An 87‐year‐old Russian‐speaking man with a history of peptic ulcer disease presented to the emergency department (ED) with 1 week of abdominal distension, nausea, and vomiting. An abdominal CT scan showed gastric outlet obstruction with findings concerning for malignancy. The patient was admitted to the medicine service for a diagnostic esophagogastroduodenoscopy (EGD). The medical team attempted to assess the patient's decision‐making capacity via a phone interpreter; however, the patient was uncooperative, and a professional, in‐per‐son interpreter was not available. The patient declined further interventions and was allowed to leave against medical advice. Over the next week, the patient was readmitted to the medicine service twice for persistent gastric outlet obstruction, coffee‐ground emesis, and worsening anemia. He continued to refuse all interventions, including blood transfusions, and left on both occasions against medical advice. Use of a professional interpreter to assess decision‐making capacity was not documented. Less than 2 weeks following his first ED presentation, the patient was admitted to the hospital a fourth time with gastric outlet obstruction, as well as acute critical foot ischemia. He was admitted to the vascular surgery service. He again declined all treatment and interventions. Psychiatry was consulted, conducting an assessment with the assistance of an in‐per‐son interpreter that concluded that the patient unequivocally lacked medical decision‐making capacity, and the patient's wife was designated as the surrogate decision maker. The patient underwent EGD and was found to have advanced gastric cancer. He was discharged a few days later with home hospice services.
Limited English proficiency (LEP) is an often‐overlooked risk factor for preventable adverse events. In this case, earlier use of a professional, in‐person interpreter would have identified the patient's lack of decision‐making capacity, led to earlier diagnosis, and prevented 3 readmissions. In the United States, approximately 19 million people have LEP, and studies have shown that these patients are at increased risk for longer hospitalizations, readmissions, and more frequent and severe adverse events, more than 50% of which are a result of communication errors. Professional interpreters are an important and effective intervention to improve patient safety and quality of care. The Joint Commission's Patient‐Centered Communication Standards recommend that hospitals identify LEP patients on admission and provide professional language services 24/7.
Physicians need to be aware that LEP is a patient safety risk and should screen and identify LEP on admission. Physicians should use professional interpreters to communicate effectively with LEP patients, and in a capacity discussion, in‐person interpreters should be used. In addition, hospitals need to provide 24/7 access to professional interpreter services.
S. Iobst ‐ none; S. Ranji ‐ none
To cite this abstract:Iobst S, Ranji S. A Case of Mistaken Capacity. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 301. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-mistaken-capacity/. Accessed September 19, 2019.