2.3 Case Studies

Case 1 – Lost in Translation

Photo of a mother and her daughter.
Photo: Courtesy of The Reception House, Ottawa, ON
Not actual patient

Mrs. A, a recent refugee from Sierra Leone gave birth to a baby girl. The newborn was diagnosed with Down Syndrome with ventricular septal defect and admitted to the Neonatal Intensive Care Unit (NICU). An NICU nurse noted that Mrs. A spoke “broken English” and contacted the child protection agency.

Upon assessment by the agency, it was discovered that 2 of Mrs. A’s 4 children had died in Sierra Leone, both under the age of 5. This finding, along with Mrs. A’s perceived low level of intelligence, broken English, and hearing deficit resulting from a bomb attack, gave rise to concern. It was also noted that Mrs. A placed a small pillow in the baby’s crib.

The agency was concerned about Mrs. A’s ability to care for her child and recommended the child be placed with a foster parent. All communication with Mrs. A was done through her older son who had immigrated to Canada a few months earlier.

Question: How would you approach this case if you were Mrs. A’s family doctor?

Lost in Translation1

  • Mrs. A arrived to Canada speaking Krio, a Creole language native to Krios spoken by 4 million people in Sierra Leone.
  • Mrs. A’s Krio was misinterpreted as broken English, suggesting lower intelligence
  • The death of 2 of her children was regarded as poor parenting capacity, yet the under-5 mortality is 30% in Sierra Leone and given Mrs. A’s experience as a refugee, this is not exceptional

Adapted from: Pottie, K. (2007) Misinterpretation. Language proficiency, recent immigrants, and global health disparities Can Fam Physician. 2007 Nov;53(11):1899-901

Phases of Working with an Interpreter2


A doctor speaking to his patient through an interpreter.

  • Discuss with the interpreter the goals of the interview
  • Inform interpreter about approximate length of interview
  • Give a brief overview of the topics to be covered
  • If ad-hoc interpreter of family/friend interpreter, explain the “rules”
  • Emphasize confidentiality

During the interview

A photo of free empty chairs.

  • Seating arrangement- avoid triangle
  • Interpreter should sit next to the patients or slightly behind to improve physician-patient connection
  • Begin with introductions
  • Explain the interpreter’s role to the patient
  • Assure confidentiality
  • Make sure patient feels comfortable asking questions
  • Frequently repeat back what you hear

At the end of the interview

A doctor with her patients: a woman and her baby.

  • Encourage patient to ask questions
  • Repeat important concepts more than once
  • Review treatment plan carefully

Adapted from: Weiner et al., Bridging Language Barriers: How to Work with an Interpreter, 2004

Case 2 – Palliative Care Discussionscasepalliative

Ms. V is an 80 year old female who resettled from Sri Lanka to Canada 16 years ago with her husband and son during the Sri Lankan Civil War. Recently, Ms. V has been diagnosed with metastatic breast cancer and the oncologists are suggesting palliative care. Ms. V appears to be very stoic and attends her appointment with her son, who acts as an interpreter.

Culturally Competent End-of-Life Care…

Question 1: What ways could an individual’s culture, ethnicity, and/or religion influence his or her experience of a terminal illness? What cultural facets must be considered when communicating with Ms. V and her son?

  • Even after living in Canada for a prolonged period of time individuals may draw heavily on their cultural background and spirituality when dealing with death
  • Cultural gaps between families and health care providers can be accentuated with language barriers and various life experiences. These gaps can be bridged by the help of cultural health brokers who not only act as interpreters, but also understand the cultural context of a patient
  • A culturally sensitive approach considers the immigrant’s life experiences, spiritual/religious needs, as well as their traditions and communication styles
  • One’s ethnic and cultural identity may influence the expression of pain and suffering, as well as their belief about the causes and meaning of their illness. For example, in this case Ms. V appears stoic and goes on to expresses that she believes that her terminal illness is a result of karma and negative actions in her previous life. Non-judgemental communication and support must be facilitated to help her process and grieve information in a way that aligns with her beliefs and culture

Question 2: How can communication be tailored when working with immigrants and refugees in a palliative care setting?

  • It is important that all relevant information is being understood by the patient and their family. To achieve this, trained 3rd party interpreters should be used whenever available when having sensitive conversations with patients
  • Use simple language and avoid sayings that could be easily misunderstood or miscommunicated through interpretation
  • Certain cultures may use distinct descriptors for pain or suffering that could lead to a misunderstanding of an individual’s experience. For example, in the Chinese tradition there is a significant distinction between the words for pain, pressure and discomfort. This could lead to a miscommunication if questions are not properly phrased. Asking a patient “are you in pain?” may not result in a true understanding of what the patient is experiencing, if they instead would describe their sensation as “pressure” or “discomfort”. As such, health providers should make an effort to ask open ended questions

Question 3: What core palliative care concepts should be applied to Ms. V?

Core Concept Explanation Special Consideration

Psychological Support

  • Provide end-of-life counselling to help patients and their families navigate death
  • Support patients in sharing their diagnosis and prognosis to family and friends
  • Psychological support is often stigmatized in refugee or other immigrant populations
  • In many countries from which refugees originate discussions around death are discouraged and considered taboo
  • Narrative storytelling can be a powerful tool to help palliative patients with their self-identity and help maintain psychological well-being during end-of-life care
Social Support
  • Social networks are important sources of emotional and practical support
  • Intergenerational networks and faith communities can provide valuable social resources during end-of-life care
 Spiritual Support
  • Facilitate dignity and meaning-based approaches to target faith and/or spiritual needs
  • Cultural beliefs about death and dying must be acknowledged in an open and non-judgemental environment
  • Cultural mediators (i.e., religious or community leaders etc.) can be called upon to support traditional and religious components of care
 Pain Relief and Comfort Care
  • Deliver person-centred care to improve the physical and psychological comfort of each patient
  • Be aware of cultural differences in expressions of pain and suffering

Adapted from: Silbermann M, Baider L, Respini D, Tralongo P, Daher M, et al. (2018) Palliative Care is a Useful Means to Overcome Intercultural Barriers Faced by Refugees in their New Host Countries. J Palliat Care Med 8: 334. DOI: 10.4172/2165-7386.1000334


Case 3 – Global Mental Healthmentalhealthcaseborder

Ms. Z recently arrived in Canada after she was forced to leave her home country of Syria. Ms. Z has been unable to secure permanent housing and is also unable to find employment since arriving in Canada. Ms. Z discloses that she is feeling irritable, has difficulty sleeping and feels hopeless about the future. She reports feeling startled by minor sounds and that some days her heart feels like it will “beat out of her chest”. Ms. Z says that she has not spoken to anyone about how she is feeling because she is worried that they will think she is “weak” or “crazy”.

Question 1: How can healthcare providers build trust with Ms. Z and other immigrants that are experiencing emotional distress or psychological effects of trauma?

Prior negative experiences with healthcare or aid workers can challenge an individual’s confidence and trust in their current healthcare professionals. Limited prior experiences with mental health professionals can increase their hesitancy to discuss feelings of psychological ill-being.  Building trust with patients experiencing psychological distress is very important for successful therapeutic relationships.

To improve trust and communication between patients in distress and their healthcare team the following points should be considered:

Recommendation Explanation 
Explicitly explain confidentiality
  • Creates a trusting and safe space
Clearly explain your role as healthcare provider
  •  Ms. Z may feel skeptical about why certain personal questions are being asked
  • Clarifying your role and how you will use the information Ms. Z provides will allow her to feel more at ease and in control

Avoid asking questions in a way that could be interpreted as interrogative or confrontational
  • Be mindful of your choice of words and tone to avoid Ms. Z from feeling judged or misunderstood
Understand how stigmatization of mental illness can affect an individual seeking help

  • Ms. Z expressed fears that she would be perceived as “weak” or “crazy”
  • Unfortunately, mental health is still stigmatized and poorly understood in many cultures and societies
  • Normalizing and validating a person’s feelings can help produce a safe environment to discuss concerns free of judgement
Be aware of your own body language and non-verbal communication
  • Trust can be built through receptive and open non-verbal communication
  • Mirroring, gesturing and eye contact are ways to positively engage patients, although cultural norms must be considered with each individual patient


Question 2: Describe the psychological consequences of migration and trauma that Ms. Z could be experiencing?

During migration, Ms. Z lost many of her social supports and networks. This could lead to feelings of isolation and shame. Ms. Z experienced numerous stressors including the loss of loved ones, employment, social capital and parts of her self-identity. These losses contribute to the migratory grieving process and may increase an individual’s vulnerability by eliminating many health protective factors.

Family losses coupled with the psychological consequences of facing violence, abuse and conflict can often contribute to forced immigrants experiencing depression, anxiety and/or post-traumatic stress disorder (PTSD). Health providers must be aware that each individual’s migration journey and how they respond to trauma is personal. Not all migrants will develop clinically diagnosable moods disorders or PTSD, but instead may experience intermittent associated symptoms that require monitoring and care.


Question 3: How can Ms. Z’s mental health be supported? What is trauma informed care?

Principles of Trauma-Informed Care³…

Principle Applying the Principle
Trauma awareness and acknowledgment
  • Be aware of the prevalence and effect of trauma on substance use, physical and mental health, and ensure that all staff members understand how trauma affects life’s experiences
  • Recognize the effects of violence and abuse on a patient’s development and coping strategies
  • Recognize the pervasiveness and long-term effects of violence and abuse
Safety and trustworthiness
  • Help patients feel they are in a safe place
  • Recognize the need for physical and emotional safety
  • Avoid interventions that might trigger or retraumatize a patient
  • Design services that maximize access and participation by trauma survivors (including flexibility in scheduling)
  • Consider cultural competence with respect to a person’s context (eg, financial instability) and life experiences
Choice, control, and collaboration

  • Include patients in decisions affecting treatment
  • Develop a collaborative relationship
  • Involve service users when designing and evaluating services
Strengths-based and skills-building care
  • Support a patient’s empowerment
  • Highlight a patient’s strengths and resilience rather than focusing on symptoms and pathology
Cultural, historical, and gender issues
  • Incorporate processes that are sensitive to a patient’s culture, ethnicity, and personal and social identity, as well as to his or her experience with trauma associated with group marginalization

(Purkey et al., CFP 2018)


Note:For additional case studies and information, you can complete the optional Blackbelt section.