Decisions regarding life support, code status, and advance directives are different for patients with limited English proficiency (LEP) in the ICU compared with patients whose primary language was English, found a recent study.1

“This is the first study to show that language is an independent risk factor for differences in decision-making and care at end of life,” says Amelia Barwise, MB, BCh, BAO, the study’s lead author.

Previous research explored the impact of race and ethnicity on end-of-life care, use of hospice, treatment withdrawal, and intensity.

“But not much has been done on the effect of LEP on end-of-life care, particularly in the ICU,” says Barwise, a research associate in the division of pulmonary and critical care medicine at Mayo Clinic in Rochester, MN. According to the study, ICU patients with LEP:

• were not as likely to change to a do-not-resuscitate (DNR) code status while in ICU;

• took 3.8 days longer to change to DNR status;

• were less likely to receive a comfort measures order set if they died in the ICU;

• took longer to transition to comfort measures only;

• were not as likely to prepare an advance directive;

• were more likely to receive mechanical ventilation;

• were more likely to be restrained, despite no documented increase in agitation levels;

• had an average length of stay 2.7 days longer;

• were more likely to have a family conference and as likely to get a palliative care consult.

Patients who died in the ICU were less likely to switch to comfort measures only. “This suggests treatment intensity continues until death,” says Barwise.

Taken as a whole, the study’s findings strongly suggest that patients with language barriers receive more aggressive care toward the end of life. The reasons for this are not entirely clear.

“It is difficult to know whether what we have found is secondary to poor communication from providers,” says Barwise.

It is possible that the patients made informed choices and that aggressive treatment is what they really wanted. On the other hand, language barriers may have limited their ability to make their goals and preferences understood.

If aggressive end-of-life care stemmed from uninformed decisions or inadequate communication, says Barwise, “these differences could be classified as a healthcare disparity.”


1. Barwise A, Jaramillo C, Novotny P, et al. Differences in code status and end-of-life decision-making in patients with limited English proficiency in the intensive care unit. Mayo Clin Proc 2018 Aug 9. pii: S0025-6196(18)30373-2. doi: 10.1016/j.mayocp.2018.04.021. [Epub ahead of print]


• Amelia Barwise, Research Associate, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. Phone: (507) 255-9007. Email: