Dr. David Warriner, a physician in South Yorkshire, England, created an ink stamp of an ethics checklist. He plans to use it in patients' charts to note any ethical issues.

Success from surgical checklists breeds idea for ethical checks

Pilot program explores a list for ethical concerns.

By — Posted April 13, 2009

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For ages, doctors have used lists and other reminders to help them give the right care to patients. Recently, the use of checklists in areas such as surgery and infection control has delivered remarkable results, greatly reducing morbidity and mortality.

Beginning in April, residents working in the intensive care unit at the Washington Hospital Center in Washington, D.C., got a different kind of reminder when caring for patients -- an ethics checklist.

The idea is the brainchild of Daniel K. Sokol, PhD, a medical ethicist at the University of London St. George's Hospital Medical School who served as a visiting bioethics scholar at the Washington Hospital Center in January and February. Sokol wrote about the ethics checklist in the March 4 British Medical Journal and said bioethicists at hospitals in Canada and the United Kingdom also are considering the idea.

"Having an ethics checklist changes the focus away from the purely clinical to include the ethical dimension," Sokol said. "In the back of my mind I had this idea of the surgical checklist, where uniformly the results have been quite astounding. I see no reason why there shouldn't be a similar thing for ethics."

The eight-item checklist at Washington Hospital Center -- actually an ID-sized badge that residents wear on lanyards -- covers ethical issues that commonly arise in the hospital setting. Is the patient able to make medical decisions? Is there a do-not-resuscitate order? Is there a disagreement among family members about how care should proceed?



Residents are asked to review the list for each patient, note any potential issues and call the hospital's bioethics staff if they need help resolving problems. The hospital's three ethics consultants already handle about 300 queries a year, said Nneka Mokwunye, PhD, director of bioethics and spiritual care. She said getting doctors to use the checklist could help avoid ugly squabbles with families and prevent lawsuits.

"We want to recognize the potential for an ethical problem earlier downstream and intervene early enough so that patient care doesn't get compromised and the family doesn't get negatively impacted by the emotional rollercoaster the ICU presents," Mokwunye said. "It's preventive ethics at its best."

Mokwunye will survey residents before and after they use the checklist to see whether they find it helpful or too time-consuming.

The idea is "fantastic," said John J. Lynch, MD, chair of the Washington Hospital Center's bioethics committee. "This is a brief list that raises the really important questions that residents and other physicians need to be clear about. It makes eminent sense."

The ethics checklist will be considered at the Loyola University Chicago Stritch School of Medicine, said Kayhan Parsi, PhD, a clinical ethicist who directs the Neiswanger Institute for Bioethics and Health Policy graduate program there.

"What the checklist does, in my mind, is it more formally integrates ethics into the care of patients so it really just becomes part of the culture," Parsi said. "It actually standardizes care so everyone gets treated in a similar fashion."

Dr. David Warriner, a physician in South Yorkshire, England, is so enthusiastic about the checklist concept that he had an ink stamp made of it so that he can quickly add it to patients' charts.

"The list stimulates doctors to think laterally, concerning themselves with the patient, the relatives and their future, not just their temperature, blood tests or scan results," Dr. Warriner said via e-mail.

Checklist hype?

But not everyone thinks the ethics checklist will make a big difference.

Atul Gawande, MD, MPH, director of the World Health Organization's Safe Surgery Saves Lives initiative, said ethics issues should be integrated into a streamlined checklist, not added as another set of items to review. Hospitals implementing the WHO checklist cut deaths after surgery by 46% and reduced surgical complications by 36%.

"Pilots don't have a communications checklist. They have a 'before takeoff' checklist on which communications is a key goal," Dr. Gawande said in an e-mail. "Likewise, clinicians probably won't have an ethics checklist. We will have an [operating room] checklist or a ward rounds checklist, on which not missing a key ethics issue may be a key goal."

Another leader in the checklist movement who expressed skepticism is Peter J. Pronovost, MD, PhD, principal investigator of a patient-safety initiative that helped more than 100 Michigan ICUs cut bloodstream infections by 66%. He said checklists must be part of a broader approach to changing medical practice.

"There is a lot of hype about checklists," Dr. Pronovost said. "Checklists are a way to summarize what to do, but it's naive to think that will change behavior. The model, as we've done with bloodstream infections, has to be combined with measurement and feedback of performance and culture change, and you put that troika together.

"Writing a checklist on a piece of paper and saying, 'Doctor, go do this,' will be no different than handing them a set of guidelines. Alone, they're not Harry Potter's wand."

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Is it ethical? Check

In April, the Washington Hospital Center in Washington, D.C., began piloting this ethics checklist among residents working in the intensive care unit.

Clinical Ethics Patient Assessment

Add relevant ethical issues to progress notes and report on rounds

  • Patient's wishes unclear/refusal of treatment
  • Questionable capacity to consent to, or refuse, treatment
  • Disagreement involving relatives/surrogates/caregivers
  • End-of-life (advance directive/power of attorney, do not resuscitate/allow natural death, withdraw/withhold Rx)
  • Confidentiality/disclosure issue
  • Resource or fairness issue
  • Other (please note)
  • No notable ethical issues

Source: "Ethics Man: Rethinking ward rounds," British Medical Journal, March 4 (link)

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External links

"Ethics Man: Rethinking ward rounds," abstract, British Medical Journal, March 4 (link)

"A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population," abstract, New England Journal of Medicine, Jan. 29 (link)

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