes patience is understanding that language doesn’t translate word for word. The English language is very direct and we are allowed to say what we need to without dancing around the subject. In other languages, language is in indirect. The only way you can say the same information is to approach it from different angles until you can finally land on the information. This will automatically take longer. It is not the fault of the interpreter if they have to say a lot to say what you have said in a few words. It is the fault of the structure of language.
5. The interpreter can also provide input on how to talk about delicate issues. We are so used to talking about body parts, diseases and personal matters that we forget how embarrassing it can be in other cultures.
6. If there isn’t an interpreter available, please use the A T and T interpreter phone line.
7. Make sure you thank the interpreter and respect that they are professionals and are there to help us, as well as the patients. They can really save you from making a terrible mistake and harming the physician/patient relationship.

Lastly, your hospital may want to consider having the interpreters round on the patients throughout the day to make sure their needs are getting met and that they feel like they have a voice in their health care. Your hospital may also think about sending interpreters into the doctor’s offices to provide interpretation services in the outpatient setting. Some hospital systems in Los Angeles have already begun doing this and it is making a difference.

Have a kind and respectful day.

“Cutural Communication Strategies”, “Communicating with Dying” and “Insiders Guide to filling out your Advance Directive” Newsletters are Available.

If you missed the last newsletters, “Cultural Communication Strategies”, “Communicating with the Dying” or the “Insider’s Guide to Filling Out Your Advance Directive”, you can still get them if you sign up under the receive newsletters section on the lower right side of the blog. When you sign up you will get the bonus office visit toolkit as well as the back issues of the newsletters. I usually send out one newsletter every month so you won’t be inundated with emails. And of course I respect your privacy and won’t release your information to anyone else.

Have a kind and respectful day.

How do you solve Nurses Moral Distress? Moral Courage – Part 1

Usually I get hired to teach doctors about ethics, communication and improving end-of-life care. Even though I am rarely hired by hospitals to help nurses with the ethical dilemmas they face, it is a privilege for me when I do get to work with them. (Hospitals will pay for the education of doctors but will pay far less money on nursing education.) When I have done ethics rounds with small groups of nurses, tears are shed, stories are told and then I can go through their story and help them work through the experience. Hopefully, they feel better after being heard. They still carry the moral burden of their actions or inactions in the cases from years ago. Sometimes all I can do is to acknowledge their grief and let them know that their instincts were right, even though they felt they were powerless at the time. Then I can help them strategize about how they would solve a similar situation in the future.

Because nurses come into their profession with such compassion and big hearts, their moral distress when witnessing terrible situations is a greater burden to them. Doctors have moral distress as well, but today, I want to talk about the nurses. What is moral distress? It is the distress you feel when you know something is ethically or morally wrong and you feel powerless to change it. And I don’t know about you, but I feel terrible when I feel powerless. Especially when you feel like you’re being forced into taking part in something you know is wrong. I know for the people reading this that aren’t nurses, you might be thinking, “Why doesn’t the nurse just speak up? Why don’t they just say no?” It’s not that simple. That’s not how it works in medicine. Nurses are supposed to follow the doctor’s orders. Just like in the military, you follow the orders of the commander above you. Now, it is much better than it used to be in the past and had nurses have a greater voice on the healthcare team, but it is still difficult to stand up to certain doctors or in certain situations, especially when you think you might get in trouble. So I understand the dilemma nurses find themselves in. But as an ethicist, and I have to say that we need to have moral courage. Otherwise, things will never change. We need to be willing to speak up when we see something that is wrong. If this was easy to do, we wouldn’t call it courage.

The other day I was speaking to a person whose parent was the victim of elder abuse at the hands of a relative. The doctors and nurses saw what was going on. But nobody said anything or reported anything, so nothing was done. The abuse continued because nobody had the moral courage to say no, “This isn’t right.” Another common thing that I see is when a medical error is going to happen and a nurse speaks up to the doctor and says, “I think this medication/treatment plan might be wrong.” Then the doctor may say, “Don’t tell me what to do. Just follow my orders as I have written them.” So what does the nurse do? Well, the first thing she or he does is to experience moral distress. You know it is wrong and you’ve tried to speak up and that didn’t work. Are you going to go to your supervisor? Are you going to refuse to give the medicine or participate in the treatment? What do you do next? If you go to the supervisor, does the supervisor support you and confront the doctor? Maybe no, maybe yes. And maybe you don’t think you have a choice but to give a treatment that you know is wrong. No matter what, you always have a choice. You have your voice.

One thing you can do as a nurse is to take these issues to the bioethics committee at your hospital. You don’t have to be certain that the situation is an ethical dilemma or a moral problem. You can just run it by the person on call and ask for help in evaluating the situation. (You can also use the chaplain for moral support.) Or you can take your concerns to risk management, the medical staff department or administration. Follow the chain of command but don’t give up. You have to persevere to keep the patient safe. This takes courage but I believe in you. You have the moral courage.

I have the moral courage to speak up when I see unethical behavior. And I am no more special than you. Sometimes I get in trouble for speaking up, and sometimes I don’t. But I will continue to speak up because maybe you are the patient in one of my hospitals and I am going to keep you safe. I want to encourage you to do the right thing because I might be a patient in your hospital some day. I might need you to protect me from someone or something that will harm me. I will show you the same respect.

Have a kind and respectful day.

“Age in Place – Putting Your Plan Into Action” Interview with Mark Hager, the founder of Aging in Place. June 24th, 9:30 AM pst

“Age in Place – Putting Your Plan Into Action” Interview with Mark Hager, the founder of Aging in Place. June 24th, 9:30 AM pst. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Mark Hager is the founder of AgeInPlace.com, a website focused on major topics around aging in place, including home modifications, real estate, assistive technology, finances and others. Mark also founded AgeInPlacePros.com, a website for those who provide services and goods to older people, focusing on local businesses meeting community needs brought on by the age boom. Mark is an advocate of planning responsibly for late life to lessen the impact on people, their families and communities. As well as, assisting local businesses prosper while serving those in their communities.

He will be answering the common questions people have about aging in place.

Have a kind and respectful day.

I thought we were all past this. Why are we still keeping gay and lesbian couples from visiting each other in the hospital?

I thought we were past this. I thought this issue was resolved but apparently it isn’t. This week in Fresno – California, a lesbian partner was not allowed in to see her partner of 3 1/2 years in the hospital. If she had said she was the woman’s sister, aunt, or friend she would have been allowed to visit. But because she is in a relationship with the patient, it was not okay. Please, we all have to get over this. It is stressful and scary enough to be in the hospital when you are in a medical crisis. This is when we all need the love and support of the people we love. Put yourself in their shoes. Would you want a healthcare professional keeping you from seeing your sick loved one?  Would you want to wait outside while your loved one dies?  No you wouldn’t.  It is none of healthcare professional’s business who visits you in the hospital. If you believe in the Golden Rule, then please respect that others would want their loved ones to visit them just like you would and don’t let this happen at your hospital.

(FYI: The best way to make sure this doesn’t happen to you is if you write out your advance directive for healthcare decisions. You can write on this document who you would want and not want to visit you. Click on my resouce page for more information about your state’s advance directive form.)

Have a kind and respectful day.

“Are you afraid of getting sued?” for healthcare professionals. An interview with Patricia Coonan, RN on June 15th, 2PM pst, 5pm est..

“Are you afraid of getting sued?” for healthcare professionals. An interview with Patricia Coonan, RN on June 15th, 2PM pst. 5PM est. There were so many listeners with questions, we have scheduled PART 2 coming on June 25th, 2PM pst, answering more questions about doctor’s documentation.

Patricia Coonan will be answering your questions regarding how to protect yourself from a lawsuit. This is a must listen to for doctors and nurses. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics. She will be discussing practical ways to help nurses and doctors stay out of legal trouble by changing your actions and changing how you document.

Patricia been a RN for 24 years and Legal Nurse since 1997. She works for the Beasley Firm as an In-House Consultant and Legal Assistant. If you are being sued, she is the person that would go through the medical records to see what happened and if you have deviated from the Standards, Protocols and Industry Practices and if you may be negligent.

Patricia has also created a training program for those nurses interested in going into the legal field. If you are interested, you can find her products on eBay under Prrn12 or at www.legalnurseprrn12.com or at pc-rn@comcast.net.

You can reach Patricia at Facebook as Patricia Coonan RN, or follow her on Twitter: pcRN.

For legal help, The Beasley Firm website is http://www.beasleyfirm.com and their offices are as follows:
The Beasley Building
1125 Walnut Street
Philadelphia, PA 19107
Phone (215) 592-1000
Fax (215) 592-8360
3000 Atrium Way
Suite 258
Mount Laurel, NJ 08054
Phone (856) 273-6966
Fax (856) 273-6913
Have a kind and respectful day.

“Navigating the Disability Benefit Process” interview with Philip Lewis PhD & J.D. on June 16th, 10AM pst.

“Navigating the Disability Benefit Process” interview with Philip Lewis PhD and J.D.on June 16th, 10AM pst. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Are you recently disabled and need to begin to apply for benefits? Or are you in the middle of trying to receive benefits and are up against a road block? Philip Lewis can help. Philip S. Lewis has worked in the field of vocational rehabilitation since 1979, assessing and providing placement assistance to persons with disabilities. He has been representing persons with disabilities to pursue benefits from the Social Security Administration since 1994. As a professional in private practice, he has provided evaluation services in varied compensatory systems including Workers’ Compensation, Longshore and Harbor Workers, Long Term Disability, and Social Security. Following graduate training in industrial psychology at California State University Long Beach, he earned a Certificate in Human Resources Management from California Lutheran University , and a Ph.D. in forensic rehabilitation and industrial psychology, from the Union Institute Graduate School. He holds a juris doctor degree from the Ventura College of Law, and completed a certificate in Alternative Dispute Resolution at Pepperdine University, School of Law. He maintains board certification as a Certified Rehabilitation Counselor.

He has represented hundreds clients both before the Social Security Administration for initial claims, as well at the Office of Disability Adjudication and Review, for those clients appearing before an Administrative Law Judge. As a former Vocational Expert appearing under contract to the Office of Hearings and Appeals, he has a detailed working knowledge of the procedural and vocational issues raised at the Hearing level. In each case heard at the Office of Hearings and Appeals, a hearing brief is prepared, which outlines the background of the claimant, summarizes the medical conditions as they apply to the “listings of impairments”’ asserts all applicable rules and case law supporting of favorable decision and confirms that in a prevailing case, that an accurate accounting and payment of all past due benefits is effected.

The claimant seeking Social Security benefits based on a disability must be prepared to aggressively pursue this claim. The initial step is filing the claim for either disability insurance benefits and/or supplemental security income benefits. Ultimately, most claimants winning their claim must appear before an Administrative Law Judge and meet the administrative requirement of establishing a disability which precludes all work in the national economy.

Mr. Lewis will be discussing the process of applying for Social Security benefits, the rules of eligibility, program differences (SSI vs. SSDI) supporting medical coverage, benefit entitlement, burdens of proof and time frames, including appeals.

Philip can be reached at http://www.hearingrepresentative.com/ or at 805-642-6080.

Have a kind and respectful day.

Taking The Car Keys Away Part 2 – Dealing with the Emotions

I have been surprised by how many people have contacted me about the issue of taking the car keys away from a loved one. What I want to add to the discussion is that we have to remember to address the emotional issues being experienced by the person losing their driving privileges. They should be angry. They should be sad. These are normal emotions as they come to terms with not only the loss of driving but the loss of their mental and physical abilities. It is a good idea to sit with them and let them speak their mind. All you have to do is listen. Don’t defend yourself. Don’t defend the doctor. Just listen. As you hear their words, think about the day when you will lose your driving privileges and find compassion for your loved one.

One technique you can use is something called active listening. With active listening, what you do is to repeat back the words and the emotions you are hearing. For example, when your mom says, “I am so mad at you for telling the doctor that I shouldn’t be driving anymore.” What you can say is, “I understand that you’re really mad at me mom and that you wish I hadn’t told the doctor.” Your natural instinct is to defend yourself or to explain the reasons you did what you did. This conversation is not about facts, it is about emotions. Just hear your mom’s heart and allow her to experience her feelings. It will probably take a while as you listen and acknowledge her feelings. As she feels heard, she will calm down. And it may take a number of conversations so don’t be upset about this. Don’t you sometimes have to vent more than once about something you are dealing with in your life? Just accept that this is part of her healing process. Hopefully over time, she will come to terms with this loss and move on in her life. But don’t expect her to be happy about losing her ability to drive. It will always be a disappointment.

Lastly, I encourage you to take a look at the first part of the HBO Alzheimer’s special found online at http://www.hbo.com/alzheimers/. It is called, “The Memory Loss Tapes” episode. About halfway through this first section, a woman whose doctor has recommended she stopped driving is put through a driving evaluation test. It is shocking to see how bad it has gotten and that to realize that she just recently lost her privileges. This woman has been a danger on the road for a long time. Please take action sooner than later and save lives.

Part 1, When should I take away the car keys? http://tinyurl.com/c9zjqp

Have a kind and respectful day

“Should you try an experimental treatment if the doctor has nothing else to offer” interview with Carol Mack PhD, June 8th at 9AM pst

“Should you try an experimental treatment if the doctor has nothing else to offer” interview with Carol Mack, June 8th at 9AM pst.

Carol Mack PhD is an oncology nurse and clinical researcher who will be answering the questions you have about signing up for an experimental treatment or Phase 1 trial. Carol did research on patients’ experiences with clinical trials. She is currently an Associate Professor of Nursing at Western University of Health Sciences.

She will discuss the differences between the different phases as well as the ethical questions that need to be asked.

Founded in 1977, Western University of Health Sciences is a nonprofit, graduate university for the health professions. The university campus is located on 22 acres in downtown Pomona, California.

Western University is one of the largest graduate schools for the health professions in California. It currently comprises the College of Osteopathic Medicine of the Pacific, (the founding college), the College of Allied Health Professions, the College of Graduate Nursing, the College of Pharmacy, and the College of Veterinary Medicine. Additionally, it will open four new colleges in August 2009: Dentistry, Podiatry, Optometry, and Biomedical Sciences. Alumni rank among the very top leaders in health care and medicine throughout the country and the world.

All of the health care programs have professional accreditations, and the university is accredited by the Accrediting Commission for Senior Colleges and Universities of the Western Association of Schools and Colleges.

What makes Western University distinctive is its commitment to humanistic values. Underlying a regimen of scientific and technical course work is a strong moral, humanistic approach to education and health care. According to Dr. Philip Pumerantz, the President of Western University, the university uses this humanistic commitment to give its students ” an education that will assist them in becoming humane, sensitive, and technically competent health care professionals. ”

Have a kind and respectful day.

“The World of the Child Who Has Lost Their Parent” interview with Margaret Allan on June 10th at 10AM, pst

Margaret Allan is a LCSW, Licensed Clinical Social Worker with a PsyD, a clinical doctorate in psychoanalysis. She is affiliated with the Institute of Contemporary Psychoanalysis in Los Angeles and is a member of the National Association for Psychoanalysis in Clinical Social Work. Margaret is a psychotherapist in private practice in Westlake Village, CA and works with Hospice of the Conejo as a facilitator in their Family Services, with individual adolescents and in a grief support group for adolescents that meets on Tuesday evenings at HOSPICE of the Conejo. http://www.thewisesource.org/hospice/

Have a kind and respectful day.

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