Trends in Palliative Care Research 2020; Issue #8

Commentary by Dr. Sara Taub, MD, MBe, Assistant Professor, Pediatrics; Division of Pediatric Palliative Care, Division of General Pediatrics, Oregon Health and Science University

Feature Articles: Weaver, M. S., Roeth, A., Navaneethan, H., Shostrom, V. K., & Contreras-Nourse, M. (2020). Translating Pediatric Hospital Interpreters’ Feedback From Difficult Conversations into Improved Communication. J Palliat Care, 825859720933112.

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In my experience, developing relationships and building trust are key ingredients in providing excellent pediatric palliative care to the patients and families we serve. How this happens is so variable depending on the circumstances and the family. Nurturing the so-called “rapport bucket” when times are calm, however, and then staying present during challenging periods, are both important components.  The way our team carries out these steps is often spontaneous and organic.  Certainly, we do have some pre-scheduled appointments and care conferences. Many times though, we capitalize on opportunities when we find families, at bedside, in a space to “go deep” – we lean in.

I have been struck by how much more complex relationship building can be when our team does not speak the same language as the patient and/or family. In those instances, we must rely on the professional services of language interpreters, preferably in person though sometimes, by necessity, via phone. These encounters often require more concerted planning, and so have a tendency to be agenda driven rather than more open-ended. What is more, they rely on an intermediary, which introduces the possibility for substantial variability. In some instances, the process is near seamless or may actually add value. This was the case for a recent encounter in which the interpreter had gotten to know the family. As such, she had some valuable background on earlier conversations with other teams, and was able to inform the discussion with important cultural dimensions to take into consideration. I have witnessed circumstances where the process introduced distance between the family and the team. I remember, for instance, a care conference that came to a sudden halt, at an emotionally charged moment, when the language interpreter (not at my current institution) declared the meeting had become too exhausting and sad, before taking leave! These experiences have left me wondering what safeguards and strategies can be put in place to strive to ensure that families are offered the same level of palliative care, irrespective of language concordance.

The featured article for this month begins the process of framing these questions and endeavoring to answer them. The pilot study conducted by Dr. Weaver and colleagues was built around inviting suggestions from medical interpreters to palliative care teams for how to effectively incorporate them into language discordant difficult news and end-of-life conversations. In particular, it queried responders around their inherent disposition toward interpreting in these circumstances. It surveyed aspects they identified as most meaningful and challenging. Finally, it invited specific suggestions they might have for enhancing effectiveness.  

Among the multiple themes that emerged from the study results, two interrelated ones that I found particularly intriguing were:

  • The role of the interpreter as a “communication advocate,” who can help foster a better understanding of cultural, relational and spiritual beliefs, rather than as an “invisible party” or a “neutral translator.” In this capacity, the interpreter becomes far more than an intermediary converting a message from one language to another. The interpreter serves as a navigator and a member of the team in their own right.
  • An acknowledgement of the unique insights an interpreter may have in dynamics, if they have been working with a family and have been privy to prior conversations between the family and other teams.

Insofar as there is a trusting relationship between the interpreter and the palliative care team, a shared paradigm around the purpose of an encounter, and overall agreement around scope of professional roles, the possible contributions of the interpreter could be foundational and substantial. These assumptions, however, are not inconsequential and likely would require a fair amount of prework between the interpreter and palliative care team.

The authors are proactive in acknowledging that their contribution should be seen as an early contribution in a field that deserves more consideration. After all, they have labeled their work a “pilot study” and recognize some of the limitations inherent in gathering data from a single site, with a small sample size, using a tool that is not formally validated. Nonetheless, their work lends itself to starting a conversation around some best practices for how interpreters and palliative care teams can work together. Beyond the concerns they raise, it would be interesting to parse out variations in such practices depending on whether an interpreter is physically present. Insights from palliative care teams as well would also further illuminate the discussion. Since reading this research, our team has been more deliberate about premeeting with our language interpreters. We endeavor to enter patient rooms with a shared understanding of content and to explore in advance considerations surrounding cultural context and values. We also have been trying to debrief conversations afterwards to refine how we can make our respective expertise additive. Anecdotally, we are finding this helpful in creating a stronger sense of partnership and making strides in connecting with some families that we previously had difficulty reaching emotionally. At a time when a bright light is being shined on health care access inequities and outcomes disparities that persist in the United States (and beyond), we must ask how our field can better meet the needs of all the patients we serve.