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LANGUAGE DIFFICULTIES
Entering a health care facility or using a health care service can be a daunting experience for a person who does not speak English. Nurses and other health care workers face similar obstacles to communication. A patient may be unable to communicate questions, concerns, needs, and fears, and the nurse may be unable to perform a health history, ask about symptoms, or provide education. In fact, every part of the nurse-patient relationship may be compromised.
When a patient does not speak English, the nurse will need to find an interpreter. Interpreters should not be family members, interpreters should be objective translators hired by the facility or through a translator service. Telephone interpretation services are also available. It is best to use an objective translator because family members can be biased and not accurately reflect the patient’s words, or patients may be reluctant to be truthful with family member as translator. The facility should supply an objective interpreter or employ a service. Health care providers need to obtain truthful history information from the patient and in some cultures this may not be possible if you use a family member as a translator. This is a patient safety issue.
Children and adolescents should never be put in a situation in which they are expected to interpret for parents and other adult family members unless it is an emergency situation.
For informed consent or end-of-life care conversations, finding a neutral third party who also speaks the patient’s language is a prudent
idea when possible. Health care institutions are supposed to provide interpreters or interpretation devices for patients who cannot speak English. A spouse or family member or a staff member should not be used for interpretation in order to maintain confidentiality for the patient. Failure to have a reliable translator can result in a lack of informed consent and liability for the health care facility.
idea when possible. Health care institutions are supposed to provide interpreters or interpretation devices for patients who cannot speak English. A spouse or family member or a staff member should not be used for interpretation in order to maintain confidentiality for the patient. Failure to have a reliable translator can result in a lack of informed consent and liability for the health care facility.
Essential Documentation
The nurse needs to:
Document the primary language spoken by the patient.
Include the names, addresses, and telephone numbers of interpreters.
Place in the patient’s chart a list of staff members approved by the facility to act as interpreters. When a translator is used for an event, such as patient education, discharge instructions, or informed consent, record the name of the translator on the appropriate form or in the nurse’s notes. If a telephone interpretation service is used, record the call number assigned by the service for future reference.
Describe alternative forms of communication used, such as a picture board or flash cards.
Because narrative notes are often permitted but rarely used in electronic health records (EHRs), a narrative note should be inserted. The nurse needs to describe why the interpreter was called, particularly if the conversation is a preoperative or preprocedural informed-consent discussion. Interpreters are absolutely required in the creation of vital documents such as a health care power of attorney (HPOA) or guardian for surrogate decision-making, durable power of attorney (DPOA), or creation of last will and testament. These are legal documents that have requirements in order to be considered valid. If there is concern about how these conversations are being conducted, it is necessary to notify the nursing supervisor and the agency’s on-call administrator. It is important to document the names of all present during conversations and their relationships to the patient, as well as to document the patient’s level of consciousness (LOC) and ability to participate in the discussion.
LAST WILL AND TESTAMENT, PATIENT REQUEST FOR WITNESS OF
Patients, especially those who believe or have been told that they are dying, may ask that the nurse witness a last will and testament. In many states, a nurse can witness a patient’s signature on a will. However, the nurse does not have a legal or ethical responsibility to act as a witness. Before witnessing a will, a nurse should check the facility’s policy or ask the facility’s legal consultant. (See Witnessing a will, page 233.)
If patients ask the nurse to be a witness for either an informed-consent conversation or when they draw their last will and testament, the nurse should notify the health care provider and supervisor before acting as a witness. It is not appropriate to give any legal advice or offer assistance in the wording of the document. Equally inappropriate is commenting on the nature of the patient’s choices. The nurse’s note should document the nurse’s actions. The nurse should avoid being involved in the creation of a last will and testament if the patient does not meet the four tests of legal competency: (1) that a choice has been made, (2) evidence of choice, (3) that the choice is one that a reasonably prudent person would also have made under similar circumstances, and (4) the patient’s understanding.
LEGAL CASEBOOKWITNESSING A WILL
In many states, the nurse’s signature on a will certifies that
the nurse witnessed the signing of the will,
the nurse heard the maker of the will declare it to be the patient’s will, and
all witnesses and the maker of the will were actually present during the signing.
By attesting to the last two facts, the nurse helps to ensure the authenticity of the will and the signatures. However, the nurse’s signature does not certify the competency of the maker of the will.
Before signing any document, the nurse should read at least enough of it to make sure it is the type of document the maker represents it to be. Usually, it does not require reading all of the text, and legally, that is not necessary for the nurse’s signature to be valid. However, the nurse should always examine the document’s title and first page and give careful attention to what’s written immediately above the place for the witness signature.
Because family members’ judgment may be swayed according to whether or not they are beneficiaries of the will, a court-appointed guardian ad litem may be indicated in some cases. The American Nurses Association (ANA, 2015) Code of Ethics for Nurses with Interpretive Statements places the primacy of the patient as the nurse’s first priority. If the nurse suspects coercion, inducement, or unfair persuasion of the patient, it is essential to notify the supervisor and the organization’s legal counsel immediately.
Essential Documentation
When witnessing a written will, the nurse should:
Document that it was signed and witnessed, who signed and witnessed it, who was present, what was done with it after signing, and what the patient’s condition was at the time.
Document the name of the health care provider, facility attorney, or any other person (e.g., nursing supervisor) who was notified, and record the time of notification.
Record instructions that were given and the actions taken by the nurse.
Record that the nurse heard the maker of the will declare it to be the will of the patient and that all witnesses and the maker of the will were actually present during the signing.
Make sure to obtain and make copies of any documents, such as living wills, durable HPOAs, DPOAs, or other legal documents pertaining to provision of the nursing and other health care providers at hand, and include them in the patient’s paper record or scan them into the patient’s EHR.
Witnessing a Will
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LATE-DOCUMENTATION ENTRY
Late-documentation entries are appropriate in the situations noted in the following list. However, keep in mind that a late or altered chart entry can arouse suspicions and can be a significant problem in the event of a malpractice lawsuit. (See Avoiding late entries, below.)
If the chart was unavailable when it was needed—for example, when the patient was away from the unit (e.g., for x-rays or physical therapy)
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