September 11, 2018 / 5:59 PM / 14 days ago

Limited English may mean less-gentle death in ICU

(Reuters Health) - Death for patients in U.S. intensive care units may look a lot different for people with limited English proficiency than for native speakers, a large study suggests.

About 8.5 percent of U.S. adults don’t speak English as their primary language, researchers note in Mayo Clinic Proceedings. While communication is crucial for decision-making at the end of life, it’s not been clear how language skills might influence the type of care dying patients receive.

For the current study, researchers examined data on 27,523 patients admitted to intensive care units (ICUs) in a large academic hospital over a three-year period. The total included 779 people, or about 3 percent, with limited English proficiency.

Death rates in the ICUs were the same no matter what language patients spoke most fluently, averaging 2.8 percent for both native speakers and those with limited English proficiency.

But among patients who died in the ICU, those with limited English proficiency were 62 percent less likely to have orders for comfort care before they died, and they took an average of 19 days longer to transition from active treatment to only measures designed to ease pain and suffering. Non-English speakers were also 26 percent more likely to be placed on breathing machines and 36 percent more likely to be put in restraints.

Patients with limited English proficiency were 38 percent less likely than native speakers to formally request what’s known as a do-not-resuscitate (DNR) order when they entered the ICU. A DNR tells hospital staff not to take measures to revive them if their heart stops working.

Non-English speakers were also 77 percent less likely to have an “advance directive,” a legal document that spells out what type of care patients want and who should make decisions on their behalf when they’re no longer able to communicate.

“This study shows that the end of life care that patients with limited English proficiency receive is different than for those who do not have language barrier,” said lead author Dr. Amelia Barwise of the Mayo Clinic in Rochester, Minnesota.

“This may be because more patients with limited English proficiency have an authentic desire to die with more aggressive medical therapies or that communication or other barriers prevent health care teams from optimally assessing and implementing a less aggressive approach for dying patients with limited English proficiency,” Barwise said by email.

The differences persisted even after the study team accounted for other factors that can independently impact care at the end of life like race, religion and age.

The study wasn’t a controlled experiment designed to prove how language abilities might directly impact care at the end of life. Another limitation is that it looked at a single hospital and might not reflect what happens elsewhere.

Even so, the findings resonate with other research suggesting that limited English skills can influence how patients are treated, said Dr. Gary Winzelberg, a researcher at the University of North Carolina at Chapel Hill who wasn’t involved in the study.

“Patients with limited English proficiency are less likely to have advance directives because these documents were not designed for patients with low health literacy or patients from diverse cultural backgrounds,” Winzelberg said by email.

Interpreters can help.

“Families should insist on having an interpreter present during family meetings and other communication during which patients’ condition and care options are discussed,” Winzelberg added. “If an interpreter cannot be physically present, there are alternatives including connecting to an interpreter by phone - families should not be asked to serve as interpreters.”

SOURCE: bit.ly/2LOZ3GO Mayo Clinic Proceedings, online August 9, 2018.

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