In this national survey of trained health care interpreters, the vast majority reported experience interpreting a wide variety of discussions about end-of-life issues, and most reported participating in these conversations at least weekly. Whereas 85% of respondents felt comfortable interpreting these discussions, less than half reported that discussions about end-of-life issues usually went well, and the majority found interpreting these discussions more stressful than interpreting routine clinical encounters. Almost all interpreters agreed that physicians and interpreters would benefit from additional training in how to conduct language-discordant discussions about end-of-life issues and were personally interested in more instruction in this area.
Although there has been increasing attention paid to the perspectives of health care interpreters in a variety of clinical settings,2,15–17
to our knowledge this is the largest and only national survey of interpreter experiences in health care to date. Interestingly, attitudes toward interpreting end-of-life discussions among this cohort did not differ by interpreter demographics or qualifications. Although we had hypothesized that older interpreters and those with more experience or training might feel more comfortable and less stressed when interpreting these discussions, we found no difference in attitudes by these interpreter characteristics. We did find that when interpreters felt clear about their role and felt that the physician understood their role, they were more likely to feel comfortable and to think that discussions went well. These findings suggest that factors that are amenable to change, such as specific physician and interpreter behaviors, are important determinants of how interpreters view these interactions. These recommendations could be incorporated into training programs for clinicians.18
Future research should examine the effect of specific training elements and different interpreter roles on patient, clinician, and interpreter understanding and satisfaction and patient outcomes in language-discordant discussions about end-of-life issues.
Participants also strongly endorsed the need for more interpreter training and almost universally felt that they would personally
benefit from additional focused training in how to interpret discussions about end-of-life issues. Interestingly, whereas more than half of participants had received at least a year of training, and most had more than 5 years of interpreting experience, more experienced and highly trained interpreters were no more likely to feel that discussions about end-of-life issues usually went well and equally endorsed the need for more training. Formal training opportunities for health care interpreters have grown significantly in recent years, with increasing attention being paid to improving interpretation quality through the implementation of national standards and the goal of establishing a national certification process in the United States.19–21
Our study suggests that existing training programs in the United States may fall short in preparing interpreters for commonly encountered discussions regarding palliative care issues such as giving bad news, discussing code status, or notifying a family that their loved one has died. Such discussions are more likely to involve unique vocabulary (such as “hospice,” “palliative care,” or “life support”), clinically important cultural differences (such as how bad news should be conveyed and who should be told), complex family dynamics (one or more family members present may speak English fluently, whereas others may be limited in their English proficiency and require interpretation), and emotional distress than is commonly seen in more routine clinical encounters. Our findings also speak to the need for improved emotional support of interpreters involved in end-of-life care. Opportunities to observe and practice interpreting end-of-life discussions, to discuss cases that were particularly difficult or emotionally challenging, and to reflect on the emotional aspects of providing care for seriously ill patients and their families could form a cornerstone of a national interpreter certification program, given how common it is for interpreters to be involved in such discussions. The California Healthcare Foundation has recently developed a free online curriculum for interpreters in palliative care.22
Our study had several limitations. To target the largest number of interpreters, we used a national convenience sample. We do not have a response rate. Nonetheless, with 142 respondents nationally this is the largest survey of its kind. It is possible that respondents differed in significant ways from nonrespondents, and our findings may not generalize to all heath care interpreters. However, demographic characteristics of participants with respect to gender and primary language were similar to a previous web-based marketing survey of interpreters in North America.23
Given our recruitment approach targeting professional interpreter organizations, it is likely that respondents were more highly trained and more likely to be certified than the general interpreter population. In this sense, our findings may represent a “best case scenario” in that respondents may have more experience and comfort with interpreting discussions about end-of-life issues than nonrespondents. We were unable to verify experiences or certification. However, the range of responses suggests there was no bias in reporting. We also do not have information on whether respondents worked primarily in an inpatient or outpatient setting or whether experiences differed by the modality of interpretation (i.e., in-person versus over the phone), as has been suggested in previous research.24
Finally, results represent the views of interpreters and may not be shared by clinicians, patients, or families involved in these discussions.
Interpreted discussions about end-of-life issues present common challenges for interpreters independent of training and experience. Interpreters may benefit from targeted educational interventions that could improve the quality of care for vulnerable patients and families in these difficult situations. Health systems and interpreter certification programs should incorporate specific training on how to interpret discussion about end-of-life issues.