A recent study posted in Mayo Clinic Proceedings[1] reported some startling revelations about how Limited English Proficient (LEP) patients are treated during end of life care. The study looked at patients in intensive care units (ICUs) in a large academic hospital over a three-year period. For the Limited English Proficient patients who passed on in the ICU, the study showed that they were:
- 62% less likely to have orders for comfort care before they passed;
- 26% more likely to be placed on breathing machines;
- 36% more likely to be put in restraints;
- 38% less likely to formally request a do-not-resuscitate (DNR) order;
- 77% less likely to have an advance directive (a legal document indicating the patient’s end of life wishes);
- Spent 2.7 more days in the ICU; and
- Were kept on active treatment versus measures designed only to ease pain and suffering 19 days longer.
Demonstrably Different Treatment
It is uncertain whether these statistics reveal that LEP Patients tend to desire more aggressive medical care to prolong life,[2] or that language barriers prevent effective communication regarding the LEP Patient’s or his/her decision maker’s actual wishes. It is, in all likelihood, some combination. What is certain, however, is that end of life care for LEP Patients is demonstrably different than English speakers.
Communication for Patient-Centered End of Life Care
End of life is not the time for doubt on whether patients’ wishes are truly heard and understood. Patient-centered care dictates dignity, respect, and compassion during the final stages of patients’ lives. For LEP Patients, providing a language interpreter both ensures that the patient is at the center of his/her end of life decision making, but also complies with the laws and accreditation standards that mandate language access services.[3]
How Interpreters Help
Medical interpreters ease the pain and anxiety of end of life care discussions and decision making. Involving interpreters keeps the focus on the patient’s comfort, helps the patient and his/her family understand their options, and can even help bridge cultural gaps that interfere with understanding.
Comfort
When the patient or his/her family is struggling to understand the diagnosis, prognosis, and care options, the important aspects of psychological care and comfort can be overlooked. Medical interpreters take the focus off communication and put it back where it should be – on the patient’s physical and psychological comfort.
Choices
In the United States, only the individual (or his/her legally designated surrogate) can choose when to switch from life-saving treatment to pain management to ease the end of life. In some cultures, however, it is common practice to shield patients from a fatal prognosis. Instead, instead address end of life decisions lie with family. In other cultures, ending life-saving treatment violates cultural or religious strictures. Ultimately, it is the patient’s right to decide who will be involved in end of life care discussions and decision making (and, where necessary, referred for assistance in signing legal documentation that memorializes those choices). Likewise, it is the patient or surrogate’s choice whether to adhere to cultural or religious rules.
The concept of the right to decide for yourself or designate someone else to decide for you is not an easy one. It involves understanding legal rights and frequently includes preparing legal documentation. Even patients and family with some English proficiency are likely to struggle with a complex mix of legal and medical jargon. Language interpreters are necessary to discuss this delicate and complex subject.
Culture and Values
As mentioned above, different cultures – whether based on religion, geography, or other factors – have differing beliefs regarding end of life. For example, Muslim Iranians tend to have strong beliefs against removing a patient from life support. This remains true even when the patient is suffering. The patient’s pain and suffering is seen as an opportunity to demonstrate courage and faith in Allah.
In contrast, some Chinese Americans see foregoing life support as the patient’s act of compassion. This is especially true where life support would be an economic or emotional burden on the family. The patient is seen is performing an act of compassion by foregoing life support.[4]
Medical staff should, of course, receive regular training on cultural competence. However, staff cannot be expected to understand every culture’s beliefs on every topic. Where appropriate to ensure effective communication, language interpreters may act as cultural mediators. In this role, they can explain the differing value system behind what might be considered unusual or irrational decision making.[5]
Vocalink Global is honored to help its clients provide compassionate, patient-centered end of life care for patients across language and culture. Our medical interpreting solutions are designed to allow patients, their loved ones and medical staff to focus on what’s important: the patient’s comfort. For more information, connect with us today.
Footnotes:
[1] See Differences in Code Status and End of Life Decision Making in Patients with Limited English Proficiency in the Intensive Care Unit, Volume 93, Issue 9, Pages 1271-1281, available online at: https://doi.org/10.1016/j.mayocp.2018.04.021 and summarized by Reuters in its article, Limited English may mean less-gentle death in ICU, September 11, 2018, available online at: https://www.reuters.com/article/us-health-language-icu/limited-english-may-mean-less-gentle-death-in-icu-idUSKCN1LR27P
[2] Notably, the research team accounted for other factors like race, religion and age that can affect end of life care decisions, and the differences between LEP and English-speaking patients remained the same.
[3] Title VI of the Civil Rights Act of 1964; Section 1557 of the Affordable Care Act; Executive Order 13166; the Joint Commission’s Effective Communication Standards
[4] Cultural examples in this Blog are from Caring for Patients from Different Cultures, Fifth Edition, Geri-Ann Galanti. Visit http://www.ggalanti.org/geri-ann-galanti/ for more information about this incredibly informative book and other resources from Ms. Galanti.
[5] See, for example, the International Medical Interpreters Association’s Code of Ethics, Number 7: “Interpreters will engage in patient advocacy and in the intercultural mediation role of explaining cultural differences/practices to health care providers and patients only when appropriate and necessary for communication purposes, using professional judgment.
