Top Ten Tips Palliative Care Clinicians Should Know About Working with Medical Interpreters

Introduction

The large population of limited English proficiency (LEP) individuals currently living in the United States is approximated at over 25 million people, and the numbers continue to grow. ¹ Patients with LEP experience higher rates of adverse medical outcomes, receive less information about their illness, have longer hospital stays and higher readmission rates, and are less satisfied with care.^2,3 These disadvantages are compounded in the intensive care unit (ICU) where many patients with LEP may receive less information, have less understanding of their condition, have poor symptom control, and suffer poor end-of-life discussions.^4–6 Barwise et al. showed that patients with LEP in the ICU had lower rates of comfort measure orders and completion of advance directives. In addition, patients with LEP had higher rates of use of restraints and lower rates of noninvasive ventilation, despite rates of agitation that were similar to those documented for English speakers. ⁷

Communication barriers are particularly dangerous for patients and their families at the end of life. Clinicians must partner with trained medical interpreters if they are to ensure that patients with LEP receive adequate information and engage in effective communication about their illness, prognosis, and wishes. However, clinician practices while working with interpreters vary widely. Some practices for clinicians, described below, have been demonstrated to enhance communication and improve care delivery to patients with LEP. ⁸ In this article, we compile a list of 10 tips for palliative care (PC) clinicians working with interpreters that can lead to linguistically and culturally effective communication with patients with LEP with serious illnesses and their families.

Tip 1: Ensure the Presence of a Professionally Trained Medical Interpreter during Encounters and Avoid Assigning Family Members or Bilingual Staff to the Role of the Interpreter

Professional medical interpreters have been repeatedly shown to improve the care provided to patients with LEP, patient comprehension, and satisfaction with care.^2,9 In the United States, access to adequate interpretation is a federally mandated civil right for all patients with LEP. ¹⁰ However, often family members or bilingual staff members are asked to provide interpretation during medical encounters instead of a professional interpreter. Interpretation is a complex task and differs from translation. Interpreters are trained to convert spoken words from one language into another taking into account the overall meaning of the sentence and the cultural elements at play, which sometimes necessitate paraphrasing to covey the correct meaning; however, translation converts written material from one language to another. There has been a strong body of evidence highlighting the dangers of allowing family members to act as interpreters during medical encounters.^3,4,11

English-speaking family members are commonly asked to provide interpretation. It seems more convenient for the medical team, and clinicians commonly assume that family members are familiar with the patient's medical history. However, Flores et al. commented on the dangers of this practice, including the possibility of compromising the integrity of the message being delivered.^2,4,12 The clinician has no control over the message the family member conveys to the patient; family may wish to shelter the patient from bad news or simply forget part of the message and therefore may not deliver the message in its entirety. ⁴ Asking family members to facilitate communication also places an undue burden as it forces them to simultaneously process the information given by the clinician and convey that information to a loved one. In addition, it violates the patient's privacy should they not welcome the English-speaking family member into a particular encounter.

It is essential that a professional medical interpreter is included by phone, video, or in person during all encounters, not just those focused on goals of care discussions or encounters where a decision is expected to be made by the patient or family. Studies have shown that patients with LEP and families receive less information from medical teams during daily rounds. ¹³ Working with an interpreter during daily visits with the patient gives the patient and their family a good understanding of their illness and creates a trusting relationship with the interpreter and the team; the interpreter can often offer the clinician insights into patient and family concerns and inform them about important cultural aspects that affect their care.

Tip 2: Conducting a Preencounter Huddle Can Provide Interpreters with Appropriate Context for the Encounter and Facilitate the Discussion

Preencounter huddles with interpreters are the best way to begin an encounter with patients with LEP. ¹⁴ Silva et al. commented on the value of these short huddles to give the interpreter the opportunity to understand the patient's condition before conducting the encounter. ¹⁴ Some interpreters do not have access to the medical records so can be unaware of the patient's diagnosis or the extent of the patient's knowledge about their disease.

While interpreters are trained to expect a preencounter huddle, preencounter huddles seldom happen in practice and are especially rare with telephone and video interpreters. Time constraints on clinicians and interpreters often mean that interpreters arrive immediately before an encounter and are asked to begin interpreting without any prior knowledge about the patient, their condition, or their understanding of the condition.^2,4,6,15,16

An ideal preencounter huddle begins with a one-sentence summary of the patient's condition and the goals of the meeting. During these huddles, PC clinicians can also share any relevant information about patients' understanding of their condition. That information helps interpreters confidently interpret with proper contextual understanding of the patient's illness and meeting goals. Including remote interpreters in preencounter huddles is equally valuable and necessary for interpreters to know the goal of the encounter and the roles of the people involved. Moreover, huddles help interpreters prepare themselves for emotionally charged situations and give them the contextual information needed to find the best way to express the meaning intended by the clinician. This is especially true for remote interpreters who need to gain familiarity with both the physical location of the encounters as well as the content.

A final important value of preencounter huddles is to assure the interpreter that the clinician welcomes interventions by the interpreter during the encounter if the interpreter senses a culturally based misunderstanding. The power differential between physicians and interpreters may make interpreters apprehensive about intervening during encounters to address cultural misunderstandings. Wu and Rawal showed that some interpreters remained apprehensive about pausing to correct cultural misunderstandings even when the misunderstanding had serious safety implications. ¹⁷

Tip 3: Partnering with the Interpreter to Help Them Manage a Family Meeting Is Critical to Ensuring Effective Communication

Clinicians should partner with interpreters before starting the meeting to address important logistics such as who will lead the meeting, what is the best location for the interpreter, and how to handle clarifications of unfamiliar terms. Interpreters may feel apprehensive stopping a physician when they do not clearly understand what is being said; PC clinicians, therefore, should invite the interpreter to stop them at any time if the message is not clear. During the encounter, the clinician should address the patient directly rather than addressing the interpreter and include appropriate pauses during the discussion. Pausing appropriately after each thought, rather than speaking in long sentences, can improve the accuracy of the interpretation. ¹⁸

Interpreters are tasked with managing the flow of information during clinical encounters, which can be a challenge at times. Ensuring that the interpreter is positioned where they can see and hear both the clinician and patient or family member for whom they are interpreting is essential to their work. PC clinicians can help the interpreter manage conversational turn-taking by asking participants to speak one at a time, pause for interpretation, and avoid side conversations with each other. Interpreters particularly appreciate this support in larger group family meetings.

Remote interpretation poses additional challenges. To enhance remote interpretation, being cognizant of the quality of the sound during the encounter and ensuring video availability whenever possible are essential. Video interpretation has been shown to provide similar quality interpretation compared to in-person, but patients with LEP typically prefer in-person interpretation.^9,19 Video interpreters, in contrast to phone interpreters, perceive the participants' nonverbal cues and incorporate the meaning conveyed into the interpreted message. It is important to determine the patient's and family's preferences of type of interpretation before the encounter because patients with LEP from some cultures may prefer remote telephone interpretation, which maintains the patient's privacy and allows some patients to discuss their current condition more freely.

Tip 4: Discussing with Interpreters the Best Approach to Handle “Untranslatable” Words Can Reduce Miscommunication

While the meaning of “palliative care” is well known in Western society, it remains an unfamiliar specialty in many regions of the world.^20,21 Some languages do not have a verbatim translation for PC. In addition, when PC clinicians use terms such as “hospice house” without providing additional explanation, interpreters often face difficulties trying to convey a meaning that does not exist in the patient's language. Many interpreters without prior experience in PC conversations find these situations difficult to navigate. ²² Being mindful of terms used in PC such as hospice care, quality of life, advance directives, and goals of care, as well as explaining the meaning of these terms is recommended.

Interpreters and PC clinicians can plan how they want to address “untranslatable” terms. A recommended approach is for interpreters to alert clinicians during the encounter when faced with such terms and ask the PC clinicians to expand on the meaning of these terms. This ensures that the patient is provided with accurate information and alleviates the pressure from the interpreter to provide the patient with an explanation based on the interpreters' personal understanding, which is also a violation of the interpreters' standards of practice.^13,22 It is often useful for PC clinicians to collaborate proactively with the interpreters in their institution to define standard scripts introducing the concept of PC to patients and loved ones.

Tip 5: Patients' Family Dynamics May Reflect Their Cultures and May Include Unique Patient and Family Roles during End-of-Life Discussions

People from all cultural backgrounds have specific practices regarding their role during medical discussions and when receiving bad news. Interpreters act as cultural mediators when they suspect that a barrier to effective communication may stem from cultural differences. They can share this with a clinician and can then help the clinician explore a patient's common practices when engaging in difficult conversations. Interpreters may offer insight on best ways to approach end-of-life discussions with patients with LEP and their families. At the onset of the encounter, PC clinicians could inquire about patient and family preferences regarding participation in medical discussions and receiving bad news. The patient may want to delegate all medical decisions to their family and may or may not want to be involved in the discussion. Clinicians can partner with interpreters to explore the patient's and family's preferences during these encounters.

PC clinicians can also request the interpreter's input on cultural nuances in end-of-life discussions and hospice care if applicable. ²³ In addition, interpreters who interpreted for the patient in other settings may be able to give input on family dynamics and the role of the patient in a particular culture, providing PC clinicians with a better understanding of patients and their background. ¹⁵ In many smaller communities/language groups, interpreters interpret for the same patients repeatedly. PC clinicians can encourage interpreters to help the team tailor the encounter in a manner that best serves the patient and their family by sharing any pertinent information based on their prior experiences with the patient.

Tip 6: The Interpreter's Role Extends Beyond Being a Language Conduit and Includes Cultural Mediation and Occasionally Patient Advocacy

The complexity of an interpreter's role is often overlooked in the medical community, with some limiting the interpreter's role to the confines of being a language conduit. ²⁴ Several studies have addressed the multifaceted roles of interpreters, whose role extends beyond interpretation and involves cultural mediation and patient advocacy.^20–23 Rosenberg et al. commented on the interpreter's role as an active participant in the conversation. ²⁴

Many interpreters observe multiple cultural elements that influence the patient's care and can offer their insight into the cultural background that is at play during the encounter. Interpreters can guide a clinician to explore with patients their cultural norms when they suspect that cultural considerations may be preventing effective communication. Interpreters may also play a patient advocacy role.^24,25 Interpreters may need to advocate for their patients when they observe mistreatment or suboptimal care affecting the patient's safety, health, or dignity. PC by its nature can be heavily influenced by the patient's culture, so encouraging interpreters to utilize their cultural mediation role can help clinicians deliver their messages in a culturally concordant manner and minimize cultural conflicts.^15,26

Tip 7: Using the “Teach Back” Method with Patients with LEP Can Ensure Improved Patient Understanding

Encounters with patients with LEP are often lengthy and complex. At the end of such encounters, the “teach back” method, a technique in which patients or their families summarize what has been discussed during the encounter in their own words to demonstrate understanding, can be used with patients and family members to give both the clinician and the interpreter a clear idea of the patient's understanding. ¹⁸ It also allows PC clinicians to address any misunderstanding and ensure that the patient understood the overall goal of the encounter. Given the multiple opportunities for miscommunication during encounters with patients with LEP, it is easy for patients to confuse concepts or technical points during an encounter. The “teach back” method provides a layer of safety to ensure appropriate understanding.

Tip 8: Providing the Patient and Interpreter with Contact Information for PC Clinicians Can Facilitate Continuity and Accessibility of PC to Patients with LEP

Ensuring that patients with LEP have access to the appropriate contact information after an encounter with the PC team is imperative. In prior years, patients with LEP who could not call the clinician's office directly often called the interpreters' office to clarify points discussed in the care plan. Interpreters then had the burden of contacting different offices to communicate the patient's concerns and convey the answers back to the patient. In this era, where remote interpretation is becoming increasingly common, reconnecting becomes more challenging if patients with LEP are not provided with a contact number either for an interpreter or for the PC team.

To improve communications post-visit, PC clinicians can provide the patient with their contact information, which serves as an invitation to continue communicating with the PC team. The team thereby gains the ability to clarify next steps for the patient or family member both in the inpatient and outpatient setting or when the patient is transitioning from inpatient to outpatient care.

Tip 9: Involving Interpreters in Post-Encounter Team Debriefings Can Improve Patient Care and Team Dynamics

After end-of-life discussions or complex goals of care conversations with patients with LEP and families, the PC team often holds a debriefing session. Interpreters and especially remote interpreters are rarely involved in such sessions, but there is tremendous value in including them in the debrief. Interpreters can add their unique viewpoint and comment on patient and family understanding; they can also get support from the team for any personal distress the encounter raised for them. Debriefing with interpreters after routine encounters is equally important. It provides the interpreter with an opportunity to comment on the encounter and on ways to enhance future communication. Short one- to two-minute debriefs are sufficient to communicate important points and build a culture of collaboration, constant feedback, and growth. ¹⁵

During debriefs, both in person and remote, interpreters may provide insight on how to approach additional meetings with the patient, points that need to be expanded on during future discussions, and cultural elements that were at play during the encounter.^2,4 Debriefs can also allow for a short discussion on the quality of communication during encounters and ways to improve various aspects of these complex interactions.^15,16,23 Both clinicians and interpreters can share their reactions to the meeting and provide mutual support around the distress often generated by meetings about goals of care, resuscitation choices, or moving toward comfort care.

Tip 10: Interpreters May Experience Emotional Distress When Delivering Bad News and Are Vulnerable to Experiencing Vicarious Trauma

Interpreters can be and often are emotionally impacted by PC encounters as these meetings are often emotionally charged. In addition, interpreters speak in first person and are the ones giving bad news directly to patients, making professional distancing even more challenging. Over time, many interpreters develop a personal connection with their patients and the patients' families. Interpreters from smaller language groups/communities may have interpreted for patients for many years and know the patients well, providing yet another challenge to professional distancing.

After delivering bad news or having difficult conversations, PC clinicians should acknowledge the emotional burden placed on interpreters and recognize that interpreters often carry a deep connection to their patients. Interpreters have reported being deeply emotional after such encounters and often have no support system available. ²² Even when the interpreter does not know the patient personally, many share cultural bonds and similar experiences with their patients, which further adds to their emotional response to encounters. Video and telephone interpreters also share such experiences and emotional distress. Naming and addressing the emotions interpreters experience will help provide interpreters with space to discuss their emotions and debrief.^15,22,27

Conclusion

Compared with English speakers, patients with LEP face disproportional disparities while receiving care. Integrating interpreters into the medical team and relying on the interpreter's skills as facilitators of effective communication across both linguistic and cultural differences rather than a language tool alone can reduce rates of miscommunication, improve team dynamics, and facilitate effective communication. Understanding and valuing the multifaceted aspects of the interpreters' role are critical to minimizing cultural conflicts and increasing mutual understanding during encounters with patients and families with LEP, in addition to improving patient care and patient satisfaction.