The author has a background in ASL and Deaf culture, having a son who is Deaf and having provided residential supports for Deaf people with disabilities. She has spoken on Deaf Culture and Mental Health in Deafness in her home state of Michigan.

I have a new patient who is deaf. What do I need to know about communicating with her?

I am assuming you are talking about a person who uses sign language as her primary way to communicate. Late-deafened people and those who have some hearing (correctly referred to as "hard of hearing") need special considerations for communication, but their needs are different from those who use sign language. This column will address the needs of those who use sign language.

Deaf (this is the proper term, never "hearing impaired") people who use sign language are one of the most misunderstood groups in the United States.

Here are a few things you should know about Deaf people:

1. Deaf (often capitalized to show pride and connection with the Deaf community) people usually do not consider themselves to have a disability. Rather, they consider themselves to be members of a linguistic minority, like Spanish speakers. They do not want to have their ears fixed.

2. Deaf people often have strong bonds with other Deaf people. These individuals have their own community with social norms, customs, art, history, and culture that is different from the hearing (this is how Deaf people refer to non-Deaf people) community.

3. Although some Deaf people can speak and/or read lips to an extent, if their primary means of communication is sign language, you cannot rely on these methods when discussing serious matters such as health. Reading lips is notoriously difficult. Only about 25% of English is visible on the lips. Relying on lip-reading when discussing medical topics can lead to tragedy.

4. Typically, in the United States, English is a Deaf person's second language. Because the rules of spoken language and those of sign language are very different, many Deaf people have difficulty mastering English. Writing back and forth may be acceptable when making small talk but not for giving information about a medical condition, diagnosis, and treatment. If the person grew up in a country where the dominant language is not English, even small talk may not be possible using pen and paper.

5. When in the presence of a sign language interpreter, always look at the Deaf person, not the interpreter, even when the Deaf person is concentrating on the interpreter.

6. Some Deaf people may prefer to use technology to communicate, for example, a phone app that turns English into the printed word.

7. Another means of communication is Video Remote Interpreting (VRI). VRI involves a computer screen and a camera that allows a person in a remote location to act as an interpreter. However, there are significant limitations with this technology. For example, the interpreter may not be able to see the Deaf person's body language, or, depending on their body position (such as lying in bed), their hands, and face. Because a significant part of sign language involves the face and body, it is critical that the interpreter be able to see the whole person. Many Deaf people see the VRI as a poor substitute for a live interpreter.

8. To assure a positive outcome, it is very important that the Deaf person be allowed to pick the method of communication. Do not pressure the person to choose an option because it will save money. Err on the side of an interpreter.

9. You may encounter a person whose primary sign language is not American Sign Language (for example, Mexican Sign Language). On rare occasion, you may have a patient who has little to no language, either signing or written (for example, a person who was born in a country where no education was afforded to the Deaf). There are special interpreters who can assist in these situations. If you have such a patient, contact the local deaf advocacy organization for direction.

10. Encourage your agency to include information about the Deaf community as part of it's diversity training.

Here are the rights of the Deaf under the Americans with Disabilities Act (ADA), (U.S. Department of Health and Human Services, 1990).

1. Your agency cannot refuse to serve someone because he or she is Deaf or because the agency does not want to pay for an interpreter. Large penalties can apply if your agency is sued.

2. Your agency must facilitate "effective communication" with the Deaf person. In many cases, that will be a sign language interpreter. The cost of the interpreter is borne by the agency.

3. There are a few exceptions to having to use the method of communication picked by the patient:

a. If the method would provide an undue financial or administrative burden to the agency. For most home healthcare agencies, this would not be a legitimate claim.

b. If the method would fundamentally change the service. This exception does not apply to the situations addressed in this article.

c. Another method would result in a service that is equally effective. This is the claim some agencies make for using VRI, but as we have discussed, there may be significant problems with VRI.

4. Many agencies believe they are in ADA compliance if they have a TTY (or TDD; different names for a text telephone) but these machines have long been obsolete. Most Deaf people use texting or VRS (video remote services) that allow the Deaf person to communicate with an interpreter via camera, while the interpreter calls the agency to translate. It is important that your agency know the method the person uses to contact your office. Deaf people tend to be very technologically savvy so the technology for communication is always evolving.

5. The ADA requires that your agency provide a "qualified" interpreter. You cannot rely on a person who has taken a few sign classes or just anyone who claims he or she knows sign. Each state has its own rules for interpreter certification. In some states, special certification is required to do medical interpreting. Always use a reputable organization for your interpreters and encourage the patient to ask to see the interpreter's proof of competency.

6. If a hearing patient has a family member or other involved person who is Deaf, you must provide an interpreter for that person.

7. Do not rely on a companion or family member, especially a child, to interpret. These individuals most likely lack the impartiality and specialized vocabulary to be effective in medical situations.

8. There are two exceptions when a companion or family member can be used instead of a qualified interpreter:

a. In an emergency involving imminent threat of safety or welfare, but only until a qualified interpreter arrives.

b. If both the Deaf person and the companion (or family member) insists upon this. This exception does not apply to minors or where the agency has reason to doubt the person's impartiality or effectiveness. Best practice is to have both parties sign a statement that they agree to this arrangement without being pressured.

All these dos and don'ts may make you hope you never get assigned to care for a Deaf patient. However, working with a Deaf person (like anyone from a culture different than yours) is an enriching and rewarding experience. Deaf people will welcome hearing professionals who are open-minded, respect their choice of communication, and strive to provide the same quality of care provided to other patients. You may even find yourself learning a little sign language!

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