Shared Decision-Making in the ICU -Communicating with patients who speak a Language of Lesser Diffusion.

Effective bidirectional communication is crucial during end-of-life decision-making, which requires clear understanding between clinicians and patients/family members about treatment options, preferences, and goals of care. For those who have a non-English language preference (NELP), or who have difficulty speaking, reading, writing, and understanding English, interpreters are essential. However, patients who speak rarer languages, known as languages of lesser diffusion (LLDs), such as Karen spoken in Thailand and Myanmar, face unique challenges due to limited interpretation resources. In this work we discuss the case of a Karen-speaking patient admitted to the ICU who lacked decision-making capacity, requiring the involvement of family members who also spoke Karen, for a code status discussion. Despite efforts to find an interpreter, no Karen interpreter was initially available, complicating the communication and decision-making about changing the code status to DNR/DNI. A remote Karen interpreter was later identified allowing for effective communication, and clinician assurance that the family did understand the implications of their decision and had made it voluntarily. End-of-life decision-making is complex and challenging, requiring culturally sensitive communication. Patients who speak LLDs face unique difficulties in these discussions compared to those who speak more common languages due to lack of interpretation resources. The purpose of this case report is to draw attention to these specific challenges and explore ethical concerns when engaging in decision-making conversations with patients and families who speak a LLD.