As the distribution and utilization of technology in critical care medicine expands, patients experiencing respiratory failure, heart failure, or cardiac arrest are increasingly being treated with extracorporeal membrane oxygenation (ECMO). Although not customarily responsible for managing ECMO, hospitalists need to understand the rudiments of this technology and its associated ethical issues to assure that ECMO use is consistent with patient preferences and goals of care. This review aims to help prepare hospitalists for these clinical responsibilities. Following a brief review of modern‐day ECMO, including both venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and venovenous extracorporeal membrane oxygenation (VV‐ECMO), we highlight special ethical considerations that may arise with VA‐ECMO and present an ethically grounded approach to the initiation, continuation, and discontinuation of treatment.

Many of the questions regarding the use of ECMO will be familiar. Certainly, similar questions arise with other life‐sustaining therapies; however, the general hospitalist may be a bit unfamiliar with ECMO and its unique ethical challenges. For example, ECMO is only provided transiently and generally while patients are in an intensive care unit. Unlike mechanical ventilation, which may be provided long‐term via tracheostomy, there is no comparable, enduring form of ECMO. Next, patients requiring ECMO are utterly dependent on the machine for their survival. If they do not recover and are not candidates for a ventricular assist device (VAD) or transplantation, there are no other therapies to offer. In this scenario, terminal discontinuation is the only option.

Informed hospitalists, who bring to counseling sessions both an understanding of the patient and family, and technical knowledge and background information on ECMO, will be far better equipped to help patients and families facing these difficult choices. As the use of ECMO becomes more prevalent, hospitalists must be prepared to address questions related to this evolving technology.

TECHNICAL AND HISTORICAL BACKGROUND

Extracorporeal life support (ECLS) involves the use of mechanical devices when native organ function fails.[1] ECMO involves the application of ECLS to provide a replacement form of cardiac and/or pulmonary function. An illustrative figure of the ECMO circuit may be seen at The Extracorporeal Life Support Organization (ELSO) (http://www.elsonet.org). ECMO is similar to a cardiopulmonary bypass machine.[2] Venous blood is drained from the body via catheters implanted through either transthoracic or percutaneous cannulae into the circuit where gas exchange occurs across a semipermeable membrane. Oxygenated blood is then returned to circulation.[3] There are 2 types of ECMO. VA‐ECMO replaces native cardiac function and is generally used for patients with heart failure. Here, oxygenated blood is mechanically pumped back into the arterial circulation, bypassing the diseased heart.[4] With VV‐ECMO, generally used for patients with respiratory failure but intact cardiac function, oxygenated blood is returned to venous circulation for the patient's own heart to circulate.[5] Patients on ECMO receive systemic anticoagulation to prevent thromboembolic complications. Major complications include stroke (1%11%), bleeding (7%34%), thrombosis (8%17%), and infection.[6] A detailed description of the different ECMO machines and circuitry, the indications for ECMO, and the outcomes including rates of complications are beyond the scope of this article, but available in several review articles.[5, 6, 7, 8]

Encouraging outcomes of clinical trials have ushered in enthusiasm for adult ECMO in the United States.[9] For example, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial, a prospective study of adult VV‐ECMO for respiratory failure conducted in the United Kingdom from 2001 to 2006, demonstrated a measurable survival benefit. Patients with severe adult respiratory failure randomized to an ECMO center (75% received ECMO) had a 63% 6‐month survival without severe disability, versus 47% for patients managed conventionally at a tertiary care center.[10] Similarly, data from the 2009 H1N1 flu virus epidemic in Australia and New Zealand suggested a benefit when patients with acute respiratory distress syndrome, who had failed mechanical ventilation, were treated with ECMO; 76% survived, which was an improvement over previously reported mortality rates of 30% to 48%.[11]

With respect to VA‐ECMO, recent studies and case reports out of Taiwan, Germany, and France propose a survival benefit when ECMO is used in patients with cardiac failure.[12, 13, 14, 15] Patients with in‐hospital cardiac arrest refractory to cardiopulmonary resuscitation (CPR) in Taiwan had close to a 20% increase in survival to hospital discharge when treated with VA‐ECMO.[12] A retrospective study of 1764 patients who had cardiac surgery from 2002 to 2006 in Taiwan demonstrated that, of the nearly 3% who required ECMO for postoperative cardiogenic shock, 53% were successfully weaned from ECMO and had a 1‐year survival approaching 30%.[13] A 2003 to 2006 study of 5750 patients undergoing cardiac surgery in Germany found that of the 0.8% of patients requiring VA‐ECMO for refractory cardiogenic shock, 29% survived to discharge, and 22% were alive at 1 year.[14] In France, among 81 patients who received ECMO for refractory cardiogenic shock from 2002 to 2006, 42% survived to hospital discharge.[15]

The survival benefit associated with adult ECMO is thought to stem both from improvements in circuit design (advancements in the pump and oxygenator), as well as from better patient selection. Further, antithrombotic circuit tubing has allowed for lower levels of anticoagulation and less risk of fatal bleeding.[16] According to the ELSO, a group that maintains an active registry of data from medical centers providing ECMO, in 2013 there were approximately 223 ECMO centers, a significant increase from the 83 centers present in 1990; there were nearly 4400 ECMO cases (all ages) in 2013.[17]

Although the number of physicians, patients, and families who consider ECMO as a treatment option have all expanded considerably in recent years and continue to rise, the use of the technology is often discretionary, and decisions as to whether and when to initiate and discontinue ECMO are not always clear‐cut either clinically or ethically.

TREATMENT WITH ECMO

Typically ECMO is initiated not as a treatment itself, but rather as a means to support a patient with cardiopulmonary failure, in order to buy time. Time for an intervention that may serve to fix the underlying organ defect, or time to allow the organ to heal on its own. As such, ECMO is often considered either a bridge to recovery or a bridge to a definitive and longer‐term treatment option (ie, VAD, heart or lung transplantation).[16, 18] ECMO is especially valuable given that the mechanical oxygenation and perfusion provide time for additional workup and intervention, which would not otherwise be feasible for a patient suffering from acute cardiopulmonary collapse.

There are 3 possible clinical outcomes for patients treated with ECMO: (1) native cardiopulmonary recovery and successful weaning off ECMO; (2) failure to recover, with ECMO serving as a bridge to a longer‐term circulatory support device or heart or lung transplantation; or (3) death.

Presently, ECMO may only be provided in an intensive care setting and only temporarily. Patients on VV‐ECMO may be maintained on the machine for weeks to months in some cases, and may be awake, walking, and talking, potentially allowing for these individuals to directly participate in discussions about goals of care.[19, 20] In contrast, adult patients on VA‐ECMO historically have only been maintained for days to weeks on the machine, intubated and typically sedated, making their participation in goals of care discussions generally more difficult, if not impossible.[7] As collective expertise in adult VA‐ECMO grows, however, patients awaiting heart or heart/lung transplants are similarly finding support for longer periods of time, enabling wakefulness and the ability to participate in decision making. Generally speaking, if a patient on ECMO neither recovers nor is a candidate for a longer‐term support device or transplantation, the risks of thromboembolic and infectious complications from continuing the treatment will eventually outweigh any real benefit. Accordingly, ELSO recommends that ECMO should be discontinued promptly if there is no hope for healthy survival (severe brain damage, no hope of heart or lung recovery, and no hope of organ replacement by VAD or transplant).[21]

Given that approximately 32% of adults treated with ECMO for cardiac failure and 47% treated for respiratory failure will survive to hospital discharge, many patients and families will be forced to make difficult, end‐of‐life decisions with ECMO.[22] ECMO is different from other life‐sustaining therapy (LST), such as mechanical ventilation, in that it may only be provided in an intensive care setting. Furthermore, unlike patients who cannot wean from a ventilator and thus are transitioned to a tracheostomy, there is no long‐term treatment option with ECMO. Terminal discontinuation is the sole option for patients on VA‐ECMO who do not recover and are not candidates for VAD or transplantation.

The remainder of this article will examine the ethical issues that emerge with ECMO. We will focus more specifically on VA‐ECMO, although certainly issues described and the guidance offered are relevant to VV‐ECMO. VA‐ECMO presents some unique issues, however, as patients are generally (although not uniformly) intubated, sedated, and thus incapacitated and unable to participate in goals of care discussions once treatment is initiated. Thus, the hospitalist can help ensure, preemptively, that the provision of VA‐ECMO is consistent with patient preferences and goals of care. In addition, VA‐ECMO is also unique in that some patients suffering from cardiac arrest refractory to cardiopulmonary resuscitation and advanced cardiac life support may be successfully oxygenated and perfused with VA‐ECMO; thus, VA‐ECMO extends the boundaries of what we commonly consider to be the limits of cardiac resuscitation, perhaps suggesting a need to reframe do not resuscitate (DNR) discussions.

VA‐ECMO: ETHICAL CONSIDERATIONS

Ethical concerns and difficult decisions may arise at any time during treatment with VA‐ECMO. For teaching purposes, we have conceptualized the treatment trajectory as consisting of 3 phases: (1) initiation, (2) continuation, and (3) discontinuation, each with its own set of issues (Table 1). Clinically, however, each phase of treatment is intrinsically linked to the others, and in reality clinicians must look forward, anticipate upcoming decisions to the extent possible, and prepare families for what lies ahead. Before we attend to each phase, we will briefly review who makes these decisions.

CONCLUSION

With indications for and utilization of ECMO in adult patients expanding, hospitalists may be expected to encounter these technologies with greater frequency and guide patients and families with medical decision‐making. Although the ethical issues reviewed are certainly not exclusive to ECMO, specific facets of ECMO, as discussed, may precipitate unique challenges or exacerbate common ones. Hospitalists can help to uphold patient autonomy by providing information that enables patients and surrogates to actively participate in goal setting and decision‐making. As the utilization of this technology grows, further research will need to address decision‐making in the context of ECMO to ensure that the process remains optimally patient‐ and family‐centered.

As the distribution and utilization of technology in critical care medicine expands, patients experiencing respiratory failure, heart failure, or cardiac arrest are increasingly being treated with extracorporeal membrane oxygenation (ECMO). Although not customarily responsible for managing ECMO, hospitalists need to understand the rudiments of this technology and its associated ethical issues to assure that ECMO use is consistent with patient preferences and goals of care. This review aims to help prepare hospitalists for these clinical responsibilities. Following a brief review of modern‐day ECMO, including both venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and venovenous extracorporeal membrane oxygenation (VV‐ECMO), we highlight special ethical considerations that may arise with VA‐ECMO and present an ethically grounded approach to the initiation, continuation, and discontinuation of treatment.

Many of the questions regarding the use of ECMO will be familiar. Certainly, similar questions arise with other life‐sustaining therapies; however, the general hospitalist may be a bit unfamiliar with ECMO and its unique ethical challenges. For example, ECMO is only provided transiently and generally while patients are in an intensive care unit. Unlike mechanical ventilation, which may be provided long‐term via tracheostomy, there is no comparable, enduring form of ECMO. Next, patients requiring ECMO are utterly dependent on the machine for their survival. If they do not recover and are not candidates for a ventricular assist device (VAD) or transplantation, there are no other therapies to offer. In this scenario, terminal discontinuation is the only option.

Informed hospitalists, who bring to counseling sessions both an understanding of the patient and family, and technical knowledge and background information on ECMO, will be far better equipped to help patients and families facing these difficult choices. As the use of ECMO becomes more prevalent, hospitalists must be prepared to address questions related to this evolving technology.

TECHNICAL AND HISTORICAL BACKGROUND

Extracorporeal life support (ECLS) involves the use of mechanical devices when native organ function fails.[1] ECMO involves the application of ECLS to provide a replacement form of cardiac and/or pulmonary function. An illustrative figure of the ECMO circuit may be seen at The Extracorporeal Life Support Organization (ELSO) (http://www.elsonet.org). ECMO is similar to a cardiopulmonary bypass machine.[2] Venous blood is drained from the body via catheters implanted through either transthoracic or percutaneous cannulae into the circuit where gas exchange occurs across a semipermeable membrane. Oxygenated blood is then returned to circulation.[3] There are 2 types of ECMO. VA‐ECMO replaces native cardiac function and is generally used for patients with heart failure. Here, oxygenated blood is mechanically pumped back into the arterial circulation, bypassing the diseased heart.[4] With VV‐ECMO, generally used for patients with respiratory failure but intact cardiac function, oxygenated blood is returned to venous circulation for the patient's own heart to circulate.[5] Patients on ECMO receive systemic anticoagulation to prevent thromboembolic complications. Major complications include stroke (1%11%), bleeding (7%34%), thrombosis (8%17%), and infection.[6] A detailed description of the different ECMO machines and circuitry, the indications for ECMO, and the outcomes including rates of complications are beyond the scope of this article, but available in several review articles.[5, 6, 7, 8]

Encouraging outcomes of clinical trials have ushered in enthusiasm for adult ECMO in the United States.[9] For example, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial, a prospective study of adult VV‐ECMO for respiratory failure conducted in the United Kingdom from 2001 to 2006, demonstrated a measurable survival benefit. Patients with severe adult respiratory failure randomized to an ECMO center (75% received ECMO) had a 63% 6‐month survival without severe disability, versus 47% for patients managed conventionally at a tertiary care center.[10] Similarly, data from the 2009 H1N1 flu virus epidemic in Australia and New Zealand suggested a benefit when patients with acute respiratory distress syndrome, who had failed mechanical ventilation, were treated with ECMO; 76% survived, which was an improvement over previously reported mortality rates of 30% to 48%.[11]

With respect to VA‐ECMO, recent studies and case reports out of Taiwan, Germany, and France propose a survival benefit when ECMO is used in patients with cardiac failure.[12, 13, 14, 15] Patients with in‐hospital cardiac arrest refractory to cardiopulmonary resuscitation (CPR) in Taiwan had close to a 20% increase in survival to hospital discharge when treated with VA‐ECMO.[12] A retrospective study of 1764 patients who had cardiac surgery from 2002 to 2006 in Taiwan demonstrated that, of the nearly 3% who required ECMO for postoperative cardiogenic shock, 53% were successfully weaned from ECMO and had a 1‐year survival approaching 30%.[13] A 2003 to 2006 study of 5750 patients undergoing cardiac surgery in Germany found that of the 0.8% of patients requiring VA‐ECMO for refractory cardiogenic shock, 29% survived to discharge, and 22% were alive at 1 year.[14] In France, among 81 patients who received ECMO for refractory cardiogenic shock from 2002 to 2006, 42% survived to hospital discharge.[15]

The survival benefit associated with adult ECMO is thought to stem both from improvements in circuit design (advancements in the pump and oxygenator), as well as from better patient selection. Further, antithrombotic circuit tubing has allowed for lower levels of anticoagulation and less risk of fatal bleeding.[16] According to the ELSO, a group that maintains an active registry of data from medical centers providing ECMO, in 2013 there were approximately 223 ECMO centers, a significant increase from the 83 centers present in 1990; there were nearly 4400 ECMO cases (all ages) in 2013.[17]

Although the number of physicians, patients, and families who consider ECMO as a treatment option have all expanded considerably in recent years and continue to rise, the use of the technology is often discretionary, and decisions as to whether and when to initiate and discontinue ECMO are not always clear‐cut either clinically or ethically.

TREATMENT WITH ECMO

Typically ECMO is initiated not as a treatment itself, but rather as a means to support a patient with cardiopulmonary failure, in order to buy time. Time for an intervention that may serve to fix the underlying organ defect, or time to allow the organ to heal on its own. As such, ECMO is often considered either a bridge to recovery or a bridge to a definitive and longer‐term treatment option (ie, VAD, heart or lung transplantation).[16, 18] ECMO is especially valuable given that the mechanical oxygenation and perfusion provide time for additional workup and intervention, which would not otherwise be feasible for a patient suffering from acute cardiopulmonary collapse.

There are 3 possible clinical outcomes for patients treated with ECMO: (1) native cardiopulmonary recovery and successful weaning off ECMO; (2) failure to recover, with ECMO serving as a bridge to a longer‐term circulatory support device or heart or lung transplantation; or (3) death.

Presently, ECMO may only be provided in an intensive care setting and only temporarily. Patients on VV‐ECMO may be maintained on the machine for weeks to months in some cases, and may be awake, walking, and talking, potentially allowing for these individuals to directly participate in discussions about goals of care.[19, 20] In contrast, adult patients on VA‐ECMO historically have only been maintained for days to weeks on the machine, intubated and typically sedated, making their participation in goals of care discussions generally more difficult, if not impossible.[7] As collective expertise in adult VA‐ECMO grows, however, patients awaiting heart or heart/lung transplants are similarly finding support for longer periods of time, enabling wakefulness and the ability to participate in decision making. Generally speaking, if a patient on ECMO neither recovers nor is a candidate for a longer‐term support device or transplantation, the risks of thromboembolic and infectious complications from continuing the treatment will eventually outweigh any real benefit. Accordingly, ELSO recommends that ECMO should be discontinued promptly if there is no hope for healthy survival (severe brain damage, no hope of heart or lung recovery, and no hope of organ replacement by VAD or transplant).[21]

Given that approximately 32% of adults treated with ECMO for cardiac failure and 47% treated for respiratory failure will survive to hospital discharge, many patients and families will be forced to make difficult, end‐of‐life decisions with ECMO.[22] ECMO is different from other life‐sustaining therapy (LST), such as mechanical ventilation, in that it may only be provided in an intensive care setting. Furthermore, unlike patients who cannot wean from a ventilator and thus are transitioned to a tracheostomy, there is no long‐term treatment option with ECMO. Terminal discontinuation is the sole option for patients on VA‐ECMO who do not recover and are not candidates for VAD or transplantation.

The remainder of this article will examine the ethical issues that emerge with ECMO. We will focus more specifically on VA‐ECMO, although certainly issues described and the guidance offered are relevant to VV‐ECMO. VA‐ECMO presents some unique issues, however, as patients are generally (although not uniformly) intubated, sedated, and thus incapacitated and unable to participate in goals of care discussions once treatment is initiated. Thus, the hospitalist can help ensure, preemptively, that the provision of VA‐ECMO is consistent with patient preferences and goals of care. In addition, VA‐ECMO is also unique in that some patients suffering from cardiac arrest refractory to cardiopulmonary resuscitation and advanced cardiac life support may be successfully oxygenated and perfused with VA‐ECMO; thus, VA‐ECMO extends the boundaries of what we commonly consider to be the limits of cardiac resuscitation, perhaps suggesting a need to reframe do not resuscitate (DNR) discussions.

VA‐ECMO: ETHICAL CONSIDERATIONS

Ethical concerns and difficult decisions may arise at any time during treatment with VA‐ECMO. For teaching purposes, we have conceptualized the treatment trajectory as consisting of 3 phases: (1) initiation, (2) continuation, and (3) discontinuation, each with its own set of issues (Table 1). Clinically, however, each phase of treatment is intrinsically linked to the others, and in reality clinicians must look forward, anticipate upcoming decisions to the extent possible, and prepare families for what lies ahead. Before we attend to each phase, we will briefly review who makes these decisions.

CONCLUSION

With indications for and utilization of ECMO in adult patients expanding, hospitalists may be expected to encounter these technologies with greater frequency and guide patients and families with medical decision‐making. Although the ethical issues reviewed are certainly not exclusive to ECMO, specific facets of ECMO, as discussed, may precipitate unique challenges or exacerbate common ones. Hospitalists can help to uphold patient autonomy by providing information that enables patients and surrogates to actively participate in goal setting and decision‐making. As the utilization of this technology grows, further research will need to address decision‐making in the context of ECMO to ensure that the process remains optimally patient‐ and family‐centered.

As the distribution and utilization of technology in critical care medicine expands, patients experiencing respiratory failure, heart failure, or cardiac arrest are increasingly being treated with extracorporeal membrane oxygenation (ECMO). Although not customarily responsible for managing ECMO, hospitalists need to understand the rudiments of this technology and its associated ethical issues to assure that ECMO use is consistent with patient preferences and goals of care. This review aims to help prepare hospitalists for these clinical responsibilities. Following a brief review of modern‐day ECMO, including both venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and venovenous extracorporeal membrane oxygenation (VV‐ECMO), we highlight special ethical considerations that may arise with VA‐ECMO and present an ethically grounded approach to the initiation, continuation, and discontinuation of treatment.

Many of the questions regarding the use of ECMO will be familiar. Certainly, similar questions arise with other life‐sustaining therapies; however, the general hospitalist may be a bit unfamiliar with ECMO and its unique ethical challenges. For example, ECMO is only provided transiently and generally while patients are in an intensive care unit. Unlike mechanical ventilation, which may be provided long‐term via tracheostomy, there is no comparable, enduring form of ECMO. Next, patients requiring ECMO are utterly dependent on the machine for their survival. If they do not recover and are not candidates for a ventricular assist device (VAD) or transplantation, there are no other therapies to offer. In this scenario, terminal discontinuation is the only option.

Informed hospitalists, who bring to counseling sessions both an understanding of the patient and family, and technical knowledge and background information on ECMO, will be far better equipped to help patients and families facing these difficult choices. As the use of ECMO becomes more prevalent, hospitalists must be prepared to address questions related to this evolving technology.

TECHNICAL AND HISTORICAL BACKGROUND

Extracorporeal life support (ECLS) involves the use of mechanical devices when native organ function fails.[1] ECMO involves the application of ECLS to provide a replacement form of cardiac and/or pulmonary function. An illustrative figure of the ECMO circuit may be seen at The Extracorporeal Life Support Organization (ELSO) (http://www.elsonet.org). ECMO is similar to a cardiopulmonary bypass machine.[2] Venous blood is drained from the body via catheters implanted through either transthoracic or percutaneous cannulae into the circuit where gas exchange occurs across a semipermeable membrane. Oxygenated blood is then returned to circulation.[3] There are 2 types of ECMO. VA‐ECMO replaces native cardiac function and is generally used for patients with heart failure. Here, oxygenated blood is mechanically pumped back into the arterial circulation, bypassing the diseased heart.[4] With VV‐ECMO, generally used for patients with respiratory failure but intact cardiac function, oxygenated blood is returned to venous circulation for the patient's own heart to circulate.[5] Patients on ECMO receive systemic anticoagulation to prevent thromboembolic complications. Major complications include stroke (1%11%), bleeding (7%34%), thrombosis (8%17%), and infection.[6] A detailed description of the different ECMO machines and circuitry, the indications for ECMO, and the outcomes including rates of complications are beyond the scope of this article, but available in several review articles.[5, 6, 7, 8]

Encouraging outcomes of clinical trials have ushered in enthusiasm for adult ECMO in the United States.[9] For example, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial, a prospective study of adult VV‐ECMO for respiratory failure conducted in the United Kingdom from 2001 to 2006, demonstrated a measurable survival benefit. Patients with severe adult respiratory failure randomized to an ECMO center (75% received ECMO) had a 63% 6‐month survival without severe disability, versus 47% for patients managed conventionally at a tertiary care center.[10] Similarly, data from the 2009 H1N1 flu virus epidemic in Australia and New Zealand suggested a benefit when patients with acute respiratory distress syndrome, who had failed mechanical ventilation, were treated with ECMO; 76% survived, which was an improvement over previously reported mortality rates of 30% to 48%.[11]

With respect to VA‐ECMO, recent studies and case reports out of Taiwan, Germany, and France propose a survival benefit when ECMO is used in patients with cardiac failure.[12, 13, 14, 15] Patients with in‐hospital cardiac arrest refractory to cardiopulmonary resuscitation (CPR) in Taiwan had close to a 20% increase in survival to hospital discharge when treated with VA‐ECMO.[12] A retrospective study of 1764 patients who had cardiac surgery from 2002 to 2006 in Taiwan demonstrated that, of the nearly 3% who required ECMO for postoperative cardiogenic shock, 53% were successfully weaned from ECMO and had a 1‐year survival approaching 30%.[13] A 2003 to 2006 study of 5750 patients undergoing cardiac surgery in Germany found that of the 0.8% of patients requiring VA‐ECMO for refractory cardiogenic shock, 29% survived to discharge, and 22% were alive at 1 year.[14] In France, among 81 patients who received ECMO for refractory cardiogenic shock from 2002 to 2006, 42% survived to hospital discharge.[15]

The survival benefit associated with adult ECMO is thought to stem both from improvements in circuit design (advancements in the pump and oxygenator), as well as from better patient selection. Further, antithrombotic circuit tubing has allowed for lower levels of anticoagulation and less risk of fatal bleeding.[16] According to the ELSO, a group that maintains an active registry of data from medical centers providing ECMO, in 2013 there were approximately 223 ECMO centers, a significant increase from the 83 centers present in 1990; there were nearly 4400 ECMO cases (all ages) in 2013.[17]

Although the number of physicians, patients, and families who consider ECMO as a treatment option have all expanded considerably in recent years and continue to rise, the use of the technology is often discretionary, and decisions as to whether and when to initiate and discontinue ECMO are not always clear‐cut either clinically or ethically.

TREATMENT WITH ECMO

Typically ECMO is initiated not as a treatment itself, but rather as a means to support a patient with cardiopulmonary failure, in order to buy time. Time for an intervention that may serve to fix the underlying organ defect, or time to allow the organ to heal on its own. As such, ECMO is often considered either a bridge to recovery or a bridge to a definitive and longer‐term treatment option (ie, VAD, heart or lung transplantation).[16, 18] ECMO is especially valuable given that the mechanical oxygenation and perfusion provide time for additional workup and intervention, which would not otherwise be feasible for a patient suffering from acute cardiopulmonary collapse.

There are 3 possible clinical outcomes for patients treated with ECMO: (1) native cardiopulmonary recovery and successful weaning off ECMO; (2) failure to recover, with ECMO serving as a bridge to a longer‐term circulatory support device or heart or lung transplantation; or (3) death.

Presently, ECMO may only be provided in an intensive care setting and only temporarily. Patients on VV‐ECMO may be maintained on the machine for weeks to months in some cases, and may be awake, walking, and talking, potentially allowing for these individuals to directly participate in discussions about goals of care.[19, 20] In contrast, adult patients on VA‐ECMO historically have only been maintained for days to weeks on the machine, intubated and typically sedated, making their participation in goals of care discussions generally more difficult, if not impossible.[7] As collective expertise in adult VA‐ECMO grows, however, patients awaiting heart or heart/lung transplants are similarly finding support for longer periods of time, enabling wakefulness and the ability to participate in decision making. Generally speaking, if a patient on ECMO neither recovers nor is a candidate for a longer‐term support device or transplantation, the risks of thromboembolic and infectious complications from continuing the treatment will eventually outweigh any real benefit. Accordingly, ELSO recommends that ECMO should be discontinued promptly if there is no hope for healthy survival (severe brain damage, no hope of heart or lung recovery, and no hope of organ replacement by VAD or transplant).[21]

Given that approximately 32% of adults treated with ECMO for cardiac failure and 47% treated for respiratory failure will survive to hospital discharge, many patients and families will be forced to make difficult, end‐of‐life decisions with ECMO.[22] ECMO is different from other life‐sustaining therapy (LST), such as mechanical ventilation, in that it may only be provided in an intensive care setting. Furthermore, unlike patients who cannot wean from a ventilator and thus are transitioned to a tracheostomy, there is no long‐term treatment option with ECMO. Terminal discontinuation is the sole option for patients on VA‐ECMO who do not recover and are not candidates for VAD or transplantation.

The remainder of this article will examine the ethical issues that emerge with ECMO. We will focus more specifically on VA‐ECMO, although certainly issues described and the guidance offered are relevant to VV‐ECMO. VA‐ECMO presents some unique issues, however, as patients are generally (although not uniformly) intubated, sedated, and thus incapacitated and unable to participate in goals of care discussions once treatment is initiated. Thus, the hospitalist can help ensure, preemptively, that the provision of VA‐ECMO is consistent with patient preferences and goals of care. In addition, VA‐ECMO is also unique in that some patients suffering from cardiac arrest refractory to cardiopulmonary resuscitation and advanced cardiac life support may be successfully oxygenated and perfused with VA‐ECMO; thus, VA‐ECMO extends the boundaries of what we commonly consider to be the limits of cardiac resuscitation, perhaps suggesting a need to reframe do not resuscitate (DNR) discussions.

VA‐ECMO: ETHICAL CONSIDERATIONS

Ethical concerns and difficult decisions may arise at any time during treatment with VA‐ECMO. For teaching purposes, we have conceptualized the treatment trajectory as consisting of 3 phases: (1) initiation, (2) continuation, and (3) discontinuation, each with its own set of issues (Table 1). Clinically, however, each phase of treatment is intrinsically linked to the others, and in reality clinicians must look forward, anticipate upcoming decisions to the extent possible, and prepare families for what lies ahead. Before we attend to each phase, we will briefly review who makes these decisions.

CONCLUSION

With indications for and utilization of ECMO in adult patients expanding, hospitalists may be expected to encounter these technologies with greater frequency and guide patients and families with medical decision‐making. Although the ethical issues reviewed are certainly not exclusive to ECMO, specific facets of ECMO, as discussed, may precipitate unique challenges or exacerbate common ones. Hospitalists can help to uphold patient autonomy by providing information that enables patients and surrogates to actively participate in goal setting and decision‐making. As the utilization of this technology grows, further research will need to address decision‐making in the context of ECMO to ensure that the process remains optimally patient‐ and family‐centered.

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.