Page last updated at 10:32 GMT, Monday, 19 January 2009

The New Kid on the Ward Round

By Dr Daniel Sokol and Dr Nneka Mokwunye

Taking a patient's temperature
Sometimes medicine is not straightforward

In 1661, the Board of Directors at the Hôtel-Dieu hospital in Paris, concerned that their doctors were spending too much time with wealthy private patients, instructed the doctors to spend at least two hours a day on ward rounds.

Today, such rounds are a routine part of hospital life.

A medical team led by a senior doctor wanders from bed to bed, while a nurse or junior doctor presents each patient to the senior who then decides on their ongoing care.

Thus a junior doctor might present Mr Smith, who was admitted the day before with abdominal pain, and the senior doctor might decide to start the patient on intravenous fluids and list him for surgery.

Rounds are intimate and sometimes intimidating encounters between the patient and the clinical team.

Friends and relatives are usually asked to leave for the duration of the visit.

In leading hospitals in the US, the hallowed tradition of the ward round has been changing.

The private club, previously limited to the senior doctor and his entourage, has opened its doors to a new member: the clinical ethicist.

Preventive ethics

One hospital that routinely uses clinical ethicists on ward rounds is Washington Hospital Center (WHC) in Washington DC.

Dr Evan DeRenzo, one of the rounding ethicists at WHC, said: "Although the doctors were apprehensive at first they now find our input to ward rounds useful and are comfortable having us there."

Ethicists like Dr DeRenzo, who usually hold a PhD in bioethics rather than a medical degree, help anticipate or defuse potentially explosive situations that may arise in end-of-life care and other sensitive areas.

They can provide useful support to clinicians faced with ethically troubling cases and with worried, sometimes angry relatives.

Ward rounds tend to be highly technical, focusing on physiology and therapeutics.

The danger is that this emphasis on the clinical details may obscure the ethical aspects of the case.

The ethicist serves a preventive role, fostering communication of the ethical issues early on.

For cost-conscious hospital managers, preventive ethics can also save money. A single law suit avoided is worth the ethicist's weight in gold.

A case example

During a ward round, a junior doctor presents the case of Mr Jones, an unconscious 65-year-old man with pancreatic cancer.

The outlook is bleak and the team believes it is time to shift from curative treatment to comfort care.

The senior doctor asks his junior colleague to inform the family of both the prognosis and the plan to shift the level of care.

The team moves on to the next patient. As the ethicist walks on, the junior doctor asks to speak with her in private.

He reveals that the patient has an advance directive that clearly states a refusal of all treatment in the terminal stages of the disease.

Dr John Tuohey (left) on his ward round
This helps to keep ethics a practical discipline, rather than an abstract one
Dr John Tuohey
The doctor wants to know who determines if the patient is 'terminal', and what he should say to the "hostile and angry" family.

The ethicist tells him that deciding if a cancer is in its terminal phase is a clinical matter. As for the family, the ethicist offers to discuss the issue with them.

When she spoke to the family, the ethicist did not sense hostility or anger, but frustration.

"The family felt that the doctors were not giving them enough information on their relative's condition," said Dr DeRenzo.

"They were happy to have someone listen to their concerns and help them work with the doctors to finalise the care plan."

The junior doctor was able to have a productive conversation with the family, the patient's advance directive was respected, and the family developed a trusting relationship with the clinical team.

The issue was addressed before it became a full blown conflict.

Independent voice

While nurses and junior doctors may feel reluctant to question someone higher up in the hierarchy, ethicists are more independent.

They are not attached to a particular unit.

If the senior doctor fails to raise an issue, the ethicist is in a position to do so.

Dr John Tuohey, director of ethics at Providence St Vincent Hospital in Portland, Oregon, said: "As a member of the rounding team I can pose an ethical question to the team if I hear something that sounds odd or unclear.

"I can also use the opportunity to make a teaching point during the ward round.

"This helps to keep ethics a practical discipline, rather than an abstract one."

Over time, the clinicians learn to ask key ethical questions without prompting, and this gradually becomes part of the normal presentation of patients.

Value of bedside ethics

Although the practice of having ethicists on ward rounds is increasingly common in US hospitals, it does not exist in the UK.

In the UK, you will find professional medical ethicists in university offices - not at the bedside.

As with all suggestions for change, there is resistance to the idea from some clinicians. A key barrier in the NHS is cost.

In the US, some ethicists in large hospitals are paid over $160,000 a year (£105,000), although $100,000 is more common (£65,450).

Are hospital ethicists a good use of limited resources or are they a luxury? Do they have a place in the 21st century hospital?

Dr Daniel K. Sokol is a medical ethicist at St George's, University of London and Director of the Applied Clinical Ethics course at Imperial College London.

Dr Nneka Mokwunye is a clinical ethicist and Director of the Center for Ethics at Washington Hospital Center, Washington DC, USA.

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