D. Sokol knows what his answer would be but it's not the same as mine
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
Rapid Response:
D. Sokol knows what his answer would be but it's not the same as mine
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