When a patient with dehydration and nausea from severe gastroenteritis arrives in the emergency department, the admitting hospitalist faces a dilemma. Should she prescribe the latest, most effective brand-name drug, or a much cheaper but roughly equivalent generic alternative? If she feels cost shouldn't matter, she might choose the former, but this doesn't necessarily pass an ethics test.
“You can't give a cheaper treatment that is dramatically less effective, but if the difference is tiny, you should at least try the less expensive route first. It likely won't harm the patient but may benefit the health care system, said Clarence H. Braddock III, MD, FACP, director of clinical ethics at Stanford University's Center for Biomedical Ethics and a member of ACP's Ethics, Professionalism and Human Rights Committee.
Ensuring effective and efficient use of resources is one area addressed by the recently released sixth edition of the ACP Ethics Manual, which has been updated to reflect emerging issues in health care, such as health system reform and increasing use of technology. The manual provides ethical guidelines for dealing with a wide range of clinical situations, but a few are particularly relevant for hospitalists, such as stewardship of resources, communicating with patients and other clinicians, and dealing with conflicts over treatment goals.
“The major ethical issue is how do you balance doing good, and not doing harm, with involving patients in shared decision making and making sure resources are justly distributed to everyone,” said Virginia L. Hood, MBBS, MPH, MACP, ACP's immediate past president and past chair of the Ethics, Professionalism and Human Rights Committee. “Considering the escalating cost of health care, we as physicians need to be looking at what we can do to reduce the kind of care that doesn't help patients and just adds to overall costs, and limits the resources available for care that people need.”
The manual also gives hospitalists an ethical framework for parsing out their primary obligation to the patient in the face of other pressures, said Dr. Braddock.
“The hospitalist can be a powerful voice for other physicians in making the distinction between eliminating wasteful practices and compromising care in the interest of cost,” he said. “Hospitalists have an ethical obligation to be the voice of reason around how to be parsimonious in a responsible way.”
As employees of the hospital, hospitalists often face dual-loyalty dilemmas that aren't shared by some other physicians involved in a patient's care, said Matthew Wynia, MD, FACP, an infectious diseases specialist at the University of Chicago Medical Center and director of the American Medical Association's Institute for Ethics. The hospitalist may be acting ethically in considering cost, but the primary care physician who has no financial ties to the hospital often has a different perspective.
“In the community, it's more common for physicians to be worried about a particular intervention and whether it provides value to the patient,” he said. “In the hospital setting, physicians are also concerned about length of stay—is this intervention likely to make this person improve enough to get out of the hospital?”
The hospitalist is acting ethically when she discharges a patient as soon as appropriate and defers non-urgent tests to the outpatient setting, said Elmer Abbo, MD, a hospitalist at the University of Chicago Medical Center who teaches health policy and ethics to first-year medical students. “But the outpatient physician may see [early discharge] as ‘You're dumping extra work on me’” because she now has to follow up to make sure the patient gets the non-urgent tests.
“The hospitalist makes a clearer demarcation between what is needed to take care of the patient safely in the hospital and what can wait until later in a less intensive, less expensive setting,” said Dr. Abbo. “Cost doesn't drive the decision but it absolutely informs it.”
Hospitalists are often reluctant to cite cost as a factor in their decisions, fearing that they will be perceived as the “bad guy,” said Dr. Abbo. While ACP's manual urges physicians to consider the “cost-effectiveness of different clinical approaches” when making recommendations to patients, traditional ethical teaching for many years counseled that cost has no place at the bedside.
Realistically, though, it's just not possible to provide everything every patient needs in every situation, noted Dr. Braddock. Hospital physicians are constantly making decisions about how to use limited resources in the most efficient, effective way.
“It happens every day in the ICU,” said Dr. Braddock, who was once an ICU director. “Say a 10-bed unit is full but a patient in the ED who is young and healthy but has severe infection and sepsis needs an ICU bed for aggressive treatment resuscitation. Should you say we'll do the best we can for this person on the hospital floor or should you go through the 10 existing ICU patients and move the one who is least sick onto the floor to make room for the sicker patient in the ED?”
Disagreements about treatment
As the attending of record, hospitalists often have to make serious treatment decisions with patients and families they have just met. That's particularly difficult when patients refuse a recommended treatment or procedure and may lack the capacity to make rational decisions due to their illness.
For example, a patient diagnosed with new malignancies may refuse to consider further recommended treatment, but may be confused due to his underlying disease process, said Anthony C. Breu, MD, a hospitalist at Beth Israel Deaconess Medical Center (BIDMC) in Boston who serves as the hospitalist liaison with the hospital's ethics programs. A psychiatric consultation may determine that the patient lacks the capacity to refuse, but the hospitalist still faces an ethical dilemma.
“Should we perform a procedure when someone is refusing?” said Dr. Breu. The psychiatric evaluation that someone lacks capacity is often considered enough to justify going forward, he noted, but ethically, the hospitalist is on much firmer ground if he also seeks out a surrogate or relative to help him decide whether the procedure is consistent with what the patient would want, if they had capacity.
Disagreements with patients or families are never easy to navigate, but hospitalists can avoid deadlock by explaining the principles of shared decision making upfront, said Lachlan Forrow, MD, FACP, an internist and director of ethics and palliative care programs at BIDMC.
For example, he recalled one case in which two men whose mother was dying of breast cancer announced that, while they would consider physicians' input, they would have the final say on their mother's treatment decisions.
“I told them that's exactly half right because there are two parts to any good decision,” said Dr. Forrow. “You are your mother's voice about goals and values. If there is a disagreement about goals and values, the patient's voice is what matters, but if there is disagreement about the best medical way to achieve those goals, the physician is responsible for deciding.”
The physician should try to follow the patient's wishes as closely as possible within the scope of what's medically possible, he said. However, it is ethical to refuse treatment that the physician considers either ineffective (additional chemotherapy that won't change a patient's outcome, for example) or harmful (such as a treatment with substantial suffering or other burdens grossly disproportionate to any benefits).
Difficult treatment decisions can affect communication among physicians as well, noted Dr. Abbo. As a palliative care specialist, he frequently sees conflict among various clinicians involved in the care of a patient who is dying.
A common scenario would involve a patient dying of cancer whose oncologist has recommended further chemotherapy that the hospitalist suspects is futile, he said. “The family grabs on to this sense of hope that the oncologist is presenting, but the suggestion may be misleading and prevents the patient and family from accepting the circumstances. How do you as a hospitalist get the oncologist to move toward a comfort care strategy? That conversation isn't easy to have, and hospitalists often avoid it.”
No one likes arguing with colleagues, but in cases like this one, the hospitalist has an ethical responsibility to articulate his point of view, Dr. Abbo said. The cost of remaining silent goes beyond money, he added, because the patient could be discharged without hospice and end up being admitted to the ICU a few days later in much worse condition.
“Hospitalists are sensitive to the costs and benefits because we are the ones who will readmit that patient and deal with the consequences,” said Dr. Abbo. “We need to bring that direct patient care knowledge to bear on decision making. That requires us sometimes to be in conflict with our colleagues, and that is one of the biggest ethical challenges for hospitalists.”
Using consult services
Hospitals are required by the Joint Commission to establish committees or consult services to address ethical dilemmas that come up in practice. However, actual use of ethic consultations varies widely. A 2007 national survey of 600 general hospitals done by the National Center for Ethics in Health Care in the Department of Veterans Affairs found that the services performed a median of three consults per year. Only 41% of those performing consults had any training in ethics consultation.
The qualifications of ethics consultants tend to correspond to the size of the hospital, said Dr. Braddock. Hospitalists at large academic teaching hospitals may have access to experienced and trained ethicists, but small community hospitals may contract with outside consultants with very little ethics training. Use of the service depends on awareness and perceptions, he added, which requires hospitals to provide education on the purpose of consults and how to access them.
One key to making consults useful is positioning them as “support” services rather than as entities that tell people what to do, said Dr. Forrow, who leads BIDMC's ethics support service.
“When a hospitalist needs support in addressing a matter with ethical issues, we help them think through the issues and what they think is the best course of action, provide moral support when the right course of action is difficult, and facilitate helping people step back and understand that the whole goal is to take care of the patient the way she would want within the medical options that physicians have identified,” he said.
That mediator or facilitator approach creates confusion for some physicians, admitted Dr. Breu. “Some physicians are at their wits' end and just want someone to come in and give them the answer. If I want to know how to treat an infection, I expect an exact right answer from the infectious disease consultant—some people have a sense that the ethics consult service ought to provide that same kind of very directive clarity.”
However, ethical dilemmas aren't usually black and white, he said. The consult service, called to assist in over 100 cases each year, provides a framework for thinking about the issues and encourages all parties involved to talk things through with the goal of creating consensus on a patient-centered plan of care.
BIDMC also has a monthly case conference for all medical staff to discuss recent ethics consults, as well as monthly unit-based conferences when someone from the consult service (which includes Dr. Forrow plus a social worker and a nurse) meets with individual divisions to discuss a recent case.
“There is a huge benefit to preventative ethics,” said Alex Carbo, MD, ACP Member, a hospitalist and chair of BIDMC's ethics advisory committee. “The hope is that if we discuss ethical issues we can head off problems before they happen. Hearing about a case might help a hospitalist communicate better the next time they're in that situation.”