The ethical checklist

The routine use of an ethical checklist was proposed by Daniel Sokol, a medical ethicist (see box 1). He argues that an ethical checklist is an important new tool for the ward round.3 It can prompt the medical team to consider ethical issues that can then be anticipated or dealt with to ensure that patients are treated with the dignity and respect that is expected as one of the government’s healthcare standards4 as well as being a baseline element of good medical practice.5

However, I have found it can also be a useful tool for teaching and learning about the practical application of ethical principles. I used the checklist in a number of ways; when reviewing patient notes, as a guide to further discussion with patients, when observing the professional behaviours and communication of the multidisciplinary team and as a guide for case-based discussions. For example, I would attend the morning handover, receive a brief outline of the patient history along with any recent changes in their condition or management and then read the patient’s notes; including admission clerking, consent for treatment forms, medical and surgical notes and communication with the family. Following this I would attend and contribute to the consultant ward round. I was also able to return and talk to some patients when their conditions had improved and they were more alert and orientated. This allowed me to find out how they felt about some of the ethical issues I had identified such as treatment without a process of consent when the patient had temporarily lacked capacity. Using the checklist at each stage helped me identify any possible ethical issues that had arisen, or could potentially arise, allowing me a deeper understanding of the patient’s healthcare needs. I then used the checklist and my notes in a daily consultant tutorial, discussing each of the ethical principles and observed professional behaviours, in the same way that I would discuss the clinical diagnosis and management of a patient case on a normal clinical attachment. Having not previously encountered the patients, it took me approximately 30 minutes to fill in the ethical checklist as I often had several weeks of clinical notes to review. This length of time would be impractical for healthcare professionals as a daily activity; however, if the checklist was used from the day of admission and updated regularly it could be completed by clinicians in just a few minutes on each encounter, building up a record of any ethical issues relating to past, current and even future care.

The ethical issues

I had attended a lecture regarding the difficulties in applying legal rules such as the Mental Capacity Act and the need for continued ethical practice in acute care situations, but the number of ethical problems I came across still surprised me. On critical care not only did every patient have at least one ethical issue relating to their care, but some of the issues that I identified had not been considered openly or clearly documented by the medical team treating the patient. One example of this was a patient who had a prolonged cardiac arrest, requiring over one hour of active resuscitation with multiple shocks, followed by several further arrests. When we saw the patient several days later, the patient was alert and orientated, sitting out of bed. This point in recovery seemed like an ideal opportunity to discuss future treatment with the patient with regard to resuscitation status, in order to avoid what could be a difficult decision in a pressurised situation if there was a repeated cardiac arrest. Yet none of the medical team had spoken to the patient about this matter and the high risk of ischaemic brain injury from prolonged arrest. After further consideration and discussion within the team, it was felt that this patient’s short-term memory after the first arrest was still poor and so the patient did not yet have sufficient capacity to engage in such a discussion, and the team felt that at that point it would be most appropriate to continue medical care with the presumption to favour further attempts at resuscitation should there be a further cardiac arrest. This case highlights the question of whether medical professionals should routinely use the ethical checklist: it helped to identify the need for discussion with the patient, prompted team discussion and led to a plan for management that would need to be reviewed at the point when the patient might regain capacity. I believe it could be used efficiently and effectively on the ward round. However, it is important to note that using the ethical checklist only identifies the ethical issues, so should not be used in isolation. There must also be holistic practices in place to ensure that a solution is discussed by the clinical team and actions instigated if necessary.

Due to the nature of intensive care and the need for urgent life-saving treatments in confused or hypoxic patients, consent was by far the commonest issue. Many of the patients were unconscious or receiving sedative drugs, and therefore lacked the capacity to engage in a process of discussion leading to consent for their treatment. Several had undergone emergency life-saving surgery or investigations to help diagnose their current illness without consent as it was thought to be in their best interests. Another patient had an HIV test done without consent as the detection of HIV would have an influence on the treatment for their current admission, and was therefore deemed to be in the patient’s best interests.

Consent to treatment was also a key issue for the emergency trauma list in theatre. I saw an elderly patient with a fractured neck of femur that required fixation. Due to acute confusion, secondary to a respiratory tract infection and likely dementia, this patient was deemed to lack the capacity to consent. The medical team were unable to contact her family to discuss the treatment and so went ahead with the operation. This was in the patient’s best interests as, while she had a fractured hip, not only was she in pain, she was also unable to move or sit up, putting her at greater risk of pneumonia, further increasing the already high mortality risk.

A particularly interesting case was that of a patient with a “do not attempt resuscitation” (DNAR) order. This was set up by the critical care medical team in discussion with the family, as it was felt that if the patient’s condition were to deteriorate further, active treatment would be futile. However, as the patient regained consciousness the family felt it was not in the patient’s best interests to discuss the DNAR order with her. I found this a difficult case to consider. I could appreciate that the family thought this information would make the patient agitated and upset, which could potentially set back her recovery, and so there was an arguably paternalistic argument that it was not in her best medical interests to engage in a discussion about resuscitation. However, I also thought that as the situation had significantly changed, and the patient was now conscious but drowsy, that it might be right to discuss the DNAR order with her in order to ascertain her views on end-of-life treatments. In the end the decision was made that the subject would not be broached directly with the patient, but that if she were to ask about prognosis then the healthcare team would not withhold any information. At the time, I considered this a fair compromise between looking out for the patient’s best interests, which the family are often in a better position to judge as they are more likely to know the patient’s personal views, and allowing the patient to make informed autonomous decisions on their own care. However, after discussion, I am aware that others argue that witholding information does not respect the patient’s autonomy and might not therefore be ethical practice. To me this case illustrated some of the dilemmas that can arise in treating critical care patients, allowing me to see how an ethical conflict between the clinicians and the patient’s family could potentially occur in the same way that there may be differences of opinion as to clinical management. It also highlights how using the ethical checklist can identify potential problems but cannot offer a solution. While attending the ward round I observed how it was conducted in an open environment, which could at times compromise patient confidentiality. For example, the medical management of a patient was discussed while the patient in the next bay was conscious and could potentially hear the discussion, which could include information of a personal or sensitive nature. In a ward area, patients will often freely discuss their medical conditions with each other, so could be argued not to object to a ward round discussing their care, but in an intensive care unit environment, patients are often not in a position to object. The environment is similar on the high dependency unit; however, as patients are less likely to be heavily sedated it becomes even more important to safeguard privacy and confidentiality of patient information.

So what did I learn?

This was an invaluable personal learning experience. Using the ethical checklist made me look at the patients in a way that I probably should, but never had, considered before. I was able to apply what I had already learnt in lectures to real-life situations. By discussing these cases with the consultant, I learnt how difficult medical management decisions are made, and I also came away with a much deeper understanding of legal obligations and how these tie in closely with ethical considerations of good medical practice. The complexity and severity of patients’ conditions in critical care makes it the ideal setting for learning about ethics. I considered more ethical dilemmas in that one week than I had in my previous 2 years of clinical placements. I feel I am now beginning to acquire some of the skills necessary to start to assess and discuss ethical issues surrounding a patient’s care confidently. When I clerk a patient the ethical checklist will form part of my assessment. I may initially have to carry the checklist in my pocket to remind myself of each consideration, but only by doing this will I be able to continue to develop the essential skills; an awareness of the ethical issues, knowledge of the law surrounding these issues and the ability to consider the issues from different perspectives. This week has shown me that these skills are as vital as knowing how to take a medical or social history, and I feel it is important that I continue to build on them during my final year at medical school and into my foundation years as a junior doctor.

Applying the practical approach in medical school

As medical students we aspire to behave in an ethical manner everyday. Without even thinking about it, we introduce ourselves to patients, we get consent to do a blood test and we maintain the patient’s confidentiality when presenting cases to our peers. How often do we come across the more complex issues such as capacity to consent, end-of-life treatments or resource allocation? In my experience these issues are mostly only seen in hypothetical patient cases in the lecture theatre. Is this enough to allow us to work ethically and recognise these problems as foundation year 1 doctors and beyond? Furthermore, does it provide us with the skills to implement ethical practices once the issues have been recognised, or do junior doctors sometimes falter under pressure, such as time constraints, demands from the patient or their family, or insistence from a senior colleague to act in an unethical manner? A recent paper suggests that, despite knowing on reflection what is ethically or morally correct, that putting this ethical behaviour into practice offers a far greater challenge and that more needs to be done at an undergraduate level to help combat this.6 Could a practical approach to teaching medical ethics in the critical care setting be applied to the teaching of all medical students to help overcome these apparent deficits in our training?

Personally I would welcome a more practical approach. Many students currently think of ethics as a “soft” subject. They feel it is something that is just common sense and so does not require teaching. Some even think that it does not apply to them as a medical student. Others find it complicated and confusing because of the crossover between medical ethics and the law,7 but I believe that a lot of this stems from the methods of teaching medical students. Lectures can be dry and attendance is often patchy. Small group sessions can promote useful discussions, but it is still a long way from the real patients in hospital.

By learning about medical ethics in the hospital as a clinical subject, it suddenly becomes far more relevant, and seeing the principles and concepts put into practice makes them far easier to understand. Alongside this, it is not until you see patients in real-life situations that you are truly able to explore and reflect on your own personal moral or spiritual beliefs and how they may differ from those of the patients and other medical professionals. McDougall6 suggests that writing first-person narratives about clinical experiences in medical ethics aids reflection and improves self-awareness in these difficult situations. My experience during the SSC week supports this. Reflecting on each of the patient cases enabled me to explore my own moral beliefs and gave me the opportunity to consider the case from different perspectives, allowing me to take into account the viewpoints of others involved in the patient case, whether that be family or members of the healthcare team. Writing first-person narratives also provides material for discussion in small group sessions, allowing students to learn from the experiences of others.

It has been identified that junior doctors regularly face ethically difficult situations in which they do not agree with the actions or instructions of a senior colleague. This leads to a dilemma over whether to voice their concerns and communication between junior and senior doctors regarding ethical issues is often poor.6 8 Following their undergraduate training, junior doctors can usually identify what the correct moral outcome in a situation should be but do not always have the convictions to speak up and implement this, which can create a negative experience that the doctor may look back on with regret.6 By writing reflections based on the ethical checklist medical students have a foundation for discussion with the consultant regarding the issues that have arisen, allowing them the opportunity to raise concerns they have about a patient’s care and to challenge the actions of the healthcare team in a non-confrontational and low-pressure environment. As my previous examples demonstrate, there were several occasions during my attachment when I had ethical questions concerning a patient’s clinical care; this was especially true for the DNAR cases. However, by referring to the ethical check list I was able to reflect on these concerns and discuss them with my supervising consultant, thus allowing me to utilise my new ethical reasoning skills together with the ethical concepts I had learnt in a classroom setting. In addition, I had the positive experience of speaking up in a clinical setting, which will hopefully lead to me having greater confidence in doing this as a junior doctor.

I have found the critical care setting is ideal for undertaking ethics teaching. Not only is it easy to find patients with ethical issues, but the issues that do arise are often far more complex with an interesting background history that will help to engage even the initially disinterested student. However, it is important for students to understand and appreciate that important ethical issues arise in all clinical settings, not just critical care, and it would be interesting to use the checklist in other areas, so that students could compare and contrast the types of problems encountered.

I believe it may be practical to implement the ethical checklist in the teaching of medical students. It could be used while students are on a critical care placement, in a similar manner to my own experience. A disadvantage of this is that some students only have short placements in a critical care setting, resulting in either not enough experience using the checklist or missing out on other important aspects of learning in order to fit it in. Alternatively, medical students could be instructed on the use of the ethical checklist in a tutorial and implement it on all of their clinical attachments, discussing their findings with a supervisor and writing reflections on the experience to share with other students and identify learning points. This would encourage good medical practice without taking time away from other areas of teaching and could be continued into the foundation years.

Some would, perhaps rightly, argue that we should automatically be thinking about ethics with every patient we see. However, the same could be said about communication skills, yet we still have formal ward-based teaching for that. I think that doctors and medical students should routinely be asking whether each patient we see has any ethical issues to be considered. However, without ethics becoming part of our practical training, and without medical students routinely considering the ethical issues for each patient seen, we are unlikely to achieve this any time soon.

I am not suggesting that the current methods of teaching should be discontinued. I think they are vital for acquiring a basic understanding of medical ethics and the law, but just as you would not become a doctor without having practical experience of taking a medical history from a real patient on the ward, the same should be said about having practical experience of considering and applying medical ethics.

Supervisor’s comments

Sophie approached me on the basis of a regular lecture I give to the Phase 3b acute and critical care module medical students at the University of Sheffield, asking to do a special attachment for a week in clinical ethics. As a practical ethics attachment was not a formal part of the Sheffield programme, we decided to create one together.

I was clear that I wanted Sophie to be self-directed in applying the theoretical ethics teaching she had received, and for the experience to be informative and intellectually stretching for her. I wanted her to feel that she was embedded within the teams she was working with for that week, but not to become bogged down with the delivery of clinical care. Thinking back to my own medical student experiences and learning how to take a history from a patient, I thought that having a formal structure to follow when history taking not only ensured the appropriate elements of the history were covered but also gave me a feeling of legitimacy in my need for learning experiences: the requirement to develop skills in history taking that would be subsequently discussed, validated the time patients and staff spent with me helping to achieve this.

I had read about Sokol’s ethical checklist and thought it would be a useful tool to try to use if it could help Sophie to achieve her aims. If she had a formal structure that she worked with such as the checklist, we could then meet up daily for tutorials to discuss issues that had arisen when she had used the tool. By also using the tool to observe the multidisciplinary team, it allowed her to attend rounds and meetings and observe the behaviours but ensure that she concentrated on the ethics of the decisions and the manner of their discussion. Each daily tutorial was partly further discussion of the individual ethical issues and partly reflection on the teaching of ethics and professionalism, which are issues identified as relevant by the GMC but not often clearly delineated as to how they should be taught. By agreeing that she should write a reflective essay there was a clear endpoint to the attachment as a formative assessment of her learning and experiences in the week.

I was surprised at how useful a learning and teaching tool the checklist was. By completing a sheet for each patient and laying them out in the structure of the units, we could discuss the individual patient issues but also how they related to each other. That prompted the comments and reflection on how the conduct of critical care ward rounds can be different from more conventional ward-based ones in relation to confidentiality. When we discussed the case of withholding information from a patient at the relatives’ request, I was of the opinion that had I been responsible for that patient’s care that day, I would have taken a different view as to the acceptability of the relatives’ request. I explained that I would have conducted dialogue with the relatives in an attempt to help them to understand that it may not have been in the patient’s best interests and might possibly be considered unethical to withhold prognostic information in the way requested. However, it was also important that when working within a multidisciplinary team that individual viewpoints do not override team views as it is considered better for patient care to have a consistent approach and avoid swings in management depending on the views of the changing lead clinicans. This case was a useful one in that Sophie became aware that differences of ethical opinion can be as marked as those relating to clinical care, and it is important for individual doctors to have a view that they feel is ethically supportable in their own practice. This reflective piece is a summary of her developing ethical viewpoints.

I work as part of a large cross-city multidisciplinary critical care team, and changes to patient care and unit working are made by the team after appropriate discussion. Moreover, we have computerised patient data management systems that incorporate all relevant patient notes, and so to introduce the ethical checklist into our clinical practice requires a special page to be created on the system. Many ethical issues are discussed between senior members of the team, but this is often done outside the formal ward rounds and other activities as ways of exploring the issues, eg, in offices between consultants. I was interested in using the ethical checklist as a way of bringing awareness of the need for discussions of clinical ethics out onto the clinical care areas, but wanted first to test the practicalities of using the checklist on a daily basis. Therefore, I was keen for Sophie to test the checklist out locally, so that if, as is the case, it proved useful and practical, I could bring it for discussion among the team with some small local evidence of its use; a form of ethical service review. As Sophie’s experience was a positive one, and as like Sokol, I feel that it would be a useful tool to guide less experienced staff and prompt them into thinking about the relevance of ethical issues in clinical management and relative discussions, I am now attempting to incorporate it into our unit planning. I will certainly plan to use it as a tool for the teaching of clinical ethics in my practice.