Caring for ICU Patients and Families Lacking English Proficiency

Effective communication between patients, families, and providers is pivotal to optimal medical care, particularly in the ICU. Accurate information transfer helps ensure that valid informed consent and meaningful histories are obtained and delays in care and errors are minimized. Detailed discussions are key to successful end-of-life care, especially when explaining the patient’s illness, prognosis, and treatment options, and when making choices about life-sustaining therapy. Finally, communicating effectively allows caregivers to address patients’ and families’ concerns, build therapeutic bonds, and foster emotional support (Lilly et al. Am J Med. 2000;109[6]:469; Lautrette et al. N Engl J Med. 2007;356[5]:469; Curtis and White. Chest. 2008;134[4]:835).

A rich literature addresses communication shortcomings in the ICU (Abbott et al. Crit Care Med. 2001;29[1]:197-201; Azoulay et al. Crit Care Med. 2000;28[8]:3044; Nelson et al. Arch Intern Med. 2007;167[22]:2509). The families of critically ill patients consistently cite miscommunication as a source of conflict and dissatisfaction. Important family conferences are frequently delayed and responsibilities delegated to junior members of the medical team. Discussions often lack the content necessary for patients and families to make decisions, placing too much emphasis on technical issues but too little on likely outcomes and goals of care. Many families receive inadequate emotional support, which may contribute to psychiatric morbidity (Pochard et al. Crit Care Med. 2001;29[10]:1893; Siegel et al. Crit Care Med. 2008;36[6]:1722).

A growing number of people living in the United States communicate predominantly in languages other than English, particularly Spanish (http://www.census.gov/Press-Release/www/releases/archives/american_community_survey_acs/010601.html). Up to one in five speaks a language besides English at home; of these, 44% speak English “less than very well.” Close to 5% of households are “linguistically isolated,” meaning that all household members age 14 or older have at least some difficulty with English. Residents aged 65 and older constitute the largest portion of those with limited English proficiency (LEP). Patients and families with LEP are at high risk for suboptimal communication, which may compromise their care unless special steps are taken (Norris et al. J Palliat Med. 2005;8[5]:1016).

For many years, ineffective strategies were used to address language barriers. Sometimes little effort was made to communicate with patients with LEP, particularly if interpreters were not available or time constraints precluded finding assistance. Crash courses in “medical Spanish” were offered to foster communication but probably increased the risk of misinterpretation, particularly when conversational subtleties exceeded caregivers’ linguistic skills. In many cases, bilingual coworkers and family members were recruited to interpret, the latter increasing the risk of bias if relatives filtered or censored information (Crawley et al. Ann Intern Med. 2002;136[9]:673). Even today, with the widespread availability of professional interpreter services, providers still attempt to “get by” using family members, coworkers, and their own rudimentary language skills to communicate with patients with LEP (Diamond et al. J Gen Int Med 2009;24[2]:256). All these approaches increase the risk of miscommunication and suboptimal care.

Trained interpreters can diminish or even eliminate language barrier problems. Regardless of their specific training, medical interpreters possess tested professional language skills, are trained in medical terminology, the ethics of interpreting, and abide by hospital policies and HIPAA. In 2001, the Office of Minority Health released the National Standards on Culturally and Linguistically Appropriate Services (CLAS), which made it the law that health-care institutions provide professional interpretation services to non-English speaking patients (www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15). Many hospitals provide trained interpreters in person and have independent departments to facilitate services to patients and families with LEP. When interpreters are not available in person, skilled services can be accessed remotely, for example, using video conferences, wireless speakerphones, and double headset phones. Our hospital uses several companies that provide remote interpreter services when a professional interpreter is not available on-site.

Professional interpreters offer assistance beyond simple translation. For example, interpreters can share insights regarding background factors that influence how patients and families interpret medical issues and decision making. Interpreters are likely to be sensitive to cultural subtleties, such as whether it is appropriate to make direct eye contact during conversation, how gender and age influence communication, and how formal sessions should be. Interpreters are also positioned to identify attitudes and beliefs that caregivers might not otherwise know about, such as opinions about the relationship between medicine and religion, views on the role of patient autonomy, attitudes toward suffering and talking explicitly about death, and the comparative importance of traditional Western vs alternative medical treatments (Norris et al. J Palliat Med. 2005;8[5]:1016; Crawley et al. Ann Intern Med. 2002;136[9]:673; Kagawa-Singer and Blackhall. JAMA. 2001; 286[23]:2993). Some families may consider it their responsibility to shield the patient from the truth, potentially conflictingwith the caregiver’s impulse to reveal necessary information. In such cases, interpreters should convey the family’s preferences to caregivers, allowing the latter to negotiate an approach that respects cultural sensitivities, while still meeting the ethical imperative to honor the patient’s wishes. Interpreters may also help identify educational deficits and the need for additional explanation to ensure that medical issues are fully understood. By considering the cultural background of the patient and family with LEP, the health-care team is likely to be more successful at forming bonds, communicating effectively, and minimizing disagreements (Galanti G. Caring for Patients With Different Cultures. Philadelphia, PA: University of Pennsylvania Press; 2004).

Focus groups held with professional medical interpreters have generated specific advice for physicians (Norris et al. J Palliat Med 2005;8[5]:1016). For example, physicians should meet with interpreters before conferences to ensure the latter are familiar with the issues to be discussed. This may be especially useful during emotionally difficult or complex cases, since it gives the interpreter the opportunity to be prepared to greet the patient or family appropriately or ask questions that may help providers achieve their goals. Interpreters also suggest that many conferences could be enhanced by drawing or showing pictures.

Providers and interpreters should be aware that not all terms and concepts translate directly or reliably. Clinicians’ language is often opaque, even to patients and families of similar cultural and ethnic backgrounds, particularly when medical jargon (eg, DNR, intubation) is used or vague terms (eg, poor prognosis) are left undefined.

It is important to decide beforehand whether strict verbatim translation should be used or whether the interpreter should be given leeway to compensate for words and phrases that do not translate well. Following conferences, it may be wise for caregivers and interpreters to debrief to ensure there are no persistent misunderstandings or unanswered questions.

Even with professional interpreters, conferences with patients and families with LEP pose special obstacles.

In one study investigating end-of-life conferences that included an interpreter, 55% of all translated speech contained some alteration, including additions, omissions, substitutions, and editorializations (Pham et al. CHEST. 2008;134[1]:109). Of the alterations, 93% had a negative impact on communication, for example, interfering with information transfer or reducing emotional support and rapport.

Another study found that, compared with conferences that did not require interpretation, those using an interpreter had less clinician speech and fewer expressions of support for the family (Thornton et al. Crit Care Med. 2009;37[1]:89).

In our experience, even when communication is adequate, clinicians are often frustrated by their inability to relate directly to patients and families. For example, clinicians sometimes find the interpreter’s voice distracting and lacking emotion. Some clinicians feel excluded from the dialog when patients or families speak directly to the interpreter. To address this, it may be helpful to ensure that interpreters do not interfere with the line of vision between caregivers and the patients and families, allowing direct eye contact if desired and appropriate.

Every interaction, no matter how short, offers patients and families the opportunity to express concerns, ask questions, and receive information and emotional support. The use of professional interpreters should not be limited to formal family meetings or circumstances when informed consent is required. As much as possible, interpreters’ assistance should be sought for every session, even for short, routine visits to the patient’s room.

Ensuring good communication between clinicians and patients and families with LEP imposes special challenges. Potential pitfalls need to be acknowledged, including the risk of miscommunication, cultural misinterpretation, and difficulty building rapport. Fortunately, the widespread availability and skills of professional interpreters allow clinicians to overcome these obstacles in many, if not most, ways.

By fostering communication and shedding light on important cultural factors, professional interpreters provide an indispensable service that greatly improves the quality of medical care provided to patients and families lacking English proficiency.

Jennifer Gonzalez-Stephens
Medical Interpreter
Department of Interpreter Services
Yale-New Haven Hospital
and
Dr. Mark D. Siegel, FCCP
Pulmonary and Critical Care Section
Yale School of Medicine
New Haven, CT