N Engl J Med 2017; 376:812-813March 2, 2017DOI: 10.1056/NEJMp1613163
I groan internally at the sight of the laminated yellow reminder that the next patient needs an interpreter, who is waiting patiently outside my office. Non–English-speaking patients take at least twice the time of others. Everything one says has to be understood, and some of it jotted down, by the interpreter before being relayed to the patient. It’s not the patient’s fault, but I can already picture the irritated waiting room.
Where I work, more than half the patients don’t speak English, so interpreters are common and necessary. They are highly qualified and a boon to hapless patients who would otherwise feel even more lost in the labyrinth of the health care system, but sometimes I wonder if it can really take so long to say “Tell me about your symptoms” in another language and how “Take this pill twice a day” leads to a seemingly interminable exchange, from which I’m excluded.
One of my favorite patients awaits me; the woman speaks enough English to get by if I speak slowly and look her in the eye, but I know she prefers having an interpreter. And though I know that without him, my efforts would be more arduous, I can’t help but think that his presence will change the dynamic and test the intimacy of a doctor–patient relationship forged over many years. So it is with a mix of resignation, understanding, and self-reproach that I ask the interpreter to join us.
The fluffy down of my patient’s jacket does little to conceal the bulge of her ascites. And even if you missed the ascites, the yellow in her jaundiced eyes is unmistakable. Always on the small side, she is now thin, but her loss of stamina seems only to have enhanced her dignity.
Our clinic has known her for a decade, shepherding her through initial curative breast-cancer surgery followed by adjuvant chemotherapy and radiation. She took her tamoxifen religiously, one of the few patients who didn’t need a reminder.
Then, years later, as cautious optimism replaced chronic apprehension, she felt a lump in her neck. It was indeed just the size of a baby pea, I agreed, dismayed at the incurable cancer it portended. Defying multiple lines of treatment, the pea grew in size, until, last week, I’d shown a medical student what matted, pathological nodes felt like and traced my finger down to her chest wall, a canvas of malignant cutaneous nodules. I felt as if her disease had slapped me in the face.
Now I have to tell her that refractory ascites and liver failure are the latest blow. In a place where hope is always fugitive, this morning feels particularly hopeless.
“Doctor, I have an important question for you. How long do I have to live?” The interpreter’s soft voice breaks into my reverie.
The patient is alone, as always. Her husband works shifts in a factory, speaks no English, and can’t afford to come.
“Is there anyone you’d like to have with you today?,” I ask, looking at her but listening to the interpreter.
“You can tell me, doctor,” she admonishes me gently in carefully enunciated English, mistaking my silence for hesitation. “We must all die someday. I’ve prepared for years.”
Her unflappable calm takes my breath away.
Tears prick my eyes, catching me by surprise. After all, talking prognosis with patients is hardly new for me. Yet I find myself thinking, “Be professional, be professional” — and then wondering what kind of a professional I am if I have to remind myself to be one.
I compose my reply, mindful of pausing frequently to let the interpreter catch up.
“This is a difficult conversation for us both, but I want to be honest,” I say.
She turns toward the interpreter.
“It’s clear that your condition has deteriorated rapidly in the past few weeks, to the point where you are needing weekly drains of fluid.”
She strokes her uncomfortable abdomen, her gaze never leaving the interpreter.
I pay no heed to him. Beyond being grateful that he is concise, I am too busy thinking about what to say next.
“So, doctor, would you say I have weeks or months to live?” The interpreter’s voice fills my ears. If I detect a catch in his voice, I ignore it.
“I am so sorry to say this, but I’d estimate weeks,” I say, turning my chair toward her so she can see the emotion on my face.
There, I have said it, I think, but as the patient continues to look intently at the interpreter, I realize that he is still silent. In that split second, I realize that the interpreter and I know something vastly important about the patient that she has yet to discover. A stray thought registers the temptation to tell the interpreter to hold off the answer, or at least give me a chance to make the news more palatable, but alas, I have said my piece and the interpreter will translate it verbatim (or I won’t know if he doesn’t).
It must surely be the tiniest sliver of silence, but it feels like a roar. Glancing at him, I glimpse his stricken expression. When he finally speaks, his voice is calm and emotionless, but my attention is fixed on my patient’s face, on which understanding has now dawned, and tears are falling fast. I feel miserable, thinking how easily past wins have been dwarfed by the unforgiving present.
Eventually, my patient leaves with arrangements for hospice, and I see a succession of other patients, all delayed, some cranky, but I feel numb, unable to summon anything except well-rehearsed, automatic gestures that mercifully carry me through the day.
As I sit writing notes that afternoon, sadness engulfing me like a cloud, my thoughts suddenly turn to the interpreter, and I think to check on him. I page him and can’t help but notice the weariness in his voice.
“I don’t need you back,” I reassure him. “I just wanted to see if you’re okay.”
The barriers come tumbling down. He tells me how challenging he’d found the encounter and how he fought to curb his emotions. When I acknowledge that he did a wonderful job of helping me deliver very difficult news, he tells me, and later writes me a note to repeat, just how much my call means to him. It dawns on me that in all these years I have never wondered how an interpreter copes with giving bad news. In a hospital like mine, interpreters are an invaluable aid, but of course they are also people, affected by the news they help break. Interpreters usually follow patients out of the exam room and help them book their next appointment. Then they are paged away to the next patient, who may be having a baby, losing an appendix, or needing a shelter. An interpreter has little idea of what the next consultation holds and has even fewer avenues of debriefing, but as international borders become porous and refugees, asylum seekers, and non–English-speaking migrants seek medical care, interpreters are increasingly being drawn into conversations that cover thorny social issues, not all of which have medical answers. Everyone sympathizes with stressed doctors and nurses, but who ever considers interpreter burnout?
The reality is brought home to me the next week, when my patient returns to the clinic for an unscheduled visit accompanied by a different interpreter. I coax the patient into entering inpatient hospice for terminal care, telling her that her daughter cannot and should not look after her at home. My heart constricts at the thought of the child who has gone from being 5 at the time of her mother’s diagnosis to a prematurely sagacious 15. But I am not the only one whose heart is breaking. Hours later, as the patient waits for transport, I find the interpreter still sitting with her, helping translate all the affection and regret being expressed by people who have known her for a decade.
Pulling the interpreter into my office, I thank her for going beyond the call of duty and keeping the patient company. She bursts into tears, telling me the sadness feels unbearable because she, too, has known the patient for many years. It’s her second “sad patient” that week, she says innocently, reminding me of the gulf in our experience of witnessing human tragedy.
The patient is admitted to hospice, where I intend to visit her if I can overcome my own anguish. As I sit on the fence, I receive a call to say that she deteriorated and died 2 days after admission. I go through the usual questions. Was she in pain? Was she peaceful? Did her family make it in?
And then, the unforeseen.
“I’ll tell the interpreters,” I sigh. “They were very upset in clinic.”
“They know,” the resident says. “One of them was with her in her last hours, helping us explain what was happening.”
Ten years’ worth of doctors and it fell to an interpreter to perform the final rites of kindness. I feel unexpectedly consoled and deeply humbled.
Disclosure forms provided by the author are available at NEJM.org.
From the Department of Medical Oncology, Monash Health, Melbourne, VIC, Australia.
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