The Doc Project

How one palliative care doctor strives to communicate the worst news in the best way

Communicating difficult news is Dr. Evan Schneider's stock-in-trade - in a city where 140 languages are spoken.

Sharing tough news is Dr. Evan Schneider's stock-in-trade, in a city where 140 languages are spoken

Dr. Evan Schneider hiking in Kauai, April 2018. He joined the Temmy Latner Centre for Palliative Care at Toronto's Mount Sinai Hospital in July. (Submitted by Dr. Evan Schneider)

"One of my mentors once told me that words are somewhat like a palliative care physician's scalpel."

For palliative care physician Evan Schneider, communicating bad news is a fundamental part of the job. Every day, Schneider has to navigate emotionally charged and difficult conversations with patients and their families.

What's more — Schneider works in Toronto, where 140 languages are spoken. "I only speak one language and that is English," said Schneider.

There's no one-size-fits-all approach to sharing bad news.- Dr. Evan Schneider

So Schneider often works with medical interpreters, and says he's in awe of their ability to navigate not only language, but the cultural intricacies around how death and dying are discussed.

The art of sharing bad news

Dr. Evan Schneider has been a palliative care physician at Mount Sinai Hospital in Toronto since July 2018. 

"We're dealing with very intense, emotionally charged conversations," said Schneider. "I think communication is probably the most central tenet of what we do."

The information Schneider has to convey on a daily basis includes everything from the sudden progression of a disease to a change in treatment plan, to a lack of further treatments being useful at all. Sometimes, the news he has to share comes as a complete surprise to the patient.

"There's no one-size-fits-all approach to sharing bad news," said Schneider, but clarity is key. He said his approach involves "trying to use as little overly jargony or medicalized words as necessary." 

Family matters

As a practicing doctor in Toronto, Schneider uses medical interpreters to communicate with patients who don't understand or speak English.

"We often bring a medical interpreter in when we know there is a language barrier with the patients," he said. "It's very helpful to have someone who can just objectively translate the information for us." 

Sometimes family play this informal role, providing day-to-day translation for casual meetings. But Schneider prefers to pull in an interpreter "so the family can focus on being involved in the conversation as family members, and not as interpreters, or translators, or aid."

When the patient doesn't understand what medical staff, including doctors, are trying to communicate, this can also create a situation where the family knows more than the patient does. The families may choose to withhold certain information. "Sometimes there are family members who may be wanting to protect their loved one from receiving bad news about their diagnosis or prognosis," said Schneider. 

"When we bring an interpreter into those scenarios, it can be very hard for for family members, because information can be shared through interpretation that were trying to shield their loved one. That's always a risk or a possibility when we are dealing with information that has to be translated to someone else."

Schneider sees this happen with patients' families regularly. "I have had multiple situations where, upon meeting patients for the first time who did not speak English as a first language, our conversations were actually the first time that the patient found out either that they had a diagnosis of cancer, or that the disease had spread or was so advanced to the point where it had significant implications on their disease trajectory or care plan."

While not every patient will want to know the full details of their diagnosis, it is important for them to make that decision. "Often patients do want to know their their diagnosis or know the information, or at least we offer it to them," he says. 

Dr. Evan Schneider in Lisbon, 2017. (Submitted by Evan Schneider)

The invisible interpreter

In these kinds of conversations, Schneider says the ideal interpreter is so good, he almost forgets he or she is there. "The interpreter is meant to kind of be off to the side, so as not to break the line of vision between you and the patient," he said. "A good interpreter is really there to seamlessly translate the language from the health care team to the patient family and back. I find it very helpful when I can maintain good eye contact with the person I'm speaking to, despite there being that interpretation going on." 

How many languages do we speak in Canada?

According to Statistics Canada, more than 200 languages were reported in the 2011 Census as either a home language (a.k.a. a language spoken at home) or a mother tongue. Between 2006 and 2011, Tagalog saw the biggest increase of all languages spoken at home — an increase of 64 per cent in five years. 

Overall, 20.6% of Canadians (6.8 million people) reported a mother tongue that was neither English nor French. 

Schneider knows the interpreter is doing his or her job right "when it feels like the conversation is still flowing directly between myself and the person I'm trying to communicate to." 

However, there's another consideration for Schneider when communicating with a patient through an interpreter: the patient's cultural traditions or beliefs around death and dying. "I think this is probably one of the most interesting aspects of interpretation," said Schneider, "because language is so rooted in culture. And I don't think we can tease those apart. So when we're thinking about how we communicate information, there is a very important larger cultural context behind that."

Choosing your words carefully

Schneider feels that a patient's culture "has a huge effect on the types of words that we use and on the comfort with which we talk about sickness, death and dying." And often, this responsibility falls on the interpreter.

"That's why I'm so in awe and amazed with the skill set of interpreters in terms of taking our language and translating it, but also with their awareness and comfort of the cultural context behind what they're discussing," said Schneider. 

"And I think that's such a fascinating part of what interpretation and translation is all about."

For Schneider, Canada's multiculturalism makes medical interpreters not only an asset to his practice, but a necessity.

"Patient autonomy and patient-centered care is at the core of how we practice medicine in this country. So without having access to communication, it would be very challenging to to be able to do our job effectively."

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This documentary was produced by Acey Rowe and Veronica Simmonds.