By Stacey Kusterbeck
Clinicians have begun to focus more attention on identifying and addressing patients’ social determinants of health. Ethicists are doing the same during consults.
“Socioeconomic inequities lead to health disparities,” observes Renee McLeod-Sordjan, DNP, PhDc, FNAP, director of the division of medical ethics at Northwell Health System and chair of the Northwell Health System ethics review committee.
Thus, ethicists are obligated to consider social determinants of health during consults. “Ethicists must review access to healthcare, food insecurity, functional health literacy, and social support through a lens that maximizes fairness transparently,” McLeod-Sordjan says.
There are few ways ethicists can address social determinants of health:
• Ethicists can alert other caregivers if the patient’s medical record contains ICD-10-CM codes included in categories Z55-Z65 (“Z codes”). Z codes are used to capture nonmedical factors that can affect a person’s health status.1 For example, code Z59 indicates problems related to housing and economic circumstances. Code Z60 indicates problems related to social environment. “This allows teams to identify communities of interest and stakeholder needs related to social vulnerability,” McLeod-Sordjan explains.
• Ethicists can collaborate with social workers and case managers to identify patient needs before discharge. At Northwell Health, unrepresented patients, patients without capacity, patients without social support, and patients represented by the New York State Office of Mental Health or the Office for People With Developmental Disabilities are flagged as needing early ethics consultation. This allows all caregivers to identify resources that are available for the patient and a surrogate decision-maker.
Ideally, the ethics response begins even earlier. “Proactive ethics consultation begins in the community, by meeting the needs of the vulnerable,” McLeod-Sordjan says.
Ethicists can build relationships with community stakeholders, such as clergy and religious advisors. “Education and resources can be put into place sooner to avoid miscommunication and prolonged hospital stays,” McLeod-Sordjan offers.
• During consults, ethicists can build trust by viewing the situation through the experience of the patient and family. For example, ethicists should know if the patient lacks access to food, shelter, or medications. “They can then put a plan into place that respects the individual and promotes fairness and justice,” McLeod-Sordjan says.
• Ethicists can help clinicians who are experiencing moral distress because of concerns about the discharge plan. “Ethicists must advocate for justice, fairness, and transparency while recognizing that the U.S. healthcare system has great expenditures but little social resources,” McLeod-Sordjan says.
McLeod-Sordjan often sees cases of patients who are unrepresented by family, without a surrogate. The patients cannot care for themselves but object to inpatient placement.
In one such case, a patient’s partner was living with chronic illness and required multiple visits to a clinician to prevent hospitalization. Both the patient and partner ended up hospitalized concurrently. Both patients wanted to be discharged home and return to their community. The basic necessities of life — food, shelter, and medications — became a priority.
However, clinicians were concerned about safe discharge planning. The role of ethicists is to aid the clinicians who are experiencing moral distress because they cannot provide an ideal discharge option, according to McLeod-Sordjan.
Ethicists can remind clinicians they are attempting to provide the best medical care with limited resources. Ethicists also can help the clinical team weigh the benefits and risks of the medical plan. “Ethics must aid the patients in maintaining dignity and autonomy while facing tough choices and options that frequently involve paying for healthcare at the expense of food and shelter,” McLeod-Sordjan says.
Hospitals and health systems must do more to address social determinants of health to meet an ethical obligation to improve community health status, according to Paul Hofmann, DrPH, LFACHE, a healthcare consultant and former hospital CEO. “Ethicists should be more cognizant of these factors because they can contribute to requests for ethics consults,” Hofmann says.
Ideally, ethicists collaborate with clinicians and social workers to find solutions. “Given the obvious complexity of such issues, it may be unrealistic to develop effective interventions immediately,” Hofmann admits. “But an ethics consult is a good starting point.”
For example, during a consult, ethicists may become aware of a patient’s drug addiction after speaking with a social worker. “The conversation could lead to a broader discussion of the patient’s needs,” Hofmann suggests.
REFERENCE
- American Hospital Association. ICD-10-CM coding for social determinants of health. January 2022.
Clinicians have begun to focus more attention on identifying and addressing patients’ social determinants of health. Ethicists are doing the same during consults.
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