MEDICAL ETHICS CHECKLISTS

Hospitals using a checklist designed for the World Health Organization (WHO) cut deaths after surgery by 46% and surgical complications by 36%.

Using this as an example medical 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 the 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," he said. "It's preventive ethics at its best."

The ethics checklist will be considered at the Loyola University Chicago Stritch School of Medicine, said Kayhan Parsi, PhD, a clinical ethicist."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."

Clinical Ethics Patient Assessment
• 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


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