Background     During times of emotional stress and conversations that touch the inner soul, it is most comforting and safe for patients and families to describe feelings and thoughts in their primary language. This Fast Fact reviews key issues when using interpreters in the palliative care setting.

Using Health Care Interpreters vs. Family

• Medical interpreters who have completed specific training and follow national standards/ethics of practice (National Council on Interpreting in Healthcare) should be utilized in caring for patients with limited English proficiency.
• Although using family members may seem convenient, it is fraught with problems.  There is no assurance they will have the necessary language skills to convey medical information and the patient may not feel comfortable expressing their feelings through family members.  Family members may misinterpret medical phrases, censor sensitive topics, or summarize discussions rather than translating them completely.  Family members may have strong emotions that affect their objectivity and impartiality.  Being the bearer of bad news or discussing contentious information may have negative implications for a family member following the encounter.

Interview Strategies

• Brief the interpreter before meeting with the patient/family. 
  • Explain the purpose of the encounter, your role, and the physical set-up of the room. 
  • It is important to warn the interpreter if you will be discussing end-of-life issues and/or using the word “dying.”  Emphasize that your statements should not be changed and that if your statement cannot be translated directly, the interpreter should alert you to rephrase. 
  • Ask the interpreter whether there are any anticipated cultural barriers or frameworks that should be explored during discussion with the family. Cultural frameworks may impact care and should be addressed (see Fast Fact #78 & 216). Do not assume the patient will take on any specific cultural value. 
• Allow the interpreter to introduce him or herself to the patient and explain role.
• Ensure to the patient and family that confidentiality will be maintained. 
• You and the interpreter should be at eye level with the patient and you should directly face the patient while speaking, just as you would in a non-interpreter situation.  Avoid the tendency for the patient and provider to give the appearance of speaking to the interpreter, rather than to each other.  When at the bedside, you and the interpreter should be on the same side of the bed next to each other to prevent unnecessary turning of the patient’s head from side to side. 
• Keep your sentences and questions concise.
• Avoid saying to the interpreter, “Ask him…” or “Tell her….”  Speak directly to the patient using the first person: “I am here today to talk to you about….”
• Professional interpreters are required to interpret all information that is provided as outlined in their code of ethics. Do not tell the interpreter, “Do not translate this….”
• Resist the tendency to raise one’s voice when trying to communicate with someone who speaks a different language.  
• Pause at the end of each statement to allow the interpreter time to interpret.
• Pay attention to non-verbal clues that the patient/family is confused or that your comments were misinterpreted (e.g. puzzled look, furrowed brow). Stop and clarify that the interpreter and patient/family have understood the information.
• To ensure your message is accurately understood, rephrase important points in multiple ways and use teach-back methods.
• Remember to use the same empathic listening skills and statements that you would use with English proficient patients.
• Following the interview give the interpreter an opportunity to ask you questions or make comments about the encounter.  If the discussion was emotionally charged, check-in with the interpreter, “How are you doing?”  Or, “Was that very distressing for you?”

The need to use an interpreter implies that significant cultural differences exist between you and the patient/family.  Professional interpreters can help you to provide effective and efficient communication that is culturally sensitive.  Check with your institution to see what resources are available to work with limited English proficiency patients.  Companies that provide trained telephone language interpreters for health care workers include Language Line (http://www.languageline.com), Pacific Interpreters (www.pacificinterpreters.com), CyraCom International (www.cyracom.net), Telelanguage (http://www.telelanguage.com) and MultiLingual Solutions (http://www.mlsolutions.com).

Additional Resources

Diversity Rx (http://www.diversityrx.org) and the Cross Cultural Health Care Program (http://www.xculture.org). Information about caring for patients with limited English proficiency: http://www.lep.gov.

References

1. Rushke K, Bidar-Sielaff S, et al. National standards of practice for interpreters in health care. National Council on Interpreting in Health Care Working Papers Series. 2005. Available at: http://www.ncihc.org/assets/documents/publications/NCIHC.
2. Paz Avery M, Alvarado Little W, et al. A national code of ethics for interpreters in health care. The National Council on Interpreting in Health Care Working Papers Series. 2004. Available at: http://www.ncihc.org/assets/documents/publications/NCIHC.
3. Crawley LM, Marshall PA, Lo B, Koenig BA.  Strategies for Culturally Effective End-of-Life Care.  Ann Intern Med. 2002; 136:673-679.
4. Haffner L. Translation is not enough.  Interpreting in a Medical Setting. West J Med. 1992; 157:255-259.
5. Haffner L. Guide to Interpreter Positioning in Health Care Settings. The National Council  on Interpreting in Health Care Working Paper Series. 2003.  Available at: http://www.ncihc.org/assets/documents/workingpapers/NCIHC%20Working%20Paper%20-%20Guide%20to%20Interpreter%20Positioning%20in%20Health%20Care%20Settings.pdf.
6. Herndon E, Joyce L. Getting the Most from Language Interpreters.  Family Practice Management. 2004; 11:37-40.
7. Minas M, Stankovska M, Ziguras S.  Working with Interpreters: Guidelines for Mental Health Professionals. The Victorian Transcultural Psychiatry Unit; 2001. 
8. Hsieh E. “I am not a robot!” interpreters’ views of their roles in health care settings. Qualitative Health Research. 2008;18(10):1367-1383.
9. Thornton JD, Pham K, Engelberg RA, Jackson JC, Curtis JR. Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences. Critical Care Medicine. 2009;37(1):89-95.
10. Schenker Y, Fernandez A, Kerr K, O’Riordan D, Pantilat SZ. Interpretation for discussions about end-of-life issues: Results from a national survey of health care interpreters. J Palliat Med. 2012;15(9):1019-1026.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in April 2006.  Version re-copy-edited in April 2009. Revised again August 2015 by Mary Rhodes MD.