Well, thank you very much for having me, I hope everyone can hear me. I don't know, my bio is slightly different to that. I'm Associate Professor at Mayo Clinic and Assistant Professor of Biomedical Ethics and I'm also in the Division of Pulmonary and Critical Care Medicine, but I'm not a practicing ICU clinician, so feel free to take anything I say with a pinch of salt, if you like. Okay, so I'm going to be focusing then on sort of family versus third party interpreter. Okay, so I don't have any conflict of interest or disclosures. I am funded though by the AHRQ and I'm doing a study right now, which I'm going to touch on at the end of my talk, using health information technology to promote equitable care for patients with limited English proficiency and complex care needs, which includes people in the ICU and patients at end of life. Just to give a brief outline, I'm going to touch on language barriers and decision making in the ICU briefly, talk about the benefits and under use of third party interpretation, family interpretation, ethical and practical considerations, a little bit about my research work and then we'll conclude with some recommendations. So you may have come across this phrase, limited English proficiency. Essentially it means patients who have a limited ability to read, speak, write or understand English or not speak English as a primary language, which is slightly different. But it essentially is about 25 million people over the age of five in the U.S., so about almost 10% of our population. The new term that we're trying to move towards to get rid of this sort of ethnocentric idea that Dr. Siddiqui touched on, we're trying to move now towards this phrase non-English language preference. So the literature will always use LEP. I myself have used LEP and in my grant the last couple of years, but I'm kind of trying to now move towards this non-English language preference as my acronym, the acronym. So the number of people in the U.S. that speak different languages at home is growing. So about 350 languages are spoken in the U.S., but those who have an actual language barrier or a limited English proficiency or NELP is actually sort of relatively steady in comparison. And this includes patients who obviously have immigrated here, patients even who are born here can have a language barrier. And then of course we also have patients who travel here for treatment who may have a language barrier. So that's just worth bearing in mind. We did some work in the ICU, just a basic historical cohort study several years ago, looking at the differences in outcomes in the ICU for patients who had language barriers. And I'm sure many of you have seen this in your practice, but we noted lower rates of advanced directives, longer ICU and hospital stays, increased use of healthcare utilization such as mechanical ventilation, and then lower rates of do not resuscitate and comfort measure orders as well as a longer time to reach those decisions. So after this study, we're sort of left with the question, is it a knowledge gap, poor bidirectional communication, are these authentic and normative preferences as Dr. Siddiqui touched on, cultural aspects that people make different decisions at end of life, you know there may be structural mechanisms that are causing barriers to what we might consider preferable decision making, do we consider these differences or disparities, but obviously if we are providing aggressive care that patients or families don't want or don't understand, this is not good. So we then did some qualitative work to try and understand the why this is happening, which we can't gather just from pulling data from charts. So essentially it comes down to bidirectional communication issues, which I really like to stress, I really recommend using interpreters for, but also there are definitely some cultural beliefs about de-escalation of care and interventions that have also impacted our findings. When we are working with patients who have language barriers, we should consider this triple threat idea, which means that language barriers often come hand in hand with health literacy issues, so low health literacy is more common among patients with language barriers, and then there are the cultural barriers that we've touched on. So thinking about third party interpreters, or professional interpreters I'd probably normally call them, but this can be, patients have a right to have a professional interpreter if institutions are receiving federal funding, they need to provide language services to their patients who have language barriers, and this can be in the form of a phone interpreter, a virtual interpreter through an iPad or video, as well as face to face, in person interpreters. We all know that ad hoc arrangements are frequent, not just with family, but with maybe pulling in other members of different healthcare teams, or other people who aren't on a healthcare team but work in the hospital. And really the impact of providing language services overall probably does have cost savings, the literature is a little bit conflicted about this, but it's not costing institutions more to provide service, they're not losing money providing language services let's say. So I just wanted to touch on as well, translators is really for patients who, or for translating written text, and interpreters is spoken word, so those are slightly different although they're often used interchangeably, they are actually slightly different. And interpreters really value their role, as you can see here it's the difference between life and death, and I certainly think in the ICU and managing patients' end of life complex care, it's extremely important. Interpreters professional or third party provide more accurate interpretation than patients, there's lots of studies showing this, they have professional tenets, and they do have a code of ethics, so they understand about confidentiality, they understand about the importance of accurate interpretation, and if they have dual relationships with people in their community they're very mindful of that, and you know maintaining confidentiality and privacy. They can mitigate many risks for patients, safety, quality, health outcomes, and you know there's several systematic reviews showing outcomes are better, this crosses all domains not just end of life, but outcomes are better when we use interpreters. It's also just worth noting that interpreters are variable training, so each institution will have different requirements for their in-person interpreters, and if you're using something like language line or phone interpreters, I've heard lots of stories about different levels of, you know, they're not paid necessarily very well, and they need to pick up the phone within a certain amount of time, and so there may be a lot of distractions going on if they're interpreting remotely. So just something else to bear in mind. So I think for patients who are complex, which you are all managing complex patients, we would really recommend in-person interpreters in as much as it's possible. Interpreters have several roles, they do the verbatim interpretation, which is a bidirectional communication between families and clinicians, and clinicians and families and patients. They also serve as health literacy guardians, so this is all the triple threat that we mentioned. They will help make sure, they should be helping make sure that patients understand the decisions they're making, they understand risks, benefits, alternatives, and they advocate for patients and empower them to sort of ask questions about the information, and then they also can serve as the cultural broker, you know, helping clinicians understand some of the cultural nuances, and I understand that, you know, Spanish-speaking interpreters don't know every culture that speaks Spanish. A lot of Spanish interpreters have told me this, but I still think they may have some important information to share with clinicians and enhance cultural awareness. So why are we underusing interpreters and getting by is the phrase that's used in the literature. A lot of clinicians don't understand the need and legal rights of patients. Sometimes we may not estimate what the patient's English proficiency is, might have a chit-chat with the patient and feel they have fairly good English. You know, the importance is underestimated, I think, and sometimes it can be unclear how do you reach language services, how does the service work, and we found that in our institution that a lot of clinicians just weren't quite clear how to get language services easily. And even now, we've had new nurses since COVID started, you know, young nurses who've started since COVID and some of them didn't even know we had in-person interpreters in the hospital, so it's sort of not a well-promoted service. There's obviously sometimes a lack of availability of interpreters in certain languages. The workflows are a little inefficient sometimes. Patients and sometimes clinicians are concerned about cost. Some patients believe they're going to be charged if they use an interpreter and clinicians, so just something to bear in mind, and obviously it can be time-consuming pulling interpreters into interactions. So we're really relying on clinician initiative, which I think doesn't optimize use of interpreters. And then just to highlight, really, over COVID, obviously a lot of our in-person interpreters were pulled out of the hospital, and many legal scholars have described this as a language justice issue, and so I'm really trying to kind of sort of reemphasize the importance of in-person interpreters, because I think a lot of that did get lost over COVID, and people have really got used to iPads and institutions are not necessarily going to be getting back all their in-person interpreters that they have. And so there was a lot of workarounds over COVID to try and adapt to this and use different mechanisms apart from just using iPads and video interpreters. What other issues are there with third-party interpreters? They may not be available in an emergency. There can be connectivity issues, obviously, with video and phone. I would say there's quality issues at times if you're using remote interpreters. Privacy confidentiality. And then there's this idea of languages of lesser diffusion, which are basically rare languages that aren't spoken in the community where your hospital is, so it can be really hard then to find an interpreter that provides that service, even on some of the large vendors. And then, obviously, patients and families can decline interpreters. So just thinking about family interpretation, are they ever needed or beneficial, family interpreters? The recommendations are they could be used in an emergency. Obviously, there's easy access if they're allowed to visit the hospital and they're at the patient's bedside. That's easy access. It can often shorten the exchange because they often know the history, so you don't have to kind of wait for that to come back and forth. They can often give you more context, more information, give you a link. And then, like if patients bring family members to the outpatients, they can help with recall of discussions. So it can be helpful, but they may assume the role of the patient and bring in their own agenda, which I'm going to talk about a bit more. So we did a community-engaged qualitative study talking to caregivers, community leaders, and Spanish-speaking patients, and we conducted our interviews in Spanish about, like, what was it like being in the hospital with a complex illness, and we really just defined that as someone who was in the hospital for 10 days or more. And I just wanted to touch on these two themes, what people said about family interpretation and what they said about remote interpretation. Obviously, family caregivers have multiple roles, clinical care, emotional support, and then COVID impacted visitation and access to interpreter services, so it's quite isolating for patients, especially if they didn't speak English. However, family members sometimes feel a burden to do interpretation, and sometimes patients will worry about their family members interpreting, you know, the concern about health literacy causing confusion, and then sometimes family members who are doing a lot of interpreting end up being the surrogate decision-makers by default, even if that's not necessarily what is wanted by the family. So you can see here from some of our quotes, I relied on my daughter, it was just easy, you know, she just basically sat by my bedside. And then, you know, a lot of the sense of responsibility, you know, happy to do interpreting but just didn't want to leave the room, you know, to leave their family member isolated and without being able to speak with people. But you know, the sense of obligation can also become a burden, they just sort of relied on the family member being there to do the interpretation and wouldn't call any other interpreter services. There's concerns about accuracy, you know, someone says my brother can't translate, he's trying to help but he's just causing problems. And then this idea of a heavy weight then on the person who's doing interpreting. Remote interpretation, you know, people recognize it's very immediate, convenient, and the reduction in COVID-19 risk obviously, but issues are, you know, inaccuracy because we don't know about the quality of all of the interpreters being employed by vendors. And so, you know, you say one thing, they're saying something different, I could hear dogs in the background, she wasn't translating the best way possible. And then there's connectivity issues that I'm sure everyone knows about. And then just this idea that an in-person interpreter really can provide nuances that remote interpretation misses out on. So just thinking about practical ethical considerations, this is a really interesting article. It's not an ICU patient but it's describing a sort of scenario with a family member who's doing interpreting and some of the challenges that that's causing with them, the clinical team and the decision-making. So from a clinician point of view, if you're not using interpreters, you know, for me it's really a potential to threaten autonomy, decision-making, and really to provide goal-concordant care. And I really consider this a health equity issue. And I know my colleague who's coming next is going to talk more about moral distress, but a lot of our qualitative work did show moral distress among clinicians when they felt that they were doing, for example, a lot of non-beneficial treatment and they weren't really sure if the patient wanted it or, you know, the patient had agreed to it or the family wanted it. And so this was very disturbing. Institutions, if they're federally funded in any way, they have a legal obligation to provide language services to patients. If they're using ad hoc systems, then the implications are if you're pulling in people from other teams, you're interfering with their, you know, workload. And so you shouldn't be relying on other bilingual people in the hospital to do this. We've seen that sometimes there's increased healthcare utilization if we don't have good interpretation and, you know, there's economic consequences to this. I think the languages of lesser diffusion, the rare languages, are really tricky to handle. We had someone who spoke Micronesian in our hospital and it was very, very difficult to help them get language services through the vendors that we had. And then vendors that were identified did not have the adequate security to do the remote interpretation so it was very complicated. And then obviously for informed consent, we need to be very mindful of language barriers. For third-party interpreters or professional, be they remote, in-person, you know, they, as I mentioned, have a code of ethics so, you know, they have obligations, they understand about confidentiality in these dual relationships. It's very variable how much medical information they have so that's, I mean, something to bear in mind. Our interpreters only got access to ethic in the last couple of months so otherwise they're really relying on the clinician to kind of brief them of the situation they're walking into, particularly, I would say, if it's sort of an end-of-life discussion, it's definitely worth getting together with the interpreter to fill them in so they're not walking into a conversation that's really challenging without having any background and being ready to have that discussion. Ad-hoc family interpreters only in emergencies, there is a risk of inaccurate interpretation, there's a risk of information being added, information being missed. And then we have this decision-making styles which certainly there can be relational autonomy where family members are taking on decision-making and that's appropriate but if we don't, if we have a family interpreter in the middle of that it's really difficult to untangle what's going on so they may have deliberate withholding of information that, you know, is not appropriate and then we need to consider health literacy issues. So I just wanted to touch on this, I'm just doing a study and we're using health information technology to try and improve in-person interpreter use for patients with complex care, so any of our patients in the ICU or patients who've been in the hospital for a long time or have a serious complex illness and it's a step-to-edge cluster-randomized trial and we're really identifying patients who have language barriers and a complex illness and we're letting interpreter services know and then they are nudging clinicians and kind of saying, we really think your patient's going to benefit from an in-person interpreter, you know, here's how you contact us and, you know, we'll work with you to get that interpreter to bedside as soon as we can when suits you. Another project I've been working on is this idea of check-ins, so this is the idea of having a pre-meeting, pre-encounter huddle, as I mentioned, if you have a difficult conversation it's really helpful and this is recommended in the literature but never really been, you know, implemented in care, this idea of meeting with the interpreter, bidirectional exchange between interpreters and clinicians to understand what's the purpose of the meeting, what decision are we trying to make, what do we need to know about the family, who's making the decisions, culture, religion, background, all that kind of thing, you know, any challenges and what role can we play to really help this family understand what's going on and make a decision that's best for them. So just to conclude, you know, please, if possible, use in-person interpreters for patients in the ICU or at end-of-life, any of those really challenging decision-making times. I think, you know, really to understand the limitations of remote interpretation, be it telephone or even video, I recommend meeting with the interpreter before as much as possible to share information and just consider health literacy and cultural factors and there really are some potential unintended consequences of using family members as interpreters. You know, I again consider this sort of a health equity issue, so really important and I just want to acknowledge my collaborators and colleagues who've been helping with the study and helping with a lot of the other, the work that I've been doing, so thanks everybody.

language barriers

ICU decision-making

professional interpreters

health literacy

equitable healthcare