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Journal of Obstrectic Anaesthesia and Critical Care
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Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 1-4

Enigma of valid consent continues in 2021……

Fellowship Obstetric Anesthesia, University of Toronto, Canada; Consultant Anaesthesiologist, Hinduja Hospital, Khar, Mumbai, Maharashtra, India

Date of Submission09-Mar-2021
Date of Acceptance19-Mar-2021
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Shilpa Kasodekar
Consultant Anaesthesiologist, Department of Anaesthesia, PD Hinduja Hospital, 11th Road, Khar West, Mumbai - 400 054, Maharashtra

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_22_21

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How to cite this article:
Tilak A, Kasodekar S. Enigma of valid consent continues in 2021……. J Obstet Anaesth Crit Care 2021;11:1-4

How to cite this URL:
Tilak A, Kasodekar S. Enigma of valid consent continues in 2021……. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Oct 24];11:1-4. Available from: https://www.joacc.com/text.asp?2021/11/1/1/313906

Delivering quality healthcare and accessing it is still a challenge in many developing countries. There are obvious hurdles like lack of resources and awareness. Also, there are some easy to miss factors like communication issues. In spite of a growing recognition of the importance of doctor–patient communication, the issue of language barriers to healthcare has received very little attention in India. The element of consent is one of the critical issues in medical practice. The consent is deemed valid only if explained in the language best understood by the patient. However, if this does not happen, then the patient may have grounds to sue the doctor for medical malpractice.

There are many official languages in different parts of the world [Figure 1]. However, countries like India and South Africa, with the number of official languages in double digits and an even higher number of regional dialects and variations, are an exception. Likewise, there are more than 20 languages spoken in India [Figure 2] with Hindi being spoken by most Indians. The other widely spoken languages are Bengali, Marathi, Telugu, Tamil, Gujarati, Urdu, and Kannada. As per the constitution, there are 22 official languages in the country.[1] Countries like the United States of America, United Kingdom, and other European countries with a predominantly English-speaking population are also facing difficulties since migration has made communication and information sharing really challenging.[2]
Figure 1: World map showing multilingual countries

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Figure 2: India as multi-lingual country

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According to the U.S. Census Bureau, nearly 25 million people in the U.S. have Limited English proficiency (LEP). Effective communication is such an important part of the treatment process that communication errors have been found to be the cause of 59% of serious adverse events reported to the Joint Commission.[3]

Analysis of adverse incidents in the hospital setting revealed that 49.1% of LEP patients endure physical harm, compared to 29.5% of English-speaking patients.[4]

Communication, verbal or written, is the key to provide safe patient care in the healthcare setting as it facilitates a clear exchange of information between patients and providers. Language understood and interpreted correctly, not only enhances healthcare safety but also increases patient satisfaction and confidence in the entire healthcare system. Awareness about language rights is increasing in the western world. It is a regular practice to have patient information leaflets in a few of the most commonly spoken languages. However, the situation in the developing world is more complicated.

There is a huge difference seen in Government run hospitals and private hospitals in developing countries like India. The problems in State run hospitals or smaller medical facilities are that approval of even a meagre change has to go through statutory channels and is time consuming. Thus, getting a translator either a digital app or a person, may not be on their priority list. The level of awareness and literacy among healthcare seekers in rural setups keeps them ignorant of their right to correct information. Moreover, the Government and State run hospitals in developing countries like India are clearly overburdened to handle the patient load. In this scenario, understanding the basic language problem takes a back seat. The Ministry of State for Health and Family Welfare has stated the following data in Lok Sabha: In India, there is one doctor for every 1,457 people (published in GK Today July 2019)[5] or a deficit of 600,000 doctors. The nurse patient ratio is 1:483, implying a shortage of 2 million nurses. It is interesting to know that Qatar has the most doctors per capita, with 77.4 doctors per 10,000 people.

The social reality in a country like India is that there are still many communities who speak neither the official languages nor the scheduled languages. The 2011 census of India lists a total of 99 non-scheduled and 22 scheduled languages. The 22 scheduled languages are major languages, each spoken predominantly in one particular region. 96.7% of the population has one of the scheduled languages as their mother tongue.[6] Each language has several dialects and regional variations that people outside of a very limited area do not understand.

When experience of doctors and patients with language barriers is assessed, it is found that there is an increased incidence of misdiagnosis and delayed treatment from the doctor's side. From the patient's perspective, there is a poor understanding of diagnosis and treatment and a generally low level of confidence in the healthcare encounter.[7]

  Specific Hurdles Pertaining to Anesthesia Consent Top

As anesthesia providers, it is our duty not just to fulfill our legal obligation by completing the necessary paperwork, but also to do what is ethically right for the patient. And that is, making sure the process of consent taking is followed in letter and spirit. In order to ensure safe anesthesia, it is imperative to know certain never-to-be-missed-out things such as the fasting history, medical and surgical history, and history of allergies. It is useful to learn certain keywords and small sentences in local regional language or to have a translator. It could be a nurse, attendant, patient's relative, or any hospital staff on duty, if professional help is not possible, especially in odd hours and emergency surgeries.

It can be even more difficult both practically and legally. The Obstetric Anesthesiologist has to attend emergencies wherein he/she often meets the patient for the first time either for emergency cesarean delivery or to provide labor analgesia. In such scenarios, the expectant mother may not be in a sound mental state to offer consent due to severe pain of labor. Over and above this, if there is a language barrier, then procuring a valid consent can be doubly challenging.

There is a plethora of healthcare facilities in India to cater to the population of 1.37 billion, varying from small outpatient clinics to smaller and bigger nursing homes, to government and municipal hospitals, to corporate and private hospitals. Though they are bound by some basic standards, maintaining standards as well as uniformity in practice and guidelines seems to be a difficult task. This is purely because of lack of strict monitoring by governing bodies, variability in medical qualification (allopathy, homeopathy, Ayurveda, Unani), standardization of quality of doctors, and lack of infrastructure across India especially in rural areas. This directly impacts procuring and formatting standard consent forms for medical, surgical, and anesthesia practices.

It is mandatory to have a separate informed consent form for anesthesia related complications and must be taken by an anesthesia provider as only he/she can impart anesthesia related necessary information and explain the risks involved.[8]

  Major Reasons for Language Barrier in Hospitals Across India Top

Poor literacy rate

The literacy rate of India according to the 2011 census is 74%t with a wide difference between rural and urban literacy rates (males: Rural - 78.57; Urban - 89.67 and females: Rural - 58.75; Urban - 79.92).[9] Steady rates of increase in female literacy were associated with declining maternal mortality ratios.[10]

Limited English-speaking population

In contrast to the variety of spoken languages, the language of teaching in medical schools all over the country is English. It is not always possible to translate the technical and scientific terms precisely in the local languages. Often the vernacular terms used to explain diagnosis or treatments are too crude for the patient to make a truly informed decision. Doctors across India learn and use medical terms and other terminologies in English. However, it is estimated that 10% of the Indian population can speak English as a second language.[11] This means 90% of the population will have limited ability to understand the biomedical information given to them while seeking health assistance.

Poor health literacy status

The level of health literacy determines how well people are able to use the available health infrastructure and make empowered choices. The general literacy status is not always an accurate predictor of the health literacy of the population. In a study done at a tertiary hospital in South India, it was found that health literacy levels were below adequate levels in more than 50% of the study population.[12]

Migration across state borders

Most hospitals in India attract a population from 4 to 5 different language speaking regions. This may be because of migration across state borders for employment or to seek specialized treatment. Similarly, the treating doctors often choose to live and work in a state far from the one where they have grown up or trained, depending on the job opportunities available.[13] They are thus unfamiliar with the local culture and languages.

A valid consent must be given by a competent patient, with the capacity to understand and process the information given, weigh the pros and cons of treatment options, and communicate clearly his decision,[14] which is quite problematic in the presence of language barriers.

  Barriers Specific to Obstetric Population Top

  1. In the obstetric population, there is both illiteracy and gender inequality. The inherent gender inequality makes the situation trickier for the rural Indian woman. Socioeconomic factors including education level of the female population is an important factor influencing their ability and desire to seek healthcare.[15]
  2. Pregnancy and delivery are dynamic in nature and at particularly vulnerable junctures, much more than basic literacy is needed to make a truly informed decision. Especially given the dynamic nature of obstetrics and obstetric anesthesia, it takes seconds for the situation to turn critical, taking a 180 degree turn, and that is when critical decisions requiring patient participation needs to be taken.
  3. Consent is needed each time there is a change of plan. This leaves plenty of room for misunderstanding and potential future complaints and litigation. For instance, “operation” is a very loose term that can mean anything from cesarean section to repair of a cervical tear. Obstetricians have to be extra cautious while obtaining consent for family planning procedures. Familiarity with vernacular “keywords” reassure both the doctor and the patient that the correct information has been provided and understood by both parties. Consent when given by proxy by the patient's husband or family members is often found to be delayed and associated with poorer outcomes and patient satisfaction.[16]

In the 21st century, when we talk about women empowerment, it becomes our social responsibility as an attending doctor to ensure the female patient has clearly understood the benefits and risks involved in any procedure or surgery. This will enable the patient to take ownership of her own decisions rather than family members acting on her behalf because of language barriers.

  Probable Solution for Indian Scenario Top

A multilingual setting like ours needs patient information leaflets, discharge instructions, consent forms in a few languages. The super-specialty hospitals catering to patients from all over the country especially require a team to look after the communication needs of the patients. This would be in a similar vein to a social services cell that most government hospitals have.

In a government setting where junior doctors are overworked, they may not have the luxury of time to ensure that the consent is understood before being signed. A language cell will take this burden off doctors and make for a better patient experience. For the less commonly encountered linguistic groups, translator tools might be useful. These include online applications, video conferencing with translation services, phone interpreters. Interactive audiovisual tools can be used to better explain the planned procedures and what to expect during the hospital stay. If hospital staff is familiar with other languages, their skill in explaining medical terms and procedures must be formally assessed and they could play a special role in our healthcare setting.

The intervention of professional interpreters contributes to improved patient and health professional satisfaction, guarantee of medical ethics in relation to informed consent and confidentiality, improvement of treatment comprehension, health education and information, increases efficacy and efficiency of time used during consultation, reduction of the risk of medical errors.[17] A basic requirement for the interpreters should be medical fluency in the target language and maintaining patient confidentiality. While we make use of interpreters, it is our moral duty to ensure that they sign a document of understanding to maintain privacy of patient details.

With medical tourism in India picking up pace, it is not unusual to find foreigners from other non-English speaking countries coming for treatments. In hospitals with significant inflow of foreign patients from a particular region, trained interpreters need to be made available. Ensuring their presence at crucial times in the care pathway is the key. Studies have shown that availability of professional interpreters at critical times is limited in most institutes.[18] In order to avoid errors and omissions while interpreting medical terms, the language services need to be of a certain standard and require assessment before being used.

To maintain the sanctity of consent forms and to curb this large lacuna of language barrier in healthcare industry in India, we urge the local Medical bodies such as the State Medical Council of respective states to provide standard consent forms for both surgery and anesthesia as well as high risk consent forms as a free download (with their watermark and copyright) for all medical professionals on their respective websites.

These “probable solutions” may be far from ideal, to provide good communication, but they are a step in the right direction, towards ensuring better healthcare for the population.

  References Top

Constitutional Provisions Relating to Eighth Schedule. Available from: https://Mha.gov.in/Sites/Default/Files/Eighth_Schedule.Pdf.  Back to cited text no. 1
Jaeger F, Pellaud N, Laville B, Klauser P. The migration-related language barrier and professional interpreter use in primary health care in Switzerland. BMC Health Serv Res 2019;19:429.  Back to cited text no. 2
Wasserman M, Renfrew M, Green A, Lopez L, Tan-McGrory A, Brach C, et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual 2014;36:5-16.  Back to cited text no. 3
Hu P. Language barriers: How professional interpreters can enhance patient care. Radiol Technol 2018;89:409-12.  Back to cited text no. 4
Available from: www.tribune.com 2019.  Back to cited text no. 5
de Moissac D, Bowen S. Impact of language barriers on quality of care and patient safety for official language minority francophones in Canada. J Patient Exp 2018;6:24-32.  Back to cited text no. 7
Waisel DB. Legal aspects of anesthesia care. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Miller′s Anesthesia. 7th ed. Philadelphia USA: Churchill Livingstone, Elsevier; 2010. p. 221-33.  Back to cited text no. 8
National Sample Survey Office (NSSO) | Ministry of Statistics and Program Implementation | Government of India.  Back to cited text no. 9
Pillai V, Maleku A, Wei F. Maternal mortality and female literacy rates in developing countries during 1970–2000: A latent growth curve analysis. Int J Popul Res 2013;2013:1-11.  Back to cited text no. 10
Rathnakar UP, Belman M, Kamath A, Unnikrishnan B, Shenoy KA, Udupa AL. Evaluation of health literacy status among patients in a tertiary care hospital in coastal Karnataka, India. J Clin Diagn Res 2013;7:2551-4.  Back to cited text no. 12
Narayan L. Addressing language barriers to healthcare in India. Natl Med J India 2013;26:236-8.  Back to cited text no. 13
General Medical Council. Consent: Patients and Doctors Making Decisions Together. London: GMC; 2008.  Back to cited text no. 14
Jothula K, Reddy P, Rineetha T, Sreeharshika D. Health care seeking behaviour among rural women in Telangana: A cross sectional study. J Family Med Prim Care 2020;9:4778-83.  Back to cited text no. 15
  [Full text]  
Bako B, Umar N, Garba N, Khan N. Informed consent practices and its implication for emergency obstetrics care in Azare, north-eastern Nigeria. Ann Med Health Sci Res 2011;1:149-57.  Back to cited text no. 16
[PUBMED]  [Full text]  
Is the use of interpreters in medical consultations justified? A critical review of the literature, www.pass-international.org; Ribera JM, Hausmann-Muela S, Grietens KP, Toomer E.  Back to cited text no. 17
Bischoff A, Bovier P, Isah R, Françoise G, Ariel E, Louis L. Language barriers between nurses and asylum seekers: Their impact on symptom reporting and referral. Soc Sci Med 2003;57:503-12.  Back to cited text no. 18


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