How Palliative Care Clinicians Can Effectively Collaborate with Medical Interpreters to Improve Care for Patients Preferring a Language Other Than English

Dear Editor,

The article, “Feasibility, Acceptability, and Preliminary Performance of Check In for Exchange of Clinical and Key Information: A Communication Guide to Facilitate Pre-Encounter Huddles with Medical Interpreters Prior to Conversations Around Serious Illness,” ¹ describes a study evaluating the CHECK-IN guide (Check in for Exchange of Clinical and Key Information guide), a structured guide designed to facilitate pre-encounter huddles, promoting bidirectional information sharing between clinicians and interpreters in order to enhance clinician–interpreter collaboration during serious illness conversations. Three checklists Interpreter Scale (IS), Interpreter Impact Rating Scale (IIRS), Faculty Observer Rating Scale (FORS) were used to evaluate the participant clinicians during simulated encounters.

The authors designed this study to expand on previous work intended to improve collaboration with medical interpreters, especially during serious illness conversations. They created the CHECK-IN guide for pre-encounter huddles and wanted to evaluate its feasibility and acceptability for clinicians. The CHECK-IN guide questions cover the purpose of the huddle: the patient’s medical situation; cultural/linguistic aspects of care; potential challenges; and participants’ roles.

Almost all participants (94.8%) reported increased confidence working with interpreters—some commented that they had learned the value of huddling with interpreters. Patients preferring languages other than English (LOTE) need access to interpreters to autonomously make decisions ² and communicate. ³ Clinicians who feel confident working with interpreters are more likely to engage them.

Academic medical interpreters familiar with health care interpreters’ standards of practice and code of ethics might have questioned the value of some IS checklist questions in evaluating the Guide. The IS checklist measured whether the clinician introduced the medical interpreter to the patient, accurately described the interpreter’s role, and positioned the interpreter correctly. These tasks are normally expected of professional interpreters (IMIA Medical Interpreting Standards of Practice, 1995, pages 21–32). Evaluating clinicians’ ability to describe the role of medical interpreters might be a measure of the effectiveness of the CHECK-IN guide; however, it should not be measured during a patient encounter.

Training physicians to conduct and schedule time for huddles with interpreters is commendable and should improve clinician–interpreter partnership and patient care. This is a valid endeavor because in the United States, we are mandated by civil rights law to provide qualified interpreters to all patients preferring LOTE. Interpreter best practices include holding pre-encounter huddles.^4,5 The creation of a standardized guide for huddles is laudable; studying its effect on collaboration between clinicians and interpreters should measure both interpreter and clinician performance.

Palliative care clinicians are accustomed to partnering with diverse teams of palliative care colleagues including physicians, nurse practitioners, social workers, chaplains, and pharmacists.^6,7 Therefore, they are poised to effectively integrate medical interpreters into their interdisciplinary care team. Communication during interpreted encounters is most effective when interpreters and clinicians collaborate in a delicate “dance” navigating both linguistic and cultural challenges.^8,9 Pre-encounter briefings between medical interpreters and clinicians are considered best practice.^4,5

Palliative care clinicians put great emphasis on fine-tuned communication skills with purposeful and precise wording during often delicate encounters. ¹⁰ Interpreters can most accurately convey the subtle nuances of the clinician’s message when they understand the context and intent.

Clinicians should begin the collaborative relationship with in-person or remote interpreters by booking them to participate in pre-encounter huddles. Huddling with interpreters offers interpreters an opportunity to share any relevant information they are aware of about the patient and family, and any cultural norms. Huddles also allow interpreters to prepare for emotionally laden conversations. During the huddle, interpreters expect a brief summary of the patient’s situation, the clinician’s plans and concerns for the encounter, and an introduction to the parties involved and their roles.^4,5 Clinicians and interpreters can negotiate how the interpreter will ask for clarification or share their concerns about miscommunication or cultural challenges during the encounter. A tool that reminds clinicians to cover these points and improves their confidence while huddling with interpreter colleagues is worthwhile.

Clinicians who effectively integrate professional medical interpreters into their team mitigate the power differential between them. Facilitating interpreters’ sense of agency in the collaborative relationship engenders a more effective partnership,^8,11 leading to more effective communication during the often-difficult conversations with patients and their families. In contrast, when clinicians “use” interpreters as “tools,” they risk reinforcing the power differential, rendering interpreters more passive. As a result, if an interpreter does not feel empowered to speak up,^12,13 clinicians may remain unaware of potential miscommunications or potentially harmful cultural faux pas.

A collaborative relationship between palliative care clinicians and professional medical interpreters can reduce the power differential, ¹⁴ improve interpreter confidence, ¹⁵ reduce the risk of ethical dilemmas, ¹² provide interpreters with often-needed post-encounter emotional support,^4,9 and enhance culturally responsive communication.^11,12 Palliative care clinicians often help primary teams facilitate patients’ and family members’ prognostic awareness. Patient autonomy, shared decision making, and prognostic awareness are basic tenets of palliative care and may sometimes conflict with basic tenets of a patient’s cultural norms.

Medical interpreters can help guide clinicians negotiating the terms of communication with patients and their families. Interpreters can support clinicians as they negotiate how much a patient would like to know about their condition and prognosis, and whether they would prefer to use their autonomy by delegating to their families. ⁵ Collaboration reduces the risk of putting interpreters in situations in which they may have to violate a patient’s cultural norms or create ethical dilemmas for interpreters. ¹⁶

Investigating methods for improving collaborative partnerships between palliative care clinicians and professional medical interpreters is an important endeavor. Collaborative research between academic clinicians and medical interpretation researchers is ideal. At a recent national conference ¹⁷ on health care interpreting, the dearth of such partnerships in research was lamented. Conference attendees agreed that such collaboration needs to be encouraged to improve the care provided to some of our most vulnerable patients. Collaborative academic research will lead to interprofessionally informed research designs and goals.