Communication Barriers The Need for Translation

Negotiation about the appropriateness of clinical services for patients nearing the end-of-life is a complex task when healthcare professionals, patients, and family members share fundamental goals and assumptions. By no means has a successful "formula" for such communication been established. When cultural barriers exist, particularly those created by language, the goal of open and effective communication is exceptionally difficult. Language translators may be available only intermittently, and are often poorly trained. In 2002, two hospitals in Brooklyn, New York, that routinely serve large numbers of Spanish-speaking patients were sued for failure to provide translation services, examples of a number of such legal actions dating back several decades.

The task of language translation in the arena of ethical decision making and end-of-life care is particularly complex. How does one translate a discussion about a "do not resuscitate" decision to a family with no previous experience of cardiopulmonary resuscitation (CPR), and no prior knowledge of the American bioethics tradition of requiring permission not to offer CPR, even to a patient who is actively dying an "expected" death, or may be frail because of extreme old age? What if the language characters representing resuscitation are interchangeable with those suggesting the religious concept of resurrection? Although it sounds odd from the perspective of Western, scientific understandings of death, who would not elect to have themselves or their dying loved one brought back to life if offered the choice in those words? How might medical interventions at the moment of death be understood among practitioners of Buddhism who believe that rituals spoken during the dying process guide the "soul" through dangerous spiritual territory and ultimately determine where and how a person will be reborn? How do you negotiate with a family about the location of death—home versus hospital—against a cultural background where speaking of an individual's death is thought to bring it about or where certain illnesses cannot be named? The use of family members as interpreters, which may be unavoidable, may make discussions such as these even more problematic. Family members may see their primary role as protecting others in the family from harm and thus "shield" them from information viewed as harmful. Such shielding is counter to bioethics norms ofopen disclosure.

Furthermore, models of professional translation, such as those employed in courtrooms where relationships are fundamentally adversarial rather than collaborative, assume that language interpreters should function as neutral "machines." Healthcare providers need to be aware that translation services such as those available by phone from AT&T may be based on legal models of interpretation. This stance ignores the interpreter's potential value in providing information about the family's cultural background, as well as providing language interpretation. When interpreters are engaged as full partners in providing care, they may aid in negotiations about difficult end-of-life dilemmas (Kaufert, Putsch, and Lavallee). When included as part of the healthcare team—for example, in programs where native speakers of commonly encountered languages are employed as bilingual medical assistants—interpreters can also serve the useful function of explaining the culture of biomedicine, and the seemingly peculiar assumptions of bioethics, to families.

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