Rethinking ward rounds
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b879 (Published 04 March 2009) Cite this as: BMJ 2009;338:b879
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As an RN (20 years)in Perinatology/Labor & Delivery, I've seen
nurses are dealing with ethical dilemas quite often. Patients can
introduce the spouse vs. father of the baby vs. current boyfriend or
fiancee all within a single 12 hour shift with various visitors at the
bedside.
Patients can know about their own medical history including
previous pregnancies that ended with either abortions or giving the baby
up for adoption that they "don't want anyone else to know about". Most
women delivering 3rd of 4th baby may progress on a different timeline than
a woman delivering a 1rst baby.
Women who know about their own health status and are aware of
transmissable infections like Chlamydia, Gonorrhea and others will accept
antibiotics but "don't say what the medicine is for" and women with active
Herpes requiring a c-section will instruct the staff to "make up a reason
why I need to have a c-section to tell them".
Competing interests:
None declared
Competing interests: No competing interests
Most of the points on this checklist, and the example of looking for
an advance decision in the notes, are actually clear-cut requirements of
The Capacity Act. There is no need to delve into the murky, interpretive,
world of ethics. If people carry out an assessment of capacity and then use
the best interests checklist for people who lack it, then most of the
ethical checklist points become redundant. Ignoring a properly worded,
written advance decision about life sustaining treatment (without using
The Mental Health Act to override it) is now illegal, not just unethical.
My experience, which seems to be supported by emerging research, is
that doctors, and other staff, in general hospitals have received poor
levels of training in The Capacity Act. Hence a confusion between ethics
and the law?
Competing interests:
None declared
Competing interests: No competing interests
Whilst we welcome the ‘ethics man’s’ proposed attempt to encourage
clinicians to consider a range of ethical issues as part of routine
practice (7th March 2009), we also remain ‘sceptics’. We acknowledge the
aim of the checklist is to encourage discussion around pertinent ethical
issues related to the case; however, our experience is that checklists
often encourage a tick-box mentality rather than discussion and that this
sort of approach may be suited to (supposed) avoidance of complaints or
legal action rather than encouraging critical engagement with the ethical
issues involved. For example, check lists may engender a sense that if
you have gone through the list you have covered all the possible ethical
concerns and that as long as you have ticked or crossed a box this is
evidence of having done so. We would argue that this is unlikely to be the
case. We have seen something similar happen with research ethics approval
where researchers appear to see ethics as something they need ‘to get’
rather than something they need to engage with. Our worry is that the
checklist will just be seen as another piece of paper to be completed or
just another procedure to be followed, which may undermine the very
purpose of the activity.
Competing interests:
None declared
Competing interests: No competing interests
Although common sense dictates that it should, I do not know if the
ethics checklist will lead to better patient care. This is why it is
important to conduct research to investigate its impact on healthcare
staff and patients and why I am so grateful to Washington Hospital Center
and any others who are willing to pilot the checklist. There is little to
lose and much to gain, and I would be more than happy to visit any medical
team to offer my thoughts on how to use the checklist in practice.
What is clear is that the ethics checklist will not resolve ethical
dilemmas. It identifies the key ethical issues and signals the need for
deliberation and sound judgement. However, it is well known that moral
perception is the first step towards moral action. Spotting ethical
issues does not come naturally to most of us, although we can usually see
one when it stares us in the face, if it has startled us in the past or if
we have spent time studying its features. Even those who are adept at the
exercise will have times when their moral gaze, through fatigue or some
other interference, fails to spot certain issues.
The legendary Gary Kasparov, that most precise and meticulous of
decision makers, made the occasional blunder on the chess board and most
of us, clinicians or ethicists, are no grandmasters of medical ethics. We
too blunder, with potentially far greater consequences than losing a game
of chess. If a simple checklist can help reduce the frequency of our
ethical blunders, it is consistent with the principles of beneficence and
non-maleficence, allowing us to benefit our patients with as little harm
as possible.
Competing interests:
I am the author of the article
Competing interests: No competing interests
Of course, as scholars of the English language would have realised, I
meant
Sokol's Stamp.
Competing interests:
None declared
Competing interests: No competing interests
It is necessary for me to begin with informing you of my bias - I'm
the Director of the department where Dr. Sokol did his visiting
scholarship and developed the checklist stated in this article. What I
wanted to comment on is the submission from the person who thinks that the
checklist is unnecessary since most competent and humane physicians would
be able to pick up the "few" ethical issues in everyday patient care
without the need of prompting. Frankly that is just wrong. Not saying that
physicians are not able to pick up ethical issues, they are which is why
they know to call me when it is more then they can bear, but physicians
don't have the time or really the need to address all ethical aspects of
everyday care. Saying that there are only few is clear evidence that you
don't practice medicine in a hospital that has an ethics infrastructure.
If you did then the understanding that every patient has mulitple ethical
concerns would be clear. The pratice of medicine is ethical and moral in
nature. We try to do the best for our patients and make choices that have
ethical implications. Not to say that the everyday ethics that accompanies
the practice of medicine is so great it needs a bioethicist to point them
out, but there are enough that if I was a patient I would want my
physician to pay detailed attention to the medicine and let the ethics
people pay attention to the ethics. Physicians don't need to be ethicists
as well as physicians. We complement each other in my institution very
well and our physicians have reaped the benefits of having a trusting
source of ethicists to assist them with their patient care.
When I took
the checklist to our physicians, including the cheif of medicine, the
response was unanimous in agreeing this will help the residents (house
officers) learn how to think about the issues earlier on and call us to
intervene before it becomes so clearly an ethical dilemma anyone could
point it out. Providing this service to our patients not only brings our
physicians to a higher moral authority it makes their job less complicated
because they can see areas for potential conflict and deal with them
promptly. If I was a patient in the hospital I would want my physicians to
act in my best interests from not only the medical perspective, but from
an ethical one as well. The checklist has been adopted by the physicians
in my hospital from the MICU to the NICU and now is working its way into
surgery, nursing and social work. A 926 bed urban teriatry care trauma 1
center must certainly have compentent physicians - can they all be
wrongheaded to feel this checklist is important? Probably not.
Competing interests:
None declared
Competing interests: No competing interests
Dr Sokol has proposed that ward rounds should include an ethics
checklist 1; I would suggest that this is unnecessary. The surgical
checklist to which Dr Sokol refers and that was recently published in the
New England Journal of Medicine was clearly associated with improvement in
defined outcomes2. It is hard to envisage an improvement in outcomes
following the implementation of an ethical checklist beyond the financial.
It is true that there are important ethical considerations to be addressed
on the daily ward round but these are usually quite clear and do not
require a checklist. Most doctors have sufficient training in ethics and
general life experience to be able to spot the occasional ethical dilemma.
Following the surgical checklist publication in the NEJM there has
been an increased interest in this type of patient management. However,
it is easy to become overzealous. Too many checklists (and there are
already many in use) that ‘only take thirty seconds’ soon add up and
before you know it several minutes have been added onto the patients
bedside presentation. Multiply that by forty and you have a ward round
that may take six hours rather than four, and to what end? The increased
time taken to implement this type of change eats into the time taken to
provide actual patient care in a very real way. Proposing such measures
is thus potentially dangerous.
As examples Dr Sokol describes a patient with HIV who has both a wife
and girlfriend. He then goes on to describe how the ‘ethical checklist’
would aid in such a scenario. I find it hard to believe that the
combination of HIV, wife and girlfriend would not raise a question or two
in the mind of any human being with regard to approaching the issues
sensitively. The next example is of a demented dying man who has been
admitted to ITU while no one has noticed an advanced directive requesting
‘comfort’ care only, until it is noted by the visiting bio-ethicist. This
is such a great mistake that I fail to see that an ethical checklist would
have helped. The extension of this is that the ethical checklist is
overlooked and therefore a checklist of checklists will need to be
proposed – I will call this the meta-checklist and who knows, my
successors may propose a meta-meta-checklist ad infinitum.
It is clear to me checklists can provide improved patient care when
used judiciously, but to propose a checklist for every specialty without
hard evidence of improved patient outcomes is potentially dangerous. Dr
Sokol finalises his article with the question “would you prefer your
medical team to use an ethics checklist?” and my answer is no. I would
prefer my medical team to show some humanity and a little competence
without having to revert to a checklist.
1. BMJ 2009;338:b879
2. New England Journal of Medicine 2009;360:491-9
Competing interests:
None declared
Competing interests: No competing interests
The Ethics Man strikes again.... Perhaps all wards could have a once
a week
ethics round, where by a medical ethicist can attend, listen to the
patient
narrative, the families concerns, the specialist opinion and then offer a
different
perspective. Unfortunately, I doubt there are enough Ethics Men and Women
to
provide such a service. Instead I plan to have this table converted into a
stamp,
and use it once a week on our consultant rounds, to focus the mind and
stimulate discussion. I shall call this Sokols' Stamp.
Competing interests:
None declared
Competing interests: No competing interests
Point form and checklists
Somewhere along the course of my life, I recall the introduction of
"point form" and "lists", as opposed to sentences - by people called
"teachers". Prior to that time, one was expected to be able to make
sentences, and point form would have been dismissed as inadequate English.
But since that time, point form has taken over. Thus the blind faith in
checklists which are of course, "point form" by another name. This blind
faith is built on an equally blind faith in education itself which has
become a means to employment, without which, poverty and unemployment are
assumed.
"Flow charts" too are very "in". We have one where I work, and it
goes on the back face of the insulin prescribing and administration chart
- it looks as complicated as a detailed map of London, and any clinician
who can stand at the bedside and find the time to decipher it, deserves to
be lost.
Competing interests:
None declared
Competing interests: No competing interests