Running head: LANGUAGE BARRIERS IN PALLIATIVE CARE 1

Language Barriers in Palliative Care

Ireland and U.S Comparison

Kelsi Farren

Fairfield University
LANGUAGE BARRIERS IN PALLIATIVE CARE 2

Palliative care is a fairly new method of care that is slowly emerging in healthcare

facilities around the world. It stands to maximize the quality of one’s life while minimizing pain,

suffering, and stress. It is care that takes a holistic approach on patients while understanding that

they have families, religious views, interests, opinions, and hopes. Many people have a

misperception of what palliative care is and often associate it with end-of-life or hospice care. It

is implemented shortly after being diagnosed with a chronic or life-limiting condition. With

palliative care being such a new form of care, it comes with many challenges. Although

communication is such a crucial part of palliative care, many healthcare providers lack this skill.

Understanding verbal and non-verbal ques all tie into understanding your patient in an effort to

providing the best care possible. But how does communication work when both parties speak a

different language?

With communication being a vital aspect of palliative care, language barriers are seen as

one the many challenges faced. When a patient and a healthcare worker do not speak the same

language, it is difficult to express a prognosis or explain care. Patients often want the whole

truth about their condition, but as a healthcare provider, you need to be able to read your patient

and know how much they can handle at a given time. These types of things are hard to do when

the words being spoken are not understood. Medical language can be difficult enough to

understand in one’s native language, and even more so in a new one. Accents are another

challenge when it comes to communication in palliative care. Although a doctor or nurse might

be speaking the same language, a patient might not be grasping all the information due to a thick

accent. Language barriers is one challenge that must be explored and improved to promote good

palliative care practice.

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Span (2006) studied health outcomes of Hispanic patients with language barriers. The

author reported 113 physical therapists who were members of the American Physical Therapists

Association (APTA) were given a thirteen-section survey. This survey participants were located

in varies counties throughout Florida, specifically chosen due to the high number of Hispanic

people residing in the chosen counties. This study had three main goals. The first was to

determine “the relationship between the age of physical therapists and their perception of the

impact of language barriers on the rehabilitative outcome of LEP patients” (p. 12). The second

was to assess if language barriers had an negative impact on patient outcomes. The last goal was

to understand how readily available translators and other language aids are to healthcare

providers. The first two sections of the survey gathered information regarding the physical

therapist’s age, race, ethnicity, primary language, and language used while practicing. The

remaining portions of the survey asked about language barrier encounters they have experienced

and their access to translators. The majority of the survey questions were answered with a Likert

scale. The survey also included yes/no questions and four open response questions. The survey

was non-electronic and mailed to the participants.

The study found that there was no correlation between the age of physical therapists and

their perception of healthcare outcomes when dealing with language barriers. While that

hypothesis was disproved, there was evidence to back up the remaining two. 92% of the physical

therapist’s reported encountering language barriers on a frequent basis, and of those encounters,

65.5% of the time the language barrier resulted in problems with treatment. More than half of

these healthcare providers spoke English and were incapable of speaking a second language. The

last part of this study looked at access to translation services, and 73% of physical therapists
LANGUAGE BARRIERS IN PALLIATIVE CARE 4

reported it was not readily available to them. The author pointed out that while around half of the

sample size was unilingual (57.6%), the other half was not. She explained this number was larger

than expected due to the area that was chosen to conduct the study in. A high rate of Hispanic

residents increased the likelihood of a Hispanic physical therapists. The other limitation that the

author encountered during this study was related to her sample population. The only physical

therapists surveyed were part of the APTA, which requires members to pay an annual fee. She

states, “It could be that some physical therapists, with valuable information to share that might

impact this study, could not afford to become members of the APTA” (p. 106).

MacFarlane, Glynn, Mosinkie, and Murphy (2008) studied the effects of language

barriers general practitioners in Ireland face when caring for refugees and asylum seekers. It

explored how often language barriers are experienced and the language assistance tools available

for healthcare providers. This data was collected through interviewing general practitioners via

telephone in the counties Galway, Mayo, and Roscommonn. This area was chosen for the mixed

urban and rural population, as well as the high number of general Practitioners. The GPs were

given a choice to participate or not in the survey, and up to 4 calls were attempted to each of

them. Out of the 80 general practitioners asked to participate in this study, 56 agreed to take the

survey. The 15-minuet survey consisted of 12 open response questions and 11 closed ended.

Of the 56 general practitioners interviewed, 77% reported they have had an interaction

with refugees or asylum seekers where a language interpreter aid was needed. Of those

interactions, 89% used a form on interpretation. The majority of interpretation was done by

unprofessional means such as friends or family members. The biggest take away from this
LANGUAGE BARRIERS IN PALLIATIVE CARE 5

survey is that 63% of general practitioners expressed that they have been in situations where they

felt an interpreter was needed but one was not available.

The majority of the study population could not name a professional interpreting agency

inside or outside of Ireland. Only 37% of the respondents were aware that the HSE WA (Health

Services Executive Western Area) provided funds to assist with language interpretations during

consultations. Although 56% of the GPs prefer to use informal interpreters such as family

members, the study found many problems arise with this such as HIPPA violations and false

information translated. There was no portion of this study that looked at the outcomes of patients

who did not receive interpretation services or use informal interpreters. It is anticipated that these

patient outcomes would have been less successful than patient outcomes where professional

interpretation services were used.

This study experienced few limitations, but one of them being their small sample

population. Because the sample size was only 52 general practitioners practicing in a small area

of Ireland, these results cannot generalize the national population’s views.

Jacobs, Shepard, Suaya, and Stone (2004) studies the impact a new interpretation service

had on the delivery and cost of healthcare. The new interpretation service provided 5 interpreters

that could speak Spanish and Portuguese. They worked 24 hours a day and translated either

through a phone call or an in-person visit. This new service was implemented in 4 healthcare

centers across Massachusetts that cared for nearly 122,000 patients. The study population

required patients to be 18 years of age at the start of the study, limited English speakers, and

enrolled in continuous care within 1 of the 4 healthcare centers. It included 4,499 patients, 380 of

which were receiving interpretation services while 4,119 of them were in the comparison group.
LANGUAGE BARRIERS IN PALLIATIVE CARE 6

This study compared the amount of care that was received and the total cost it for patients

receiving interpretation services to people who were not. The amount of care was measured by

4 aspects; recommended preventative services received, number of office visits made, number of

prescriptions written, and number of prescriptions filled.

This study found that the group receiving interpretation services had a significant

increase in the 4 aspects of care listed previously in comparison to the group that was not

receiving interpretation care. The results of this study suggest that the new interpretation service

increased the accessibility of healthcare to patients with limited English speaking abilities for a

small cost. The average cost of an interpreter was $79 per visit, and averaging $245,363 per year.

The average person in the interpreter services group used the services 3 times per year. The cost

of this new interpretation service split among all 122,000 patients that the facilities care for

comes to a mere $2.40 per person per year. In the study, the emergency department cost for the

interpretation service group was less expensive than that of the comparison group. The cost of

primary care was far greater for the interpreter service group than it was for the comparison

group.

The study believed that although the overall cost of healthcare was greater for the

interpretation group, it will decrease costly complications of a disease down the road. A large

portion of the care delivery increase seen in our control group was from follow up visits and

medications, factors that will help a patient in the long run maintain health.

Limitations seen in this study was the small sample size of the interpreter service group.

380 patients are not enough to have these statistics generalize a nation. This study also only ran

for one year. It was thought that one year was not enough time to adequately assess the impact
LANGUAGE BARRIERS IN PALLIATIVE CARE 7

that this new interpretation service had on the community’s healthcare delivery and costs. The

last major limitation found in this study relates to quality of care. This study looked at the

amount of care that was delivered, not the quality of it.

While studying in Ireland, the class explored many areas of palliative care. Throughout

the lectures and facility tours, I found language barriers to be a prevalent challenge that this type

of care faces. Although Ireland has not overcome all barriers that stand in the way of

communicating with foreign language speakers, they are making strides to do so. Ireland

considers themselves to be a bilingual country, meaning that most residence speak English as

well as Irish (Gaelic). Irish is taught in elementary schools and continues on through high school.

As the class toured the hospital in Galway, we noted all signs were written in both English and

Irish. Signs directing patients and families around the hospital were clear and accommodating to

both languages. The problem with doing this is that English and Irish are only two of the many

different languages tourists and residents speak in Ireland. It may be difficult for a foreigner to

get to the right healthcare facility let alone receive care. This problem was so seen in the 2004

study by Jacobs, Shepard, Suaya, and Stone. The 5 translators were very resourceful, but

unfortunately, they only spoke Spanish and Portuguese, leaving all other language speakers

without interpretation services.

With communication being the foundation of palliative care, The Galway University

Hospital and hospitals in the United States have both taken advantage of modern technology to

overcome the challenges that foreign languages bring. Interpreters are available in both countries

to translate via video chat, which is of great help in non-emergency situations. However, in

emergency situations, setting up a video chat can be a timely process. This may contribute to
LANGUAGE BARRIERS IN PALLIATIVE CARE 8

why 63% of general practitioners in the MacFarlane, Glynn, Mosinkie, and Murphy (2008) study

reported that they have been in situations where they felt an interpreter was needed but one was

not available.

Unfortunately, technology like video chatting often takes away the delicate phrasing

needed when having difficult end-of-life discussion. Therapeutic technique can get lost in a

translation, making difficult conversations appear cold and feeling less. Non-verbal ques and

tone of a patient is also hard to identify through a translator. Tone can help you understand a lot

about a patient because what one says and what one wants can be two completely different

things. Patient emotions are key in knowing how much bad news they can handle, but emotions

can be suppressed by the focus being on the medical information across. Both countries also

utilize in-person translators as well but it can again be timely to locate one with the specific

language needed and have them come in. In-person translators do not stay for the entire length of

one’s hospital stay either. They come and go for the important consultations and necessary

conversations.

Family members and friends are another common interpretation service used in Ireland,

but seen as very unprofessional. Because English and Irish are both taught in primary school, it

is often the case for a child to be interpreting difficult medical information. While this is

unethical, many young children do not even have the mental capacity to comprehend the

information being asked to be translated, promoting frequent miscommunication. In chapter 2 of

the Palliative Care and Communications textbook, we learned a key concept of communication is

having open and honest conversations. Within this concept, the book explains how patients are

often unwilling to listen right after the bad news is delivered. Everything said after the bad news
LANGUAGE BARRIERS IN PALLIATIVE CARE 9

often goes unheard because the patient’s focus is on what is wrong with them. Similar to how

patients shut down, family interpreters can too. It is not uncommon for a family interpret to

interpret the wrong message or only a small portion of it from being in shock or denial.

With palliative care and terminal illnesses having a high correlation, not all conversations

are easy. But as healthcare providers, it is our job to rely truthful information about a patient’s

prognosis. With family members being the interpreter, it is possible they could withhold

information about their loved one’s medical condition in hopes to spare feelings. In class, we

learned that it used to be thought that withholding information would create less stress for the

patient in their time left to live, but recent studies have disproved this. Many people prefer to be

told the truth no matter how hard it is to hear.

The other main issue that comes with family translators are HIPPA (Health Insurance

Portability and Accountability Act) violations. HIPPA is a national organization that protects

individuals’ health information from going public and promotes confidentiality. Seen in the

study by MacFarlane, Glynn, Mosinkie, and Murphy in 2008, HIPPA violations are common

when a patient does not want their family or children to know the full extent of their medical

condition. But in times of emergency, family members are often the only tools hospitals have

access to for translation. While speaking to healthcare professionals in Ireland, I asked ways they

get around language barriers day to day. I was told that in desperate times, they use the non-

medical staff, such the kitchen workers or cleaning employees, that speak the same language as

the patient. Unlike professional translators, these types of people are not trained or educated on

HIPPA laws. This could lead to violations and law suits in the future. Palliative care is all about
LANGUAGE BARRIERS IN PALLIATIVE CARE 10

making the patient as comfortable as possible, and having an unprofessional stranger listen in

and translate someone’s serious medical condition could cause feelings of unease.

Interpretation services might be of help even for people who speak the same language as

their healthcare provider. While learning about palliative care in Ireland, most professionals I

spoke with were speaking English. Although I am fluent in English, I still had great difficulty

understanding what they were saying due to their thick accents. I frequently found myself asking

them to repeat sentences and my peers for clarification on parts of the conversation I did not hear

correctly. Medical language is difficult enough to understand, but by adding accents and foreign

languages, it can become near impossible.

In chapter 3 of the textbook, transactional communication is discussed, specifically the

transmission model of communication. Transactional communication exhibits the proper way to

exchange of information. In an exchange of information, both parties are listening and both

parties are speaking. One person does not over power the conversation, making everyone in the

conversation of equal importance. When you add in an interpreter, the conversation often merges

from transactional communication to the transmission model of communication. The

transmission model is more common but does not promote effective communication. It is where

there is a sender and a receiver, with one person, typically the healthcare provider, dominating

the conversation. When you add in a translator, the numbers of parties in the conversation goes

from two to three. The goal of the conversation starts to focus around just getting the information

across rather than having an equal discussion. Focusing on the patient receiving the information

does not promote question asking by the other party or a balance of power.
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Language barriers are seen as major challenges in the United States and Ireland’s

healthcare system, specifically in palliative care. Both countries are making strides to improve

this issue but still have ways to go. In-person translators are great but can be a timely process to

get one into the hospital. Video chatting and using family members are also common methods

used in an effort to eliminating language barriers, but still all come with problems. The study by

Span in 2006 shows that patient outcomes are more successful when they receive interpretation

services, but in the other studies investigated, a good amount of healthcare workers feel they

don’t have adequate access to them. In order to deliver the best possible palliative care possible,

a solution to this communication problem must be found.

LANGUAGE BARRIERS IN PALLIATIVE CARE 12

References

Au, M., Taylor, E., & Gold, M. (n.d.). Improving Access to Language Services in Health Care: A

Look at National and State Efforts. Mathematica Policy Research inc.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.582.7433&rep=rep1&type=pdf

MacFarlane, A., Glynn, L. G., Mosinkie, P. I., & Murphy, A. W. (2008). Responses to language

barriers in consultations with refugees and asylum seekers: a telephone survey of Irish

general practitioners. BMC Family Practice, 9(1). doi:10.1186/1471-2296-9-68

Span, L. T. (2006). I can't understand what you're telling me. physical therapy: A study of the

impact of language barriers on health outcomes (Order No. 3206378). Available from

Nursing & Allied Health Database. (304909133).

Wittenberg, E., Ferrell, B., Goldsmith, J., Smith, T., Glajchen, M., & Handzo, T. (Eds.),

Textbook of Palliative Care Communication. Oxford, UK: Oxford University Press,.

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http://oxfordmedicine.com/view/10.1093/med/9780190201708.001.0001/med-

9780190201708.