Lost in Translation Dr Phillip Good Palliative Medicine Specialist

Transcription

1 Lost in Translation Dr Phillip Good Palliative Medicine Specialist Department of Palliative and Supportive Care, Mater Health Services St Vincent s Private Hospital, Brisbane, Australia Mater Research Institute The University of Queensland

2 Cases 1. Patient Seen regularly in conjunction with oncologists Ongoing pain issues Interpreter use was on/off Seemed to have some understanding Medications Enrolment in study 2. The long and short versions

3 Collaborations Emma Kirby Alex Broom Vanessa Bowden Zarnie Lwin Jennifer Ryan Sam Abbato Ristan Greer Petra Vayne-Bossert

4 Introduction Australia is culturally and ethnically diverse (CALD) Cultural and linguistic diversity can influence doctor-patient communication and associated treatment choices the emotional and interpersonal experience for patients and their families

5 Research Access to interpreters Interpreter experience in Palliative Care setting

6 Why use an interpreter? improves communication decreases communication errors of clinical consequence increases both patient and clinician satisfaction with healthcare increases appropriate healthcare utilisation improves clinical outcomes

7 MHB Audit 1 in 5 who need an interpreter got one in ED

8 MHB Audit 1 in 3 got an interpreter at some point (ED/MHB)

9 MHB Audit Only 1 in 11 got access to an interpreter in BOTH ED and MHB

10 Interpreting provision - LOS MHB Interpreting at ED Associated with an average 22.4 hours decrease in stay Not associated with 30-day readmission Interpreting at Ward LOS 44.3 hours longer Associated with increased odds of 1.9 of 30 day readmission

11 Why?

12 Study Method Explanatory case study Targeted sampling 13 patients and family members Chart review Data review Staff and interpreter Focus Group Discussions (n=4) Medical staff phone interviews (n=5) Staff survey (n=122) Rigour of triangulation and data saturation Thematic and content analysis Systems thinking approach

13 Why are interpreters not engaged? Decision to engage is complex and unclear Culture of cost and time concerns Lack of confidence in process Concern for quality of interpreters Bilingual staff and family are seen as an appropriate alternative in many cases Lack of knowledge of evidence base

14 Staff survey respondents (Bilingual staff) understand English and the interpreter language and are medically trained. What could be better It is not all about accreditation. It is about common sense. There are times when you use staff, times you use relatives, times you use accredited interpreters. But it is not all about accreditation...

15 Patient interview Staff couldn t understand me so they grabbed a staff who could speak Mandarin to help with our communication. However, as most people who have lived here for a long time actually cannot speak Mandarin or understand it very well, therefore he didn t grab the key point of what I said. So basically the whole communication was broken.

16 What about Palliative Care Data on CALD patient experiences of communication in oncology/palliative care settings in Australia is limited Negotiating transition to specialist palliative care is a particularly challenging aspect of CALD communication and care Interpreters play key mediating roles, yet their perspectives have rarely been examined

17 Study We analysed the experience and role of interpreters in negotiating the transition to palliative care between medical oncologists, CALD patients, and families

18 Methods: data collection Semi-structured, face-to-face interviews lasting 45 mins Key themes explored: Awareness of role, purpose and availability of palliative care amongst CALD patients and families How doctors introduce and discuss palliative care from the perspectives of CALD patients and families Quality of communication and the dynamics associated with interpreting and translation from the perspectives of CALD patients and their families

19 Population Sample and Recruitment 20 interpreters Identified as from the most common CALD communities A maximum variation purposive sampling strategy used to ensure mix of CALD communities representation

20 Data analysis We employed the framework approach of qualitative data analysis using NVivo 9 software to systematically analyze the transcripts

21 Results Theme 1: Communicating the term palliative care Theme 2: Being sensitive whilst remaining professional Theme 3: Managing in the presence of family caregivers Theme 4: Emotional burden on interpreters

22 Results Theme 1: Challenge of translating the meaning of the term palliative care Key issue was often no equivalent term to describe palliative care in the patient s language

23 Theme 1: Communicating the meaning of the term palliative care Palliative care, there s no exact word for that. There s not a replacement word for it, direct translation, but how we explain it means a caring concern or a caring care kind of thing.

24 Theme 1: Communicating the meaning of the term palliative care Usually it [ palliative care ] doesn't mean too much to people when they say it. Most of the people, I'd say 60% or 70% in my cases, would not know whatsoever what it is. The ones who know would equate it with very bad news. So that means, You can't help me anymore. I'm dying. It's very negative.

25 Theme 2:Being sensitive whilst remaining professional Conflict of verbatim translation in the form of a conduit vs. interpreters attempts for a more humanistic and emotional identity via meaning

26 Theme 2: Being sensitive whilst remaining professional..our job, first of all, is to relate meaning. Verbatim is not the right way to interpret often because if the meaning s lost or if words are used in a different manner, it s our job to recognise that and to make sure that the exact meaning of what is said is interpreted. Vs I don't do anything other than saying exactly what each party's saying. If the patient can't understand then I'll just tell the doctor exactly what he said, that the patient says, "I don't understand," and hopefully the doctor will do a bit more explanation.

27 Theme 2:Being sensitive whilst remaining professional Key element lay in balancing softening bad news with adherence to being professional

28 Theme 2: Being sensitive whilst remaining professional Sometimes you soften things. I had a case where we walked in, doctor said, "This is your scan. You've got a huge tumour on your kidney. There's nothing I can do about it". I could not do that I might have said, "I'm sorry to tell you that, but" I took liberty to do that although probably, you would say, I shouldn't have done it

29 Theme 3: Managing in the presence of family caregivers Presence of family caregivers was both beneficial and complicating for interpreters

30 Theme 3: Managing in the presence of family caregivers Frequent accounts of families pre-loading questions onto the interpreter, or asking the interpreter s medical opinion prior to/ immediately after the consultation

31 Theme 3: Managing in the presence of family caregivers The family gives a little note that says, "Don t tell my father he has cancer.

32 Theme 3: Managing in the presence of family caregivers I'm trying to be as careful as I can with those [family] exchanges. It happens sometimes [when] we [go] outside [the consultation room], doctor goes and they [family] ask, "What do you think?.

33 Theme 4: Emotional burden on interpreters Another key issue was the emotional burden on interpreters, particularly given their lack of training or opportunity to debrief from this type of work

34 Theme 4: Emotional burden on interpreters I've come out of there feeling ill for days. I'm saying all this and I'm standing there. My stomach is like this. What we need sometimes, or what I need sometimes, and I'm sure others do, is debriefing which we don t have. I've come out, I ve felt sick for days.

35 Theme 4: Emotional burden on interpreters You explain it to them as decently as possible, as kindly as possible. Our role is just to interpret but at the same time we're not robots. We have emotions too. So it is difficult.

36 Conclusions Interpreters are a critical component of quality communication in the CALD-palliative care interface Interpreters are in a precarious position within these medical encounters, with their complex balance of professional and personal identity, amongst patient/family dynamics The emotional burden of interpreters needs to be recognised, with structures of sufficient support

37 Implications for Practice Palliative care - clinicians need to explain this in a culturally competent way which can be conveyed verbatim to the patient and family Communicate in short, clear chunks The importance of checking understanding

38 Implications for Practice Awareness of process of interpretation Sensitivity to emotional demands for interpreters Thank interpreters for their work

39 Questions?