Bridging language gaps in palliative care and birth

Caring for patients in palliative care and during infertility, birth and postpartum seemingly could not be more different. However, both situations are highly emotional and stressful for patients and family members. At these times, it is especially important to provide thoughtful, culturally sensitive care. This is why professional medical interpreters are vital when treating patients during these stages of life, says Dr. Perle Feldman, a family doctor in Montreal.“My teaching site is in an area where there is an enormous number of immigrants and refugees. We serve patients who speak up to 70 different languages. To care for these people, our clinics use a large proportion of our operating budget to provide different modes of translation,” Dr. Feldman said. “The hospital, in this same area, continues to use informal translators. Nurses, doctors, secretarial and others are often called away from their duties to provide appropriate and ethical care for our many multi-ethnic and multilingual patients.”She says the hospital does not fund the necessary translation services. While there are some government services, Dr. Feldman says they are not adequate. For example, some are only available from 9 a.m. to 5 p.m. on weekdays.Dr. Feldman says lack of interpreter services also presents a medico-legal challenge. “What if a patient comes in and has placenta previa and they are bleeding,” she says. “You don’t speak their language and you’re going to coerce them into a C-section, which is necessary, but they may not survive. How are you going to get informed consent?”Doctors are often left using patients’ family members as translators. “My first experience using translators happened when I was a medical student doing an intake interview and examination for a couple at an infertility clinic,” Dr. Feldman said. “They brought the husband’s sister along to translate. You can imagine how uncomfortable and awkward that was. The questions in an infertility questionnaire aren’t things you would necessarily want your sister-in-law to know.“In fact, when we got to the questions on whether the two patients had ever had any STIs, the sister skewered me with an angry look. ‘People from my country don’t do that’ and point blank refused to translate the question.”Professional translators do not insert their own agenda, Dr. Feldman said. “Good translators are gifts from God. They are fantastic and it’s a highly skilled craft.” They can also act as cultural brokers, providing cultural context and navigating perceived cultural differences, she added.Family knowledgeDr. Adam Chen, a family doctor in Oakville, Ont., says he differs from many of his colleagues in his opinion on using patients’ family members or friends as translators. “The ideal translator is not somebody who the government brings in, who doesn’t know the family. The ideal translator is somebody who knows the family. They’re not just translating the language, but sometimes also the family’s values and stories,” he said. “The government translator leaves when you leave. But the family friend stays for dinner and chews over what you just talked about. You are basically recruiting a support system. You’re not just looking for a linguist.”Dr. Chen remembers being at a palliative care course 20 years ago and every other person in the discussion warned against using a family translator because they may filter information. Having practised palliative care for two decades since, Dr. Chen says he is even more convinced of his opinion.“In the West, we think of the person’s autonomy. And we want to make sure this person has choice and is presented with all the options. But the real world is much fuzzier. I feel like it is imposing Western philosophy on people who didn’t grow up with that,” he said.An interpreter is necessary, Dr. Chen says, in discussions with family members about their support system and logistics such as whether the patient will go to hospice or have home care.Dr. Chen says that doctors who do not speak the same language as their patient can draw on their humanity and make a connection with the patient. “In regular practice, I think language is an important start, because a lot depends on content translation. But I find that in palliative care, language is not that important,” he said. “In palliative care, you need to use the universal language of compassion and kindness.”Since well-meaning family members can often be under stress and perhaps cause anxiety for the patient, Dr. Chen says a doctor can break through that and form a mutual understanding. “They feel they can communicate with you, their discomfort or fear. They have confidence that you will understand their suffering,” he said.The way we talkDr. Feldman agreed that how you communicate is critical in birth and palliative care. “It’s not so much the information that helps people, but in the way that we talk to people,” she said.“I often have to use Google Translate unfortunately, but you can get away with that if your communication and your attitude demonstrate that you have the patient’s best interest at heart.”Dr. Feldman recalls a study in the book Blink by Malcolm Gladwell. The study, by Dr. Wendy Levinson, chair of Choosing Wisely Canada, compared doctors who had never been sued and doctors who had been sued more than twice. “They found that untrained observers could differentiate those two groups with an 80% accuracy even if they couldn’t understand what was being said,” Dr. Feldman said. “And when they analyzed the medical content of the discussions, there was no actual difference. The difference was how they talked to their patients.”But while acting with care and kindness can help doctors better communicate with patients, Dr. Feldman says systemic changes are still needed regarding medical interpretation. “It has to be considered a priority, especially in high acuity areas. In places that it can’t be scheduled, there has to be access to high-quality professional translators, 24 hours a day, seven days a week,” she said.

Bridging language gaps in palliative care and birth

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