Beyond Translation: How Palliative Care Teams Can Partner with Medical Interpreters for High-Quality, Equitable Care

I walked into a room of mostly familiar sights and sounds—the incessant beeps of the monitor and IV pumps, the whoosh of the ventilator, the steady whir of the ECMO circuit, and a mother huddled over the bed of her son whispering words of comfort and love. However, one thing was unfamiliar: I couldn’t understand the mother’s whispers. She was speaking Mandarin, the language that she and her son shared. Being unable to understand left me wondering about her hopes and fears in light of her son’s recent deterioration.

Then, in walked Eva, the Mandarin medical interpreter from an outside agency who had been assigned to this case. She transformed the experience of both the family and the clinicians. She expertly navigated her role, providing clear interpretation between the patient’s mother and the clinical team, advocating for the family by alerting the medical team to potential misunderstandings, and sharing with the team what cultural nuances may be at play during the encounter. She even provided interpretation of what this mother was saying to her son, which allowed us to learn about his favorite songs, the other important people in their lives, and her feelings of maternal guilt. Eva was alongside this family for many hours providing her services through incredibly difficult conversations. I would not have been able to do my job as a pediatric palliative care provider without her.

After a long day, I thanked her for all her work and we said goodbye. Days later, we planned our debrief with the larger interprofessional team, and we reflected on the impact Eva made. We hoped to invite her to join, but since she was not a hospital employee, we were told it wasn’t possible. I was again left wondering, this time about Eva and how she was coping following that difficult day.

The United States is culturally, ethnically, and linguistically diverse. Twenty-two percent of the population speaks a language other than English at home, and 8% have a limited ability to read, write, speak, or understand English. People with non-English language preference (NELP) are at higher risk for poor health outcomes due to barriers to both information and overall communication, as well as racial and ethnic disparities that are exacerbated by their NELP. Within palliative care, patients with NELP experience poorer pain assessment and management, higher rates of health care utilization at end of life, and lower rates of advance care planning.

One of the first and easiest steps to mitigating these disparities is to use a professional medical interpreter in every encounter for patients with NELP. Utilizing family members, friends, or staff who are proficient in the patient’s language as medical interpreters is often not only ineffective but can be dangerous, given the complex medical issues at play.

While there can be significant barriers to providing ideal interpretation services in our current health care landscape, technological advancements have made professional interpretation much more widely accessible.

Given that medical interpreters are vital to high-quality, equitable palliative care, it is imperative that we include them as members of the larger interprofessional team. Following are strategies for partnering with medical interpreters and striving for more equitable care for patients with NELP.

Professional medical interpreters are not simply conduits providing word-for-word interpretation. They have specialized training and navigate several distinct, sometimes conflicting, roles within palliative care encounters. Interpreters report that accurate interpretation of language and meaning is their highest priority and primary role. However, they can also act as cultural brokers and patient advocates. Providing cultural context and navigating cultural discordance between providers and patients is imperative, because beliefs surrounding serious illness and death are deeply rooted in culture. Medical interpreters are uniquely positioned to advocate for patients, as they are typically the only person who understands both the patient and the health care professionals. They can identify areas of misunderstanding or miscommunication, which ensures patients have the information they need to make the best decisions for themselves. Acknowledging and understanding these complex roles enhances clinical collaboration and improves the experiences of medical interpreters and palliative care professionals alike.

Pre-encounter meetings are widely accepted as best practice within palliative care. However, medical interpreters are not often included in these meetings and therefore lack vital information and context to make the encounter as successful as possible. Data show that a pre-encounter huddle is almost universally recommended by interpreters. A brief huddle allows an opportunity for an exchange of information between medical interpreters and palliative care professionals, including but not limited to: the topic and goals of the encounter, specific language that may be used, important social or cultural context, and how to navigate possible misunderstandings. These brief huddles with the interpreter should be held regardless of the mode of interpretation. Work is underway to test implementation of a tool to help structure and facilitate these huddles.

Effective communication with patients and families when working with medical interpreters relies on many of the same communication principles used for effective communication in English, applied with more care and consideration.

Medical jargon can be problematic in communication with any patient but presents a unique challenge when caring for patients with NELP and working with medical interpreters during palliative care encounters. In fact, there is no verbatim interpretation of “palliative care” in many languages. It is important not only to avoid medical jargon, but also metaphors and idioms as they are easily misinterpreted in other languages.

Interpreters recommend utilizing clear, lay language to describe medical information instead. For example, consider describing palliative care as a team of professionals focused on the physical, emotional, spiritual, and social well-being of a patient and their family throughout a serious illness. In addition to being mindful of language, it is also important to consider speech cadence. Speaking in brief sentences or phrases and pausing for interpretation allows for smoother interpretation.

Studies have shown that medical interpreters have variable emotional responses to difficult conversations. Interpreters have reported that providing interpretation during difficult conversations gives them a sense of value, meaning, and purpose. They have also reported high levels of emotional distress following these encounters. While the impact of these encounters varies, interpreters almost universally report a lack of support following difficult encounters.

As palliative care professionals, we recognize debriefing as a best practice that allows team members to provide mutual support following difficult encounters as well as an opportunity for learning. When medical interpreters are part of the team, they should be included in these practices when possible to receive support and offer their valuable insights.

As illustrated by Eva’s story, there can be significant barriers to including interpreters in staff support, especially when interpreters are providing phone or video interpretation. When including interpreters in a larger debrief session is not possible, consider taking a few moments immediately following the encounter to debrief directly with the interpreter and thank them for their services.

Medical interpreters acknowledge the need and express interest in increased palliative care education. However, there are limited opportunities for medical interpreters to gain palliative care knowledge that is tailored to their needs. Additionally, medical interpreters recommend that medical providers receive more education regarding how to effectively collaborate with medical interpreters to provide quality care to people with NELP. This presents a unique opportunity for bi-directional education and learning for both medical interpreters and palliative care professionals.

I still think of Eva often. With her expertise, she improved the experience of that family on one of their worst days and shaped how I, as a palliative care professional, conceived of partnering with medical interpreters to care for patients and families with NELP. Integrating medical interpreters as members of the palliative care team by partnering to care for patients and families with NELP, acknowledging their expertise, providing mutual support, and facilitating opportunities for bi-directional learning are steps toward ensuring more equitable, high-quality palliative care for patients and families with NELP.

For more information see the following resources:

• Palliative care training for medical interpreters
• Information about Language Justice, its origins and applications
• Applying Language Justice in Research
• Language Justice in Palliative Care