Abstract
S
As the palliative care team sensitively approached the grim reality of Anna's prognosis, the interpreter tried to translate these very calculated sentences, without so much as a few seconds notice. However, Anna's responses to questions failed to match the gravity of her clinical diagnosis. These multidisciplinary meetings, generally accompanied by the same in-house interpreter, became more frequent as Anna's hospital stay lengthened and her health worsened. In the end, Anna, a 37-year-old Russian woman with terminal acute myeloid leukemia (AML), two young children at home, and a husband who worked tirelessly as a truck driver, left the hospital against medical advice. Exhausted with the care she had received, her parting words to the hospital staff were sharp, blaming hospital construction as the source of her recurrent infections and accusing her primary oncologist of being ignorant and insensitive to her family. She left without any medications in tow, and scheduled no follow-up.
As part of the palliative team consulted for Anna's case, I've often reflected on her time in the hospital and speculated about what could have prevented Anna from leaving on such abrupt terms. Cross-cultural communication in medicine is a path difficult to navigate, perhaps especially within palliative medicine. How can palliative medicine—focused on “quality of life” and approaching death with dignity—advocate for its patients of all ethnic backgrounds?
Translation is often at the center of cross-cultural interactions and, therefore, so is the interpreter. He or she is placed at the bedside and trained to become invisible, to facilitate the seamless exchange of information between patient and provider. However, Anna's hospital stay was highlighted by a seemingly unbridgeable communication impasse.
Pain assessment and management were central themes in Anna's interactions with the team. A symptom once considered a fifth vital sign, pain became a subject highlighting how interpretation needed to go beyond just converting facts from one language into another. “She MUST be in pain” as said by Anna's nurse highlights the empathetic nature of humans, and especially those who interact with patients daily. However, this statement is often heard when patients approach their illness with stoicism. Anna herself, in response to questions about her complex symptoms, often said through the interpreter, “I don't want to talk about bad things over and over again.” This was led by her primary oncologist who stated in her discharge summary, “I am sad for the time spent discussing the disease […] no clear indication that she understands.” This communication loop was tirelessly treaded in the course of Anna's hospital stay, and highlights a cultural and communication divide that is not altogether unique.
The inability and fear to talk about negative subjects have often been discussed in relation to death but is also seen in relation to pain. Stoicism in the African Caribbean culture is seen as a reflection of strong religious faith. Similarly, Caucasian British may not express pain as evidence of their ability to withstand punishment as a test of faith. By contrast, pain is often openly expressed in patients from the Indian subcontinent with no need for self-control. 1 Pain is without a doubt more than a quantifiable number on a scale of 1–10; it varies in significance and expression depending upon the patient and his or her background.
Anna's interpreter was the one person at whom Anna smiled, and repeatedly told, “I always feel better when you are here.” She could have served as a language and cultural bridge, but this potential was left untapped.
Candid conversations with the interpreter at the patient's door revealed a cultural web around pain that was not evident in conversations at the bedside with the medical team. When pulled aside, she [the interpreter] discreetly noted the complex family dynamics of this immigrant family and the difficulties she had as a young mother in discussing medical care without her husband present. When asked to elaborate, she would also refer to the historical context of how suffering is viewed as a private matter within Russian families and how mourning a loved one is deeply hidden and not outwardly expressed. 2 However, in the midst of many of these multidisciplinary meetings, she [interpreter] was mum, reluctant to interfere even though she could sense the impending communication breakdown.
Although she was a critical member of Anna's care team, her interpreter's role was brought into question during Anna's stay. Nurses, aware of the kinship between her and Anna, often advocated for an alternative interpreter to be bought to the bedside when Anna refused to take her medications—questioning the undue influence this interpreter may have had on Anna's decisions. Anna's medical care became a choreographed dance, with different players entering and exiting each scene, often without the one interpreter with whom she had built an alliance.
Palliative medicine often serves as the medicine team's interpreter to the patient and addresses patients' concerns that extend beyond hospital walls (i.e., spirituality and quality of life). Likewise, the role of an in-house interpreter extends beyond simply having an actual person at bedside. In fact, a hospital interpreter such as Anna's is formally trained to have good understanding of cultural sensitivity and awareness, in addition to medical and colloquial terminology. In less well-equipped settings, the role of interpretation often falls on bilingual health workers who are acquainted with the patient, friends, and relatives who are readily available, or untrained volunteers. 3 If not trained formally as professional interpreters, they may lack cultural insight.
We entered Anna's care team in the last month of her hospital stay and were a consistent presence throughout the remainder of her stay. However, struggles over the meaning of pain and its interpretation highlight the need for effective cultural translation. Anna's tumultuous hospital stay left many wondering whether there was a critical point wherein a breakthrough in understanding could have been achieved, and whether Anna's course could have been different if her interpreter, who was trained to be an efficient interface for translation, felt that she could also be more, both an interpreter and an advocate.