As Hospitalists’ Role Grows, So Do the Ethical Dilemmas

Margot Eaves, JD, clinical ethicist for Cleveland Clinic, was called in for an emergency consult: A man in his early 50s was asking doctors to take him off the ventilator.

Just 24 hours before, the man with chronic obstructive pulmonary disease (COPD) okayed the life-saving treatment. The hospitalist over his care expected him to come off the ventilator in a few days, but 24 hours was too soon. He wouldn’t survive. With head nods and in writing the patient signaled that he was fully aware — he understood this would end his life. Eaves was called in to help weigh the options: Honor the patient’s wishes or help him survive.

These kinds of ethical dilemmas have become common to the burgeoning hospitalist profession. The subspecialty has claimed more doctors than any other part of internal medicine, and their takeover of inpatient care has cut costs and relieved primary care. But the nature of the work — treating patients who are both acute and temporary — also puts these doctors at the center of complex ethical issues, especially when it comes to end-of-life care.

“They get the ethical dilemmas those on the outside don’t have,” said Barron Lerner, MD, primary care physician and bioethicist at NYU Langone. “They’re usually in a lot of death and dying and [deciding] how far to push and when to pull back.”

Hospitalists regularly see patients through the most vulnerable, intimate and challenging moments of their lives despite having little to no relationship history. And while the care needs are often severe, time and beds can be very limited. In this high-demand brand of medicine, experts say every day is about deciding how hard to push and what it means to give each patient their best opportunity for success.

Defining Each Patient’s Success

“Patients come to the hospital expecting to talk about very intimate ethics of their body. Those conversations are incredibly important,“ Eves at Cleveland Clinic said. “But [hospitalists] are tackling those conversations with less history of relationships.”

They need even more communication with patients than another specialist might, she said. 

In the case of the COPD patient, additional communication probably saved his life. 

Eves never made it to the hospital room that day. The hospitalist, after asking more questions, found a solution. It turned out the patient was extremely uncomfortable because of some comorbidities that weren’t in the chart. 

“But those side effects could be managed,” Eves recalled. 

Once the doctor reassured him that she could alleviate his symptoms, the patient agreed to continue treatment. He safely came off the ventilation 3 days later.

Doctors have “an ethical obligation to optimize for a patient’s success,“ Eves said. 

But success can have very different meanings for different patients, she said. It could mean more time or less pain. Success could mean finding a new treatment, getting home, or honoring their religious beliefs. With limited history and short notice, hospitalists often must go the extra mile to understand each patient’s definition of success, Eves said.

This is especially true in the sensitive and vulnerable business of end-of-life care.

Even though they have less patient relationship to go on, some research suggests that hospitalists are better at discussing and executing end of life care compared to outpatient providers.

A 2004 study found hospitalists documented less pain, anxiety and uncomfortable breathing in the last days of life. And hospitalists documented more care discussions than community physicians did. A 2023 Taiwanese study reported similar findings: Patients under a hospitalist’s care were more likely to get a palliative care consultation. And a 2023 study in Cancer found oncology hospitalists got more patients to hospice care and faster.

Still, it’s challenging, Lerner said. “You’ve known a patient 24 hours and then there’s a life and death decision.”

Routine surveys about advanced directives can help. Surveying patients’ preferences when they arrive and getting those documents prepares physicians for the best course of action in case a patient’s condition worsens. But even still, an advanced directive can’t always be blindly followed. And care conversations must be repeated since end-of life priorities can change after admission.

Deciding Who Decides

Ethical issues become especially prominent when a patient decides to stop life-saving treatments. Hospitalists are left to balance two competing interests, the patient’s autonomy and their own obligation to promote well-being and avoid harm.

This raises issues around patient capacity, Lerner said. “If someone is refusing needed treatment…how do you judge if they have the capacity to make that decision.”

In the case of the Cleveland COPD patient, doctors confirmed multiple times that the patient understood his options and the consequences of ending the treatment. He confirmed multiple times, first with head nods and then in writing, that he understood he would die once he stopped ventilation. 

If a patient does have capacity, the hospitalist has to make sure their voice is heard, oftentimes within the patient’s own family. A 2015 study found that family differences were one of the top barriers to productive end-of-life discussions because family members often have trouble accepting a prognosis or misunderstand a life-saving treatment.

Many hospitalists devote significant mental energy to conflict within families, Eves said. But at the end of the day, their ethical obligation is to the patient, she said. They have to ensure the patient’s voice is heard.

On the other end of the spectrum, a lack of family involvement creates a different array of ethical obstacles. Not every patient has a support system or an appointed decision maker. In these cases, when the patient doesn’t have the capacity, weighty decisions fall to the hospitalist managing their care.

This is when it’s essential to “get an extra set of eyes and pause,” Eves said.

Get an ethics consult or a palliative care consult. It’s helpful to find someone to think through the options with, she said. If there are any kind of supporters — friends or case workers — have a conversation with them. They might not be able to legally make care decisions, but friends, especially, often have valuable insight into what the patient would want, she said. 

“We want to make sure those patients have every opportunity for care and recovery, the same as anyone else,” Eves said.

System Pressure

Importantly, none of the ethical dilemmas faced by hospitalists are devoid of the hospital itself. 

At their core, hospitals are fast-paced and high turnover. “[Hospitalists are] always pushed to free up beds,” Lerner said. “You’re seeing a lot of pressure to get people in and out.”

End-of-life conversations, family negotiations, advanced directive surveys, and ethics consults are essential — but they’re also time consuming and can be disruptive to the larger system. “It’s hard to be the one to say, ‘I’m calling time out so we can assess the situation,’” Lerner said. 

As a hospitalist handling tender care decisions you’re constantly working against that pressure, he said, asking yourself “do we need to have a meaningful discussion?”