Abstract
Background
Family presence is an important source of meaning and comfort to patients with serious illness and the bereaved. 1 However, coordinating visits can be challenging for patients who have loved ones living internationally. Depending on their country of origin, family members may need to obtain B1/B2 visitor visas (colloquially known as general tourist visas) to enter the United States. This can be a long and complex process—wait times for a visa interview can take over a year, and application processing after the interview can take additional months.2,3 In short, visa processing times can exceed the life expectancy of the patient. Fortunately, if a visa is available, the U.S. Department of State will consider opening an earlier visa appointment in the event of a relative’s life or death medical emergency. 4 To qualify for an earlier interview appointment, applicants must provide proof of the situation, such as a letter from a clinician explaining the medical emergency. 4 Thus, patients may ask their clinician to write a medical letter for submission with their relative’s visa application. This Fast Facts offers advice to clinicians on how to write an effective letter to facilitate visitor visas in the United States.
Requirements for a U.S. B1/B2 Visitor Visa
Clinicians may find it helpful to know that the process is not solely dependent on the letter they write. During their visa interview, they must establish other requirements, including the purpose of their trip (e.g., visiting an ill friend or family member), their ability to pay all costs of the trip, and their intent to depart the United States after the trip (e.g., offering compelling reasons to return home, like work or family ties). 5
Disparities in End-of-Life Care
In addition to facing health disparities due to cultural, financial, and language barriers, visa requirements may prevent patients who are immigrants from seeing loved ones one last time. 6 Low English proficiency and limited access to computers and transportation can make navigating the visa application process even more difficult. This adds to the overall challenge the patient and their families mutually face in an already tough situation. Writing an effective letter is one way the clinician can support vulnerable patients and families in their time of need.
Writing an Effective Letter
Remember to establish that their purpose of travel is to visit a family member facing end of life—a key consideration for an expedited visa interview. The clinician author has two main additional goals: Establishing their credentials with the Consular Officer and providing a concise and understandable medical explanation for the life-or-death situation.
Time is limited. If you believe the patient is dying and has loved ones overseas who would want to visit, proactively offer to write a letter. There’s no need to wait for the patient’s request. Obtain permission to disclose the patient’s health information to family abroad. Patients sometimes withhold medical information from their families in a desire to protect them, or they want to wait to tell families in person. Warn the patient that the letter will use explicit language like “death” and “dying.” You may even choose to write the letter with the patient to make sure they are okay with the wording. Establish credibility by using official letterhead and starting with an introduction. What is your name? What is your professional title? What is your role in the patient’s care? Identify the patient and family member, using their full legal names, nationalities, and dates of birth. Describe the medical picture. Include the patient’s diagnoses and conditions in layman’s terms. Phrases such as “not responding to treatment” or “declining despite aggressive treatment” are illustrative. Explain why the patient is not medically able to travel to see family. Be specific about prognosis. Estimated time frames such as “days to short weeks,” “weeks to a few months,” or “less than a year” are helpful. Utilize the word “hospice” if appropriate. If the patient is enrolling in hospice, specify that since this is a very understandable term and care plan to consulates. Consider what caregiving tasks are needed. Provide examples of care the patient will need. If applicable, explain that home hospice does not provide 24/7 care, and family is needed to participate. End with an invitation. Encourage the visa Consular Officer to contact you with further questions if needed. As per the U.S. Department of State, letters are required to include the clinician’s and/or medical facility’s contact information.
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A clinical social worker may also serve as a contact person for the interviewer should they have further questions.
What Happens Next? The Visa Interview
The clinician’s letter may help the family member obtain an earlier visa interview. During the visa interview, that same letter may help the applicant establish their purpose of travel by offering context and details about the patient’s condition. The applicant’s qualifications will be assessed along with other, nonmedical factors such as their ability to finance the trip and their ties to their home country. 5 If the patient’s family is having difficulty navigating the application process, a clinical social worker may be able to connect them with legal assistance resources.