All right, thank you so much. This is such a great session. Thank you for putting this together and for inviting me to speak today. This is great. So I've already been introduced, I'm sure this works. I have no conflicts of interest to disclose. I do have to say I'm not an interpreter. So I am hoping that there are interpreters in the audience who can come forward and share their experiences. The learning objectives for this talk are threefold. The first is to recognize the moral and emotional challenges that professional interpreters face during end-of-life conversations. And we've heard some of those already. The second is to describe the concept of moral distress and the impact the experience can have on interpreters and other healthcare professionals. And the third is to apply strategies to address moral distress and promote moral resilience for professional healthcare interpreters. Before we dive into specifically examining the experience of moral distress of interpreters at the end-of-life communication, we set the stage which has already been set by our two other illustrative speakers by acknowledging that end-of-life communication is challenging for everyone involved under most circumstances. End-of-life communication involves diagnoses, prognostication, uncertainty, values-based discussion, resuscitation decisions. And this is particularly difficult in the ICU where we are often performing this complicated dance between curative and comfort care. And additional challenges arise when healthcare teams and families have different paradigms as we've also heard about already, or mental models of health and illness and wellness and values around life and death. And differences in our world model, mental model, may be based on many factors that we've already heard about. Religion, geography, political affiliation, race, ethnicity, family of origin, education, country of origin, we could go on and on and on. But language differences can present significant challenges to end-of-life conversations as we've already heard about. Not only do we have differing worldviews, but now we don't even share the same words to describe and explore our underlying experiences. Language discordance as we've already heard between the medical team and the patient and family is associated with lower quality of communication and a lower quality of end-of-life care resulting in significant healthcare disparities. So professional interpreters are essential to optimizing end-of-life care for patients and families when there's language discordance. And study after study, as we are hearing, is demonstrating this essential role. If you're sitting next to an interpreter today, please thank them. But the role of the professional interpreter is not an easy one. There are many challenges that interpreters face, particularly when it comes to highly emotional, difficult communication around an end-of-life. They're often invisible, often figuratively, but sometimes literally over the phone. They're often considered a secondary team member. They're rarely in relationship with the ICU team. They're often lacking continuity of conversation with the patient and family. Rarely part of our provider medical discussions. And professional interpreters are often understaffed, placing limitations on their care. So these challenges, added to the challenges we all face in end-of-life communication, place the professional interpreter at high risk of emotional and moral distress. So what is moral distress? I imagine most of you in this room have heard the moral distress term and understand it in one of its many forms. And some of you are likely experts in the concept of moral distress. Those of you who are nurses in the room will undoubtedly be familiar with the original definition of moral distress, which was coined by philosopher Andrew Jameton in 1984 when writing about nursing ethics to describe what he was seeing in nursing students that he was teaching. And that is that moral distress, as he wrote back then, is a phenomenon in which one knows the right action to take but is constrained from taking it. I think we've come a long way in understanding moral distress since the 1980s. And there's a spectrum and it's very complex. It's been 40 years since that original definition. There's been a lot of research and advancement in understanding this phenomenon in a variety of healthcare professions. And there's many terms now describing a spectrum of experiences. To examine moral distress, I turned to one of the world's most prominent scholars on this topic and one of my own personal heroes, nurse philosopher, Dr. Cinda Rushton. In Dr. Rushton's book on moral resilience, she describes moral suffering as an umbrella term for these experiences for all healthcare workers. And this is an excerpt from her book. I'm just gonna read a section here for you. Moral suffering is the anguish experienced in response to various forms of moral adversity, such as moral harms, wrongs, or failures, or unrelieved moral stress. Moral suffering can be triggered by witnessing, participating in, or directly precipitating situations that produce a wide range of negative moral outcomes, such as observing a clinician speak to a patient who has recently immigrated to America in a condescending or disrespectful manner, participating in treatment plans that prolong an inevitable death, handling the bodies of unconscious patients in harsh, uncaring, or observing members of our team demean or dismiss our moral concerns or those of others. Clinicians who work in situations where pressures for efficiency, throughput, or inadequate staffing, when those are prominent, may acutely or chronically experience moral suffering in response to the dissonance between their professional values and their organizational mandates. Moral suffering essentially has its roots in our concern for others and our intention to bring about beneficial outcomes to relieve the pain and suffering of others or to rectify an injustice. So although different healthcare professions have unique challenges, the experience of moral distress or moral suffering is shared collectively. Moral suffering can lead to moral outrage, psychological or physical illness, depression, anxiety, bitterness, anger, dismay, burnout, indifference, or patient care delivery and leaving the profession. So what do we know about the experience of moral suffering in professional interpreters as a result of end-of-life communication? I did a literature research and honestly, there's unfortunately not a lot out there. This is a fairly under-reported field. Fortunately, there was a 2023 review article that did much of the work for me and there were a handful of other articles to add to this but it really is an under-represented area in the literature. The review article identified and categorized a spectrum of emotional responses to interpreting during end-of-life communication. There are four different categories that they identified. The first is the stress of the role. So relaying messages conflicting with cultural expectations of communication, the strain of commitment to an ethical code of accuracy versus the emotional desire to deliver information as an advocate and the inability to expand or clarify the underlying message. One quote was, I was told to say, this is your scan, you've got a huge tumor, there's nothing I can do about it. I just could not do that. The second category is emotional distress. So this has been the first, this experience is being the first to relay news to patients and receive their response. Distress when patients died experiencing them like the death of a loved one. One quote was, I would really take that home with me. I would be really upset and worried for that person. The third category is guilt. Delivering the bad news, being on the receiving end of patient and family distress and observing clinicians disengaged from distressing conversations. One quote was, the patient was angry, that's why she took it out on me. It still made me feel bad and upset. And the final one is loneliness. Isolation, abandonment, alienation and feeling disparate from clinicians or services. We are a forgotten breed. We're always needed but do not have the resources to do our job. Since this is not my lived experience and since there's little literature on the topic, this past fall in preparation for this talk, I sent out an informal survey to the professional interpreters at my institution. And what follows is a summary of their responses describing their experiences that led to emotional and moral distress in their roles. And I found many of the same themes that were reported in the literature. Empathetic over-arousal with no support for emotional distress. Quote, I felt so bad about this particular child's death. I was so connected to the family and I didn't have anyone to talk to. Concern that a family is not understanding the information. And this is becoming more and more common with increasing medical complexity. Here's a quote. I was spending hours, I was interpreting for hours, an hours long discussion about a new leukemia diagnosis. Late in the conversation, someone said cancer instead of leukemia. And the parent was like, what? My child has cancer? Helping the family to navigate complex values and a fear of influencing their values with the values of the interpreter. System constraints like time constraints, understaffing, limited time for important conversations. Quote, families can't always arrive on time, but I have to leave. Vicarious trauma, stories of trauma, poverty, grief that may occur before families are even in our care. A moral desire, but inability to attend to all needs. Disagreement with family decisions. One quote was, this child was essentially brain dead, trach dependent, but the family just wants to keep on praying. And another quote, the grandmother changed the decision against the parents and the parents now are using all resources at home to care for the child. And system injustices. So quote, frustrations that there seem to be no limits to providing medical care for children who do not seem to benefit, but we can't even provide money for gas for a family of a child who needs basic medical care. And witnessing medical team bias and racism and language biases with a lack of interpretation services, particularly for indigenous languages. Lack of preparation we've already heard of. I was caught off guard by what the team said. I was not prepared. Role constraints. I didn't get to ask questions. It is distressing seeing needs that are not even met or even seen. I asked the family if they've eaten and if they need anything. Providers often don't even ask about basic needs. Witnessing inaccurate interpretation. Providers who speak some of the language and don't wait for my interpretation, but it's clear that they don't understand. And lack of skills. Sometimes I have to interpret in religious ceremonies, but I don't have any religious education. I felt lacking in the vocabulary, and it was hard because I understood the importance of these moments for the family, and I felt they deserved someone who could use the right words for the occasion. So how do we begin to recognize and address this common but underreported experience? The following strategies summarize recommendations that came from the literature review and the informal survey. Pre-briefing. We've already heard about this one. We really need to incorporate interpreters into our pre-briefing care conferences that we do as a medical team, and prepare them emotionally, and help them to clarify concepts and cultural nuances. Debriefing. Follow up. Reflect on the patient and family encounter and the emotions associated with this. Formal support. Ensure that there's institutional access to emotional support following distressing conversations, including counseling. Interpreter training to improve knowledge of palliative care concepts, ethical decisions, and difficult communication strategies. Provider training for professionals and how to conduct, for interpreters, and how to conduct end-of-life conversations through an interpreter, for the professional, sorry. And then institutional support, which I'll get into in just a sec. What about the role of the critical care clinician, which I'm guessing are most of us in this room? How can those of us who are critical care clinicians support our professional interpreter colleagues in their roles? The first one, as I've already mentioned, is to incorporate the interpreter as an important team member. I hope we all walk away from this remembering this. Preparing the interpreter with the goals of the conversation and essential points for understanding. Requesting their feedback as a team member. Help eliciting family goals and values. Potential misunderstandings and unmet needs. And we all need to advocate for more resources for our interpreter services. I think that's one of our roles I hope we take away from this. Finally, the organizational response. I personally believe there's a moral obligation of organizations to attend to moral suffering of the healthcare workforce. Provide a mechanism for feedback, well-being surveys at a regular cadence that obviously includes our professional interpreters. Addressing recurring themes, lack of institutional services, understaffing, insufficient resources, ongoing training support. Ensure core competencies and ethics as we do for everything else. Awareness of the impact of emotional and moral suffering. Offer group debriefing and support sessions during and after difficult cases. And offer individual counseling support for workforce. And document and study novel interventions. Finally, Dr. Rushton and others are exploring the concept over the last five plus years of moral resilience. Which she defines as the ability to preserve or restore integrity in response to moral adversity. This approach empowers all of us to seek opportunities to enhance our ethical confidence and competence. And to foster mindfulness, self-regulation, buoyancy, self-stewardship and integrity. Some personal actions that we can do and help our interpreter colleagues to do to develop moral resilience are as follows. Learn ethically grounded responses. Cultivate self-awareness to recognize and respond to moral suffering. Make a personal plan of how to support our own personal well-being. Engage with workplace efforts to address moral suffering. Develop skills in communication, conflict transformation, interprofessional collaboration. And identify and use organizational community support resources. So in conclusion, moral suffering of professional interpreters is an under-described phenomenon. And more research is obviously needed. And critical care clinicians can take specific steps to reduce the experience of moral suffering for interpreters. An institution should measure and address moral suffering in all workforce members. I look forward to the discussion and hope if there are any interpreters in the audience they'll be brave enough to stand up and share their experience. Thank you so much. Thank you.

interpreters

moral distress

end-of-life care

healthcare teams

communication