Advancing the Science

Mayo Clinic Medical Science Blog – an eclectic collection of research- and research education-related stories: feature stories, mini news bites, learning opportunities, profiles and more from Mayo Clinic.

November 20, 2018

Addressing disparities in care, to the very end of life

By Elizabeth Zimmermann

Not everyone in the United States speaks English as their first language. In fact, in 2013, the U.S. Census Bureau found that one of every five residents speaks another language at home.

Unfortunately, this fact leads to another - for people with limited English proficiency, disparities are common in health care.

The Agency for Healthcare Research and Quality has an entire program addressing this. “Improving Patient Safety Systems for Patients with Limited English Proficiency” is one of many research and education programs in the U.S. designed to help patients with limited English proficiency access the same level of care that others receive.

Mandated in the Affordable Care Act, “qualified” interpreters (read about Section 1557’s expanded requirements) are required for health care discussions with patients and their families. To reduce miscommunication, interpreters help health care providers communicate accurately with their patients, and patients communicate with their providers – no matter what the patient’s preferred language might be. Interpreters not only provide bidirectional communication but often function as cultural brokers, providing religious, spiritual and other contextual inputs for discussions and decision making. They should also help to convey the clinician’s empathy and care for patients.

However, interpreters aren’t part of every conversation a patient might have regarding their care preferences, as sometimes these are iterative discussions that take place on several occasions over several days or weeks.

Missing information can lead to care disparities.

What is Mayo Clinic doing about it?

Amelia Barwise, M.B.B.Ch., conducts pulmonary and critical care research, while continuing her studies as a Ph.D. candidate in the Mayo Clinic Graduate School of Biomedical Sciences.

Every year, Mayo Clinic sees more than 1 million patients from across the U.S. and about 140 different countries. We seek to provide the best possible quality of care for all patients, regardless of language, culture, ethnicity, religion or any other potential barriers to effective communication that might exist.

Research allows us to identify causes of disparity, and evaluate potential ways to improve care and reduce those disparities.

Recently, a team led by Amelia Barwise, M.B.B.Ch., a pulmonary and critical care researcher at Mayo Clinic, examined end-of-life decision making in the intensive care unit.

“We believed that conversations  about complex and sensitive issues at end of life,” says Dr. Barwise, “combined with limited English proficiency, could easily cause suboptimal communication, and in turn to a lower quality of care.”

Dr. Barwise and her fellow researchers sought to determine if there were differences in decision making and care for patients in the ICU, by examining differences in code status and health care utilization as well as advance care planning for patients with limited English proficiency.

Their findings, which do indicate a difference between the two groups of patients, are published in the September issue of Mayo Clinic Proceedings.

Summary of the research

When reviewing three years (May 31, 2011, through June 1, 2014) of records from seven ICUs across Mayo Clinic, the team identified 2.8 percent of 27, 523 patients as having limited English proficiency.

They found that these individuals were less likely to change their code status during ICU admission from full code (do everything possible to restore and maintain heart beat and breathing) to ‘do not resuscitate,’ regardless of sex, education level, insurance status or severity of illness.

“While individual choices are expected to differ, a substantial variance connected to language indicates a possible disparity in care,” says Dr. Barwise.

“Those with limited proficiency were less likely to ask for comfort measures only,” she continues, “and among those that eventually died, transitions to DNR, or comfort measures only, were substantially delayed.”

The percentage of patients with limited English proficiency who died in the ICU, or later in the hospital, was the same as those who spoke English. But decisions sometimes made including withdrawal of active treatments and transition to comfort measures only, were less frequent and occurred later, or never, for patients with limited proficiency. This was observed despite consistent use of palliative care conferences across all patients, with even more documented family conferences for those with limited English proficiency than fluency.

The difference in overall health care utilization and choices for end-of-life care reflect two possibilities, Dr. Barwise states.

“One, more patients with limited English proficiency have an authentic desire to receive full medical interventions rather than comfort measures only;” or “Two, suboptimal communication and other barriers are preventing patients from receiving care that aligns with their values, wishes and preferences.”

She and her team believe communication is certainly an issue – one they hope to help improve. They have other research projects underway to determine where communication breakdowns occur, and also to evaluate potential interventions.


Dr. Barwise is also a pre-doctoral (Ph.D.) student in the Clinical and Translational Science Track of the Mayo Clinic Graduate School of Biomedical Sciences.

For information about Mayo Clinic College of Medicine and Science, and its five schools, visit the website.

Tags: Amelia Barwise, Center for the Science of Health Care Delivery, health disparities, ICU, intensive care unit, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic Proceedings, News, research education

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