case study
Consultations across Languages
L
ei, a twenty-seven-year-old Mandarin speaker, visits the United States seeking curative treatments for his acute myeloid leukemia. On admission, he is able to eat some food, supplemented with nutrition. Within a week, he loses decisionmaking capacity due to neutropenic fever. To prevent respiratory failure, he is placed on bilevel positive air pressure, which clinicians anticipate will be needed on a long-term basis. Various treatments are unsuccessful in slowing his cancer’s growth. His mother, Hua, has traveled with him. Neither she nor Lei speak English, and the hospital does not have an
onsite professional Mandarin-speaking interpreter. Using a professional interpreter over the phone, Lei’s oncologist, Dr. Branson, attempts to initiate a faceto-face goals-of-care conversation with Hua as the surrogate decision-maker. Dr. Branson explains that Lei has “only weeks to months to live” and recommends initiating comfort-care–only measures, but Hua says that she wants (and that Lei would want) continued aggressive measures. Unfortunately, clinicians did not gain clarity about Lei’s wishes, values, or preferences regarding end-of-life care while he had decisionmaking capacity, aside from learning his general desire for curative treatments.
commentary
strongly discourage the ethicist from acting as both interpreter and ethicist during a family meeting because of the potential for role confusion. Family members and friends occasionally serve as ad hoc interpreters. This kind of interpreter may appear to be beneficial because she or he is invested in the patient’s well-being and sensitive to the patient’s culture. However, without professional training, an ad hoc interpreter may misunderstand or misinterpret key pieces of medical information. The interpreter may also skew information out of concern for a loved-one’s emotional state. Essential information may be lost. We therefore discourage use of them as well. Dr. Branson turned to a bilingual staff member. Yet, if this person is not professionally certified, are his interpretive
by Trevor Bibler and Adam Peña
T
o facilitate conversation about a patient’s values, the clinical ethicist must analyze and plan for contingencies, especially where misunderstanding between the ethicist and the family can occur. For Lei’s case, we envision at least two face-to-face meetings that require an interpreter—one with Hua and a second with the family and Dr. Branson. Ethicists might have access to four kinds of translators: themselves, ad hoc interpreters, bilingual staff members, and professional interpreters. For Lei and Hua, even if the ethicist speaks Mandarin fluently and is conversant with medical terminology, we would
May-June 2015
Hua says that the clinical team banked her son’s blood in case he might be a candidate for a phase I trial. She would like to continue aggressive measures until the trial begins next month. Dr. Branson explains that phase I trials are designed only to identify dosage range, not to test efficacy, and that Lei would be ineligible for this trial because he is not in remission. Hua disagrees. At this point, Dr. Branson brings in Dr. Chou, a Mandarin-speaking resident, to provide face-to-face interpretation, and with his aid, Dr. Branson reinforces his earlier points. Hua insists that “there must be more standard therapies available” and says that she will wait until the trial begins. She begins crying, and the meeting disintegrates. Following this, Dr. Branson calls for an ethics consultation for “help in endof-life communicating and reconciling discordance about prognostic information.” Communication is especially challenging. How should the ethicist use the institution’s interpreter services?
skills known to be adequate? It is also not clear whether Dr. Chou can interpret in an impartial manner. He may be predisposed to agree with Dr. Branson’s position, yet if he disagrees with it, he may struggle to translate accurately. Additionally, Dr. Chou may share Lei and Hua’s cultural background, which may either facilitate or compromise translation. When the ethicist meets with Hua alone to assess her understanding, seek out her informational needs, assess her values and preferences, and identify coping mechanisms, we strongly recommend using a professional interpreter, and an in-person professional interpreter is preferable. Having an interpreter on the phone might be acceptable during early stages of the consultation, when the ethicist begins building rapport and H AS TI N GS C EN TE R RE P O RT
13
gathering information, but even at this preliminary step, in-person translation would be better. It is hard to cultivate trust through a phone line, and using the phone can involve practical challenges such as time lags and muffled words. The ethicist should insist on an inperson translator for an end-of-life
family meeting, which requires heightened degrees of empathetic listening, precise phrasing, and measured emotional investment. To ask an ethicist to perform a satisfactory clinical ethics consultation without the assurance that words will be communicated clearly is, in this context, like asking an obstetrician to perform amniocentesis without
ultrasound guidance. With the aid of only a telephone interpreter, the ethicist may not be able to discern if (or why) Hua’s positions seem intractable. The ethicist may not be able to confidently attend to Hua’s emotional and informational needs.
commentary
clinical ethicist could use this session to ensure that the translator is willing to interpret facts and has no beliefs about withholding information that could compromise translation. In turn, if the interpreter shares the patient’s or surrogate’s cultural background, he might provide information about the patient, family, or culture to help prepare the clinical ethicist. In order to make sense of the cultural standpoint, the interpreter may need to augment idioms or expressions—a practice sometimes referred to as “cultural brokering.” It is important for the clinical ethicist to know whether and when the interpreter plans on using strict interpretation versus cultural brokering. The importance of this practice lies in the practical reality that sometimes it might take the interpreter more (or less) time to interpret than what might be expected, which could create discomfort or uncertainty on the part of the clinical ethicist or others in the room. After a planning session, the clinical ethicist can engage in conversation with Hua and the interpreter. During the conversation, the clinical ethicist should look directly at Hua, as she is the relevant moral stakeholder (unless cultural sensitivities discourage eye contact). Short sentences should be used to allow the interpreter to effectively relay communication. In this case, Dr. Branson says that he knows little about the trial. This invites Hua to disregard anything he might say about Lei’s ineligibility. Thus, it would be important to have the trial investigator participate during the next family meeting to explain why Lei is not currently a candidate. Using nonverbal forms of education, such as
drawing on a dry-erase board, can help build a comprehensive picture. The clinical ethicist may need to caucus with the interpreter when they are not in synchrony or when a time-out is needed. Caucuses are private meetings between the mediator and a participant or multiple participants in order to clarify the situation and gain consensus on how to move forward. They are used to allow the expression of strong feelings in private, to obtain confidential information, or to test potential solutions. In ethics consultation, caucuses have the potential to make parties suspicious and threaten appearances of neutrality; however, in this context, the importance of synchronous communication outweighs this potential harm. To guard against misunderstanding, the clinical ethicist may want to begin the family meeting by explaining to a patient or surrogate that the clinical ethicist may have a side conversation with a participant for clarification purposes. Finally, I encourage a debriefing session between the clinical ethicist and the interpreter after the family meeting to ensure a similar understanding of the content and outcome of the meeting and to give the interpreter an opportunity to debrief. An interpreter may feel a personal (or professional) emotional burden that he may wish to share with other health care professionals, particularly when the interpreter does not agree with a case outcome or feels an outcome conflicts with his own values and preferences. Whether and how an interpreter might be influenced by such strong feelings, and how this might affect interpretation, is an area ripe for future study.
by Courtenay R. Bruce
C
linical ethicists reading this case likely feel a collective sense of anxiety, owing to the high degree of skill required to facilitate languagediscordant dialogue. Here, I focus on how to navigate a language-discordant family meeting or a one-on-one conversation between the ethicist and patient or surrogate. It is unclear whether Hua is misunderstanding what is being communicated or whether she cannot acknowledge what is being said. Therefore, the clinical ethicist should talk with Hua to introduce herself, attempt to elucidate the patient’s values and preferences, and identify Hua’s informational and coping needs through the assistance of an interpreter. To prepare for this meeting, the clinical ethicist and the interpreter should discuss what they will do to foster dialogue with Hua. It might be helpful for the clinical ethicist to provide questions she plans on asking and information she hopes to learn. The clinical ethicist will likely ask Hua some questions to which she already knows the answer (for example, “What options have the doctors discussed?”) but that she hopes will help her prime Hua’s thinking, elucidate Hua’s perspective, or assess Hua’s understanding or knowledge. The clinical ethicist could let the interpreter know about this technique, reducing the chance that the interpreter will be reluctant to interpret already-known facts or positions. A planning session also allows the clinical ethicist to prepare the interpreter for the conversation that might unfold, including emotionally charged and value-laden dialogue. Finally, the
14 HASTI N G S C E N T E R R E P ORT
DOI: 10.1002/hast.444
May-June 2015
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Consultations across Languages
L
ei, a twenty-seven-year-old Mandarin speaker, visits the United States seeking curative treatments for his acute myeloid leukemia. On admission, he is able to eat some food, supplemented with nutrition. Within a week, he loses decisionmaking capacity due to neutropenic fever. To prevent respiratory failure, he is placed on bilevel positive air pressure, which clinicians anticipate will be needed on a long-term basis. Various treatments are unsuccessful in slowing his cancer’s growth. His mother, Hua, has traveled with him. Neither she nor Lei speak English, and the hospital does not have an
onsite professional Mandarin-speaking interpreter. Using a professional interpreter over the phone, Lei’s oncologist, Dr. Branson, attempts to initiate a faceto-face goals-of-care conversation with Hua as the surrogate decision-maker. Dr. Branson explains that Lei has “only weeks to months to live” and recommends initiating comfort-care–only measures, but Hua says that she wants (and that Lei would want) continued aggressive measures. Unfortunately, clinicians did not gain clarity about Lei’s wishes, values, or preferences regarding end-of-life care while he had decisionmaking capacity, aside from learning his general desire for curative treatments.
commentary
strongly discourage the ethicist from acting as both interpreter and ethicist during a family meeting because of the potential for role confusion. Family members and friends occasionally serve as ad hoc interpreters. This kind of interpreter may appear to be beneficial because she or he is invested in the patient’s well-being and sensitive to the patient’s culture. However, without professional training, an ad hoc interpreter may misunderstand or misinterpret key pieces of medical information. The interpreter may also skew information out of concern for a loved-one’s emotional state. Essential information may be lost. We therefore discourage use of them as well. Dr. Branson turned to a bilingual staff member. Yet, if this person is not professionally certified, are his interpretive
by Trevor Bibler and Adam Peña
T
o facilitate conversation about a patient’s values, the clinical ethicist must analyze and plan for contingencies, especially where misunderstanding between the ethicist and the family can occur. For Lei’s case, we envision at least two face-to-face meetings that require an interpreter—one with Hua and a second with the family and Dr. Branson. Ethicists might have access to four kinds of translators: themselves, ad hoc interpreters, bilingual staff members, and professional interpreters. For Lei and Hua, even if the ethicist speaks Mandarin fluently and is conversant with medical terminology, we would
May-June 2015
Hua says that the clinical team banked her son’s blood in case he might be a candidate for a phase I trial. She would like to continue aggressive measures until the trial begins next month. Dr. Branson explains that phase I trials are designed only to identify dosage range, not to test efficacy, and that Lei would be ineligible for this trial because he is not in remission. Hua disagrees. At this point, Dr. Branson brings in Dr. Chou, a Mandarin-speaking resident, to provide face-to-face interpretation, and with his aid, Dr. Branson reinforces his earlier points. Hua insists that “there must be more standard therapies available” and says that she will wait until the trial begins. She begins crying, and the meeting disintegrates. Following this, Dr. Branson calls for an ethics consultation for “help in endof-life communicating and reconciling discordance about prognostic information.” Communication is especially challenging. How should the ethicist use the institution’s interpreter services?
skills known to be adequate? It is also not clear whether Dr. Chou can interpret in an impartial manner. He may be predisposed to agree with Dr. Branson’s position, yet if he disagrees with it, he may struggle to translate accurately. Additionally, Dr. Chou may share Lei and Hua’s cultural background, which may either facilitate or compromise translation. When the ethicist meets with Hua alone to assess her understanding, seek out her informational needs, assess her values and preferences, and identify coping mechanisms, we strongly recommend using a professional interpreter, and an in-person professional interpreter is preferable. Having an interpreter on the phone might be acceptable during early stages of the consultation, when the ethicist begins building rapport and H AS TI N GS C EN TE R RE P O RT
13
gathering information, but even at this preliminary step, in-person translation would be better. It is hard to cultivate trust through a phone line, and using the phone can involve practical challenges such as time lags and muffled words. The ethicist should insist on an inperson translator for an end-of-life
family meeting, which requires heightened degrees of empathetic listening, precise phrasing, and measured emotional investment. To ask an ethicist to perform a satisfactory clinical ethics consultation without the assurance that words will be communicated clearly is, in this context, like asking an obstetrician to perform amniocentesis without
ultrasound guidance. With the aid of only a telephone interpreter, the ethicist may not be able to discern if (or why) Hua’s positions seem intractable. The ethicist may not be able to confidently attend to Hua’s emotional and informational needs.
commentary
clinical ethicist could use this session to ensure that the translator is willing to interpret facts and has no beliefs about withholding information that could compromise translation. In turn, if the interpreter shares the patient’s or surrogate’s cultural background, he might provide information about the patient, family, or culture to help prepare the clinical ethicist. In order to make sense of the cultural standpoint, the interpreter may need to augment idioms or expressions—a practice sometimes referred to as “cultural brokering.” It is important for the clinical ethicist to know whether and when the interpreter plans on using strict interpretation versus cultural brokering. The importance of this practice lies in the practical reality that sometimes it might take the interpreter more (or less) time to interpret than what might be expected, which could create discomfort or uncertainty on the part of the clinical ethicist or others in the room. After a planning session, the clinical ethicist can engage in conversation with Hua and the interpreter. During the conversation, the clinical ethicist should look directly at Hua, as she is the relevant moral stakeholder (unless cultural sensitivities discourage eye contact). Short sentences should be used to allow the interpreter to effectively relay communication. In this case, Dr. Branson says that he knows little about the trial. This invites Hua to disregard anything he might say about Lei’s ineligibility. Thus, it would be important to have the trial investigator participate during the next family meeting to explain why Lei is not currently a candidate. Using nonverbal forms of education, such as
drawing on a dry-erase board, can help build a comprehensive picture. The clinical ethicist may need to caucus with the interpreter when they are not in synchrony or when a time-out is needed. Caucuses are private meetings between the mediator and a participant or multiple participants in order to clarify the situation and gain consensus on how to move forward. They are used to allow the expression of strong feelings in private, to obtain confidential information, or to test potential solutions. In ethics consultation, caucuses have the potential to make parties suspicious and threaten appearances of neutrality; however, in this context, the importance of synchronous communication outweighs this potential harm. To guard against misunderstanding, the clinical ethicist may want to begin the family meeting by explaining to a patient or surrogate that the clinical ethicist may have a side conversation with a participant for clarification purposes. Finally, I encourage a debriefing session between the clinical ethicist and the interpreter after the family meeting to ensure a similar understanding of the content and outcome of the meeting and to give the interpreter an opportunity to debrief. An interpreter may feel a personal (or professional) emotional burden that he may wish to share with other health care professionals, particularly when the interpreter does not agree with a case outcome or feels an outcome conflicts with his own values and preferences. Whether and how an interpreter might be influenced by such strong feelings, and how this might affect interpretation, is an area ripe for future study.
by Courtenay R. Bruce
C
linical ethicists reading this case likely feel a collective sense of anxiety, owing to the high degree of skill required to facilitate languagediscordant dialogue. Here, I focus on how to navigate a language-discordant family meeting or a one-on-one conversation between the ethicist and patient or surrogate. It is unclear whether Hua is misunderstanding what is being communicated or whether she cannot acknowledge what is being said. Therefore, the clinical ethicist should talk with Hua to introduce herself, attempt to elucidate the patient’s values and preferences, and identify Hua’s informational and coping needs through the assistance of an interpreter. To prepare for this meeting, the clinical ethicist and the interpreter should discuss what they will do to foster dialogue with Hua. It might be helpful for the clinical ethicist to provide questions she plans on asking and information she hopes to learn. The clinical ethicist will likely ask Hua some questions to which she already knows the answer (for example, “What options have the doctors discussed?”) but that she hopes will help her prime Hua’s thinking, elucidate Hua’s perspective, or assess Hua’s understanding or knowledge. The clinical ethicist could let the interpreter know about this technique, reducing the chance that the interpreter will be reluctant to interpret already-known facts or positions. A planning session also allows the clinical ethicist to prepare the interpreter for the conversation that might unfold, including emotionally charged and value-laden dialogue. Finally, the
14 HASTI N G S C E N T E R R E P ORT
DOI: 10.1002/hast.444
May-June 2015
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
