By Stacey Kusterbeck
When caring for non-English-language-speaking intensive care unit (ICU) patients, clinicians face all of the same ethical issues as they do with any other patient, and some additional ones. “Particularly challenging are cases involving patients who speak rarer languages, known as languages of lesser diffusion,” says Amelia Barwise, MB, PhD, an associate professor of medicine and associate professor of biomedical ethics at Mayo Clinic.
A recent case involved a patient in his 90s who spoke Karen, a language spoken in Myanmar and Thailand, who developed sepsis and was transferred to the ICU.1 The patient was intubated and placed on a ventilator because of acute hypoxia. The patient’s electronic medical record indicated full code measures. The clinical team contacted the patient’s family to discuss treatment goals. The patient’s son did not speak English, and the patient’s grandsons spoke some English. Initially, no interpreter could be located, either in-person or remotely.
After the discussion, the family agreed to change the patient’s status to do not resuscitate/do not intubate. Because of the language barrier, clinicians were uncertain if the family truly understood the implications of their decision and wanted to ensure that the patient’s and family’s values and wishes were respected.
The clinical ethics team was consulted and advised clinicians to continue to search for an interpreter. Several days later, the clinical team located a remote Karen interpreter, who confirmed that the family was making an informed decision to change the patient’s code status. Shortly afterward, the patient was extubated, and palliative care confirmed that the patient and family chose to forego any additional interventions. The patient was discharged home on hospice care.
Although ethics consults on patients who speak rare languages are uncommon, the challenges of such cases have broader ethical implications. “Patients who speak rarer languages raise issues that apply to all ICU patients,” according to Barwise.
Effective communication is necessary for all goals of care conversations. Clinicians have an ethical obligation to ensure that patients and families get the resources they need to make an informed decision based on the patient’s preferences and values. “Patients with language barriers in the ICU generally are likely to experience healthcare disparities, increased healthcare utilization, may have worse outcomes, and may be less satisfied with their care,” says Barwise. “Clinicians may experience vicarious trauma and moral distress when they can’t meet their patient’s needs.” Ethicists can help in these ways, offers Barwise:
- By encouraging clinicians to obtain a professional interpreter instead of relying on a family member to interpret. “Generally, we do not recommend family interpreters, as they are not as accurate as professional interpreters and may inadvertently or deliberately withhold information,” adds Barwise. At the institutional level, the ethics committee could advocate for improving access to interpreters. “If you can’t find an interpreter, it’s important that the ethics committee is involved and is aware of the problem,” says Barwise.
- By encouraging the healthcare team to meet with the interpreter before meeting with the patient and family. This gives clinicians the opportunity to share information about the medical context, the decision they are hoping can be made, and other relevant background. This decreases the risk of misunderstandings that can get in the way of ethical decision-making. The interpreter also may be able to share valuable cultural background information that may affect decision-making, including who is making decisions and how information should be shared. “This is similar to a team pre-encounter huddle. This bidirectional sharing of information is extremely helpful,” says Barwise.
- By encouraging clinicians to consider cultural differences when having discussions on end-of-life care with patients and family with language barriers. Advance care planning can prevent many end-of-life conflicts, since the patient’s wishes are clear to the clinical team. However, cultural differences present additional ethical challenges to this approach. For instance, in some cultures, advance care planning is not widely accepted. “Some populations don’t believe in this type of approach to end of life and have a different view of death,” says Barwise.
People may have different beliefs about who should be making decisions on behalf of the patient and about what the patient should know about their illness. “We value truth-telling and having patients make a really informed decision, based on knowing and understanding the medical information, and maybe the family will participate in shared decision-making. But in other parts of the world, it’s potentially collective decision-making with more people involved, or the decision is designated to somebody,” says Barwise.
For example, a son or daughter may not want to tell a parent the diagnosis, which conflicts with clinicians’ ethical obligation to uphold the patient’s autonomy. Clinicians are more comfortable when it is very clear in the record who is the surrogate and that the patient knows everything necessary to make an informed decision. “But if you break with what the family wants, you might be causing harm by disrupting what their norms are for decision-making,” says Barwise.
Reference
1. Karakus IS, Ahmad SR, Barwise AK. Shared decision-making in the ICU: Communicating with patients who speak a language of lesser diffusion. Chest. 2025; Feb 8. doi: 10.1016/j.chest.2025.02.001. [Online ahead of print].
When caring for non-English-language-speaking intensive care unit patients, clinicians face all the same ethical issues as they do with any other patient, and some additional ones when cases involve patients who speak rarer languages.
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