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End-of-Life Decision-Making for ICU Patients With Limited English Proficiency: A Qualitative Study of Healthcare Team Insights

Barwise, Amelia K. MBBCh, BAO, MS1,2; Nyquist, Christina A. BA2,3; Espinoza Suarez, Nataly R. MD4; Jaramillo, Carolina BA2,5; Thorsteinsdottir, Bjorg MD2,6; Gajic, Ognjen MD, MS1; Wilson, Michael E. MD1,2,4

doi: 10.1097/CCM.0000000000003920
Clinical Investigations

Objectives: Research indicates that the increasing population of over 25 million people in the United States who have limited English proficiency experience differences in decision-making and subsequent care at end of life in the ICU when compared with the general population. The objective of this study was to assess the perceptions of healthcare team members about the factors that influence discussions and decision-making about end of life for patients and family members with limited English proficiency in the ICU.

Design: Qualitative study using semistructured interviews with ICU physicians, nurses, and interpreters.

Setting: Three ICUs at Mayo Clinic Rochester.

Subjects: Sixteen ICU physicians, 12 ICU nurses, and 12 interpreters.

Intervention: None.

Measurements and Main Results: We conducted 40 semistructured interviews. We identified six key differences in end-of-life decision-making for patients with limited English proficiency compared with patients without limited English proficiency: 1) clinician communication is modified and less frequent; 2) clinician ability to assess patient and family understanding is impaired; 3) relationship building is impaired; 4) patient and family understanding of decision-making concepts (e.g., palliative care) is impaired; 5) treatment limitations are often perceived to be unacceptable due to faith-based and cultural beliefs; and 6) patient and family decision-making styles are different. Facilitators of high-quality decision-making in patients with limited English proficiency included: 1) premeeting between clinician and interpreter; 2) interpretation that communicates empathy and caring; 3) bidirectional communication of cultural perspectives; 4) interpretation that improves messaging including appropriate word choice; and 5) clinician cultural humility.

Conclusions: End-of-life decision-making is significantly different for ICU patients with limited English proficiency. Participants identified several barriers and facilitators to high-quality end-of-life decision-making for ICU patients and families with limited English proficiency. Awareness of these factors can facilitate interventions to improve high-quality, compassionate, and culturally sensitive decision-making for patients and families with limited English proficiency.

1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.

2Biomedical Research Program, Bioethics Research Department, Mayo Clinic, Rochester, MN.

3University of Minnesota Medical School, Duluth, MN.

4Knowledge and Encounter Unit (KER), Mayo Clinic, Rochester, MN.

5Harvard Medical School, Boston, MA.

6Division of Community Internal Medicine, Mayo Clinic, Rochester, MN.

This work was performed at the Mayo Clinic, Rochester, MN.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Supported, in part by grant TL1 TR002380 from the National Center for Advancing Translational Sciences and from the Mayo Clinic Critical Care Research Committee.

Dr. Barwise and Ms. Nyquist received funding from an institutional critical care research committee grant (Mayo Clinic Critical Care Research Committee). This study was supported by the National Center for Advancing Translational Sciences Grant Number TL1 TR002380. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Dr. Thorsteinsdottir’s institution received funding from National Institute on Aging K23 AG051679 training award, and she received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Amelia K. Barwise, MBBCh, BAO, MS, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail:

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