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

ABSTRACT: 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.

SUBMITTER: Barwise AK

PROVIDER: S-EPMC7643693 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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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 AK Nyquist Christina A CA Espinoza Suarez Nataly R NR Jaramillo Carolina C Thorsteinsdottir Bjorg B Gajic Ognjen O Wilson Michael E ME

Critical care medicine 20191001 10

<h4>Objectives</h4>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 Eng ...[more]

PMID: 31389838

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Project description:BackgroundLimited English proficiency (LEP) is associated with poor health status and worse outcomes.ObjectiveTo examine disparities in hypertension between National Health and Nutrition Examination Survey (NHANES) respondents with LEP versus adequate English proficiency.DesignRetrospective analysis of multi-year survey data.ParticipantsAdults 18 years of age and older who participated in the NHANES survey during the period 2003-2012.Main measuresWe defined participants with LEP as anyone who completed the NHANES survey in a language other than English or with the support of an interpreter. Using logistic regression, we estimated the odds ratio for undiagnosed or uncontrolled hypertension (systolic blood pressure (SBP) > 140 mmHg or diastolic blood pressure (DBP) > 90 mmHg) among LEP participants relative to those with adequate English proficiency. We adjusted for sociodemographic, acculturation-related, and hypertension-related variables.Key resultsFourteen percent (n = 3,269) of the participants had limited English proficiency: 12.4% (n = 2906) used a Spanish questionnaire and 1.6% (n = 363) used an interpreter to complete the survey in another language. Those with LEP had higher odds of elevated blood pressure on physical examination (adjusted odds ratio [AOR] = 1.47 [1.07-2.03]). This finding persisted among participants using an interpreter (AOR = 1.88 [1.15-3.06]) but not among those using the Spanish questionnaire (AOR = 1.32 [0.98-1.80]). In a subgroup analysis, we found that the majority of uncontrolled hypertension was concentrated among individuals with a known diagnosis of hypertension (AOR = 1.80 [1.16-2.81]) rather than those with undiagnosed hypertension (AOR = 1.14 [0.74-1.75]). Interpreter use was associated with increased odds of uncontrolled hypertension, especially among patients who were not being medically managed for hypertension (AOR = 6.56 [1.30-33.12]).ConclusionsIn a nationally representative sample, participants with LEP were more likely to have poorly controlled hypertension than those with adequate English proficiency. LEP is an important driver of disparities in hypertension management and outcomes.

Project description:BackgroundThere are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing.ObjectiveInvestigate associations between LEP and access to care in adults.DesignCross-sectional nationally representative survey.ParticipantsAdults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014-2018 Medical Expenditure Panel Survey MAIN MEASURES: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18-64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening.Key resultsAdults aged 18-64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27-2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89-2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79-2.23), cholesterol check (aOR = 1.22; CI = 1.03-1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37-1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years.ConclusionsAdults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care.

Project description:ObjectivesThe inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care.DesignQualitative research using semistructured interviews and inductive thematic analysis.SettingAn NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages.ParticipantsTen staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic.ResultsAll interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP.ConclusionsThis research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

Dataset Information

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

Publications

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

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