End-of-Life Decision Making in Internal Medicine: A Retrospective Cohort Study of Clinical Ethics Consultations

Internal Medicine physicians frequently face complex ethical dilemmas in end-of-life (EOL) care, particularly when prognoses are uncertain and patients lack decisional capacity, surrogate representation, or clear care preferences. Clinical Ethics Consultations (CECs) can provide support, yet little empirical data describe how Internal Medicine teams utilize CEC services.

To characterize the clinical features, ethical themes, and recommendations of CECs requested by Internal Medicine services, particularly in the context of EOL care.

Retrospective cohort study using structured chart review and qualitative analysis.

Single large, urban, academic referral hospital with a multidisciplinary ethics consultation service.

Adult inpatients who received a clinical ethics consultation between January 1, 2018, and December 31, 2022 (N = 216).

Receipt of a clinical ethics consultation.

Primary ethical themes, subthemes, and recommendations were identified using the Armstrong Clinical Ethics Coding System. Ethics recommendations were also categorized by theme.

Of 216 total consultations, 139 (64%) were requested by Internal Medicine services, including 86 (62% of IM consults) from Hospital Medicine. Mean patient age was 62.7 years (SD 15.6); 62% were male. Twenty-six percent (n = 36) lacked decisional capacity and representation. Among Internal Medicine CECs, 53% (n = 74) addressed EOL care. Common subthemes included futility/inappropriate or non-beneficial treatment (56%, n = 41), artificial nutrition and hydration (29%, n = 21), and withholding/withdrawing life-sustaining treatment (29%, n = 21). Recommendations included non-escalation (36%, n = 27), continuation of treatment (34%, n = 25), and goal clarification (38%, n = 28). Palliative care was consulted as a separate clinical service and involved in patient care prior to or concurrently with the ethics consultation in 35% (n = 49) of IM cases, and 49% (n = 68) of patients died during hospitalization.

Single-center design and lack of qualitative data from requesting clinicians.

CECs often support complex EOL decision-making in Internal Medicine. Subthemes like futility and artificial nutrition influence recommendations in distinct ways, underscoring ethics' role in navigating uncertainty and supporting patient-centered care.