• “Hospital admission frequently occasions sensitive and highly charged decisions about issues such as code status, aggressiveness of interventions, and end-of-life care, to name a few, at a time when patients are sickest, most vulnerable, and least able to look after their own interests.”1

Nearly 2500 years ago, the Hippocratic writers decreed in the Epidemics, Bk. I, Sect. XI., “Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm.” The basic tenets of ethics apply to all medical specialties. Hospital Medicine does not constitute a novel relationship but one founded upon a long-standing tradition of practices and manifestations of professionalism in which the physician places the interests of the patient above his or her own, and practices with competence, integrity, and beneficence. How ethical principles are applied depends on the context of care. The ethical disputes that may be encountered are not unique to Hospital Medicine, but have a rich history in bioethics, social movements, and landmark court cases.

The nature of the doctor-patient relationship and the new dichotomy of the inpatient and outpatient settings continue to evolve as specialized care becomes more localized to geographic areas such as the emergency room, intensive care unit, most recently, general medical units, and in the future, the medical home. This fragmentation of the clinical encounter into a unit of hospitalization represents a departure from the time-honored, and almost mythic, longitudinal doctor-patient relationship of general practice and primary care.

Unlike the classic doctor-patient relationship, decision making in the hospital is generally more harried and of a more critical nature. Dedication to ethical practice preserves stability in a “crisis” and promotes a culture of trust necessary for advocacy and a sound doctor-patient relationship. Especially if patients do not understand the role of hospitalists, perceive that their primary care physicians have abandoned them, or have questions of trust due to cultural differences or other factors, the doctor-patient relationship may be in jeopardy. The ethics, expertise, and availability of the hospitalist balance patient-centered obligations with the need to maximize efficiencies within temporal constraints. The old adage “the secret of caring for the patient is caring for the patient” is aided when hospitalists do not make assumptions about their patients’ priorities at the outset and evaluate each patient with a fresh perspective. Communication with the patient’s outpatient doctor, familiarization with the medical record and meetings with patients and their intimates who may have essential information to share during the patient’s illness is not only good clinical care but congruent with ethical practice.

There is an ethical mandate to optimize cooperation, or comanagement, between doctors and other members of the health care team, an essential element of the hospitalist model. Hospitals have traditionally been places where different professional specialties have their own way of functioning, often in “splendid isolation.” Hampered care coordination—and the splitting of the clinical team—has the potential to hinder the cultivation and maintenance of the therapeutic relationship. In all settings, trust is sustained by the appropriate use of consultants, an awareness of one’s sphere of practice, and an appreciation for continuity of care. Being transparent and sharing the results of consultations with patients and their families will help promote a trusting and effective doctor-patient relationship.

This chapter will review key ethical concepts and standards in the context of Hospital Medicine and explain the role of ethics consultation to facilitate patient care.

The Joint Commission requires that hospitals develop and implement a process to handle ethical issues in patient care but does not specify how this should be done. It may be done by an ethics consultant, an ethics committee, or on an ad hoc basis. Ethics committees consist of physicians, social workers, attorneys, theologians, and others representative of the immediate community that the hospital serves. Ideally, the committee should be intellectually rich with devoted members capable of ethics mediation. Importantly, the authority of ethics committees is limited to an advisory body that seeks to achieve a consensus through mediation. Recent surveys have demonstrated that ethics committees consult on a range of issues across the life cycle helping patients, families, and staff grapples with challenging questions that require expert assistance.

The Ethics Committee at New York Presbyterian

Weill Cornell Medical Center typically conducts 150 to 200 consults a year. In a recent year, 62% pertained to end-of-life care issues, 40% related to family conflict, and the remainder was evenly distributed across treatment refusals, comorbid medical and psychiatric issues, pediatrics, geriatrics, and team conflict requiring mediation. Since the initiation of the service in 1994, case volume, acuity, and complexity has risen with a clear ICU predominance of 57% in 2008.

Informed Consent and Refusal

Informed consent is the ethical lynchpin of modern medical ethics in which the dialogue between the patient and physician preserves the patient’s voice in directing care. This doctrine is rooted in respect for persons and the promotion of autonomy and patient self-determination through an interpersonal process whereby physicians and patients interact with each other in order to select an appropriate course of medical care, with the patient critically assessing his or her own values and preferences (Table 33-1).

Once a patient has made a choice, consent must be maintained over time to remain the moral warrant for permission to infringe upon the patient’s zone of privacy. Patients who provide consent retain the ability to revise that decision and withdraw it.

While informed consent imposes responsibilities on both the patient and the hospitalist, it creates an opportunity to build a trusting doctor-patient relationship. A properly executed informed consent is founded upon mutual respect, good communication, and results in a shared agreement about the course of medical care. A relationship forged through the informed consent process can facilitate realistic patient expectations and help prevent disputes. Barriers to the informed consent process include:

1. 
   

   Poor care coordination. Mixed communication, or even contradictory information to the patient and/or family, may cause confusion undermining care decisions.

   
   
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   Fragmentation of care. Lack of clarity about one’s overall condition may also encumber the patient’s ability to make informed choices.

   
   
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   Adaptation to the new set of potentially limited choices imposed on the patient by hospitalization and progressive illness. This displacement of the locus of control, outside of the patient’s prior sphere of autonomous decision making, requires both the patience and compassion of the hospitalist in order to help the patient understand how his experience of hospitalization might influence his response to illness.

The all too common refrain, “I consented the patient,” mistakenly prizes outcome (agreement to a proposed procedure) over process (a clear and informed decision whether that choice resulted in the acceptance or refusal of a treatment). The importance of the informed consent process is the act of deliberation in making a sound medical choice (Table 33-2).

Concern about patient decision-making capacity typically occurs with refusal rather than with agreement of a proposed therapy. The treatment refusal may be equated with a loss of decision-making capacity because the decision challenges the doctor’s expert recommendation. Under the rubric of self-determination, patients retain the right to refuse treatments and physicians have a orollary obligation to be sure that the patient understands the consequences of that choice. Mere refusal by itself does not mean a patient lacks capacity for decision making.