By Betty Tran, MD, MSc, Editor

SYNOPSIS: In a retrospective cohort study, patients with limited English proficiency had lower rates of do not resuscitate orders, comfort measures orders, and advanced directives; higher rates of receiving certain types of life support; and longer hospital stays compared to their English-speaking counterparts.

SOURCE: 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;93:1271-1281.

Limited English proficiency (LEP) has been associated with longer hospital stays, higher rates of readmission, less health education, worse interpersonal care, and lower patient satisfaction.1-3 In addition, in the ambulatory setting, patients with LEP often engage in lower quality goals-of-care discussions and experience poor end-of-life symptom management, especially when professional interpreters are not used, which often is the case.4 In the context of these prior findings, Barwise et al sought to close knowledge gaps regarding the effect of LEP on life support and end-of-life decisions in the ICU.

In this retrospective cohort study, 27,523 adults who were admitted to any of seven ICUs were analyzed. LEP was defined as primary language other than English as captured in the electronic medical record. The primary outcomes included code status on ICU admission, code status on ICU discharge, change in code status during ICU stay, use of life support (e.g., invasive and noninvasive mechanical ventilation, dialysis, vasopressors, cardiopulmonary resuscitation), presence of advance directives, and implementation of an institutional comfort measures only order set. Secondary outcomes included use of restraints, documentation of a family conference, presence of symptoms, ICU and hospital length of stay (LOS) and mortality, and hospital discharge location. Overall, patients with LEP were younger, more likely to be uninsured (14% vs. 2.1%; P < 0.001), scored lower on the APACHE III scale (54 vs. 58; P < 0.001), less likely to report Christian religion (38.3% vs. 77.3%; P < 0.001), or be high school graduates (18.9% vs. 30.7%; P < 0.001). After adjustment for APACHE III score, sex, educational level, and insurance status, patients with LEP were less likely to have advance directives on ICU admission (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.18-0.28; P < 0.001), a do not resuscitate (DNR) order on ICU admission (OR, 0.30; 95% CI, 0.11-0.80; P = 0.02), DNR on discharge (OR, 0.60; 95% CI, 0.45-0.79; P < 0.001), or change from full code status to DNR during their ICU stay (OR, 0.62; 95% CI, 0.46-0.82; P < 0.001). For those who experienced a change in code status, this took 3.8 days longer (interquartile range, 1.9-5.6 days) compared to patients without LEP (P < 0.001). Documentation of a family conference was higher for patients with LEP (OR, 2.53; 95% CI, 1.86-3.43; P < 0.001). Patients with LEP were more likely to receive invasive mechanical ventilation (OR, 1.26; 95% CI, 1.07-1.48; P = 0.005), but less likely to receive noninvasive mechanical ventilation. They also were more likely to be restrained (OR, 1.36; 95% CI, 1.11-1.65; P = 0.003), despite lower rates of nurse-assessed delirium, agitation, and pain. Patients with LEP were less likely to have a comfort measures only set ordered; for those who did, it took 19.1 days longer to place the order compared to patients without LEP. ICU and hospital LOS were significantly longer for patients with LEP (0.6 days and 2.5 days, respectively), and patients with LEP were more likely to be discharged home. There were no differences between groups in terms of ICU or hospital mortality or rates of palliative care consultation.


This is the first study to highlight that code status, advance directives, life support decisions, patient symptoms, and end-of-life care in the ICU are different for patients with LEP compared to patients who speak primarily English. The findings that patients with LEP demonstrate lower rates of and delayed initiation of DNR orders and comfort measures before death could imply either that more patients with LEP desire to die with full support rather than withdraw/withhold life support or that communication and other barriers exist that prevent healthcare providers from effectively assessing and implementing comfort care measures for LEP patients at the end of life. In reality, both scenarios may be true depending on the patient/surrogate involved. The factors that support the study’s findings are likely complex and intricately interconnected. Patients with LEP are a heterogeneous group regarding cultural norms, religious tenets, and languages. Given this wide range, it is likely inevitable that communication barriers will surface, especially in end-of-life discussions, which already are unique, multifaceted, and emotional. Although the investigators adjusted for severity of illness, education, sex, and insurance status, other factors such as cultural concerns, religious beliefs, trust and perception of medical providers, and communication barriers likely contribute to the differences seen between the two groups. Future reforms in improving end-of-life care for ICU patients will need to recognize the group of patients with LEP distinctly; increase awareness and respect for religious, cultural, and health literacy variations that may influence care decisions at the end of life; and focus on ensuring appropriate language interpretation during all aspects of patient care, from assessment to decision-making.


  1. John-Baptiste A, Naglie G, Tomlinson G, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med 2004;19:221-228.
  2. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med 2010;5:276-282.
  3. Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficiency patients: The importance of language concordance and interpreter use. J Gen Intern Med 2007;22 Suppl 2:324-330.
  4. Silva MD, Genoff M, Zaballa A, et al. Interpreting at the end of life: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency. J Pain Symptom Manage 2016;51:569-580.