Ethics rounds in clinical ethics have already taken hold in multiple
venues. There are “sit-down rounds,” which usually consist of
a bioethicist setting a specific, prescheduled time aside for residents
and/or others to bring a case or two for discussion with the
bioethicist. Another kind of rounds that occurs on an ad hoc or infrequent
basis is to have either a staff or outside bioethicist give hospital-wide
and/or departmental “grand rounds.” Grand rounds is a
traditional educational format in medicine and adding bioethics to the
topics covered in grand rounds is an important means of elevating ethical
awareness within a department or throughout a healthcare organization.
Newer is the rounding practice of adding a bioethicist to other
established rounding processes, such as case management and utilization
review rounds. All of these kinds of ethics rounds are important
opportunities to elevate the level of moral discourse within a healthcare
setting and are becoming part and parcel of any full-service hospital
bioethics program.
The kind of rounding that is the subject of this paper, however, is
one in which a clinical bioethicist joins regular working, or
“walking,” rounds on a hospital unit. Hereafter, it is this
kind of rounds on which we focus and the activity to which we refer when
simply using the term “rounding” or “rounds.” Our
rounding experience of more than six years teaches us that this kind of
rounding is a highly successful means of advancing the ethically
appropriate care of patients and for teaching clinical staff the
fundamentals, and ultimately the fine points, of clinical ethics.
Going Beyond Our Past
In looking back at the development of clinical ethics services, the
standard function of ethics committees became teaching, policy
development, and case consultation. Ethics committee case consultation was
expected to produce an acceptable moral consensus,1
Moreno JD. Deciding Together: Bioethics and Moral
Consensus. New York: Oxford University Press; 1995; Society for
Health and Human Values—Society for Bioethics Consultation; Task
Force on Standards for Bioethics Consultation. Core Competencies for
Health Care Ethics Consultation: Report of the American Society for
Bioethics and Humanities. Glenview, Ill.: American Society for
Bioethics and Humanities; 1998.
assure ethically optimal patient
care, and teach medical ethics to hospital staff. The initial thought was
that, where there are conflicting moral judgments, conflicts result from
legitimate values conflicts; where there are legitimate values conflicts,
resolution is best sought through the pluralistic process of ethics
committee consultation. We believe these assumptions have much merit. The
diversity of perspectives represented on an ethics committee can provide
insight and thoughtful deliberation where deciding what is ethically
optimal is truly dilemmatic.
Mostly, however, ethical issues arise in a routine fashion in the
everyday care of patients, and many of the cases that come to ethics
committees arrive because routine ethics issues have gone unnoticed or
unaddressed so long that having missed them produces conflict. Whether
conflicts arise between patients and/or surrogates and clinicians or
within the clinical team, these differences ordinarily will not rise to
the level of a bona fide ethical dilemma. Rather, they are merely the
ethical aspects of everyday clinical practice. They are the kinds of
ethical issues that even if complex, even if emotionally wrenching, can be
sorted out at the bedside with a minimum of conflict and moral distress if
handled expeditiously. It is this kind of ethical case input that ethics
committee case consultation is ill suited to provide.
The core limitations of ethics committee consultation for everyday
utility are that it is retrospective and conflict centered. That is, by
the time an ethics committee consult has been called, there is so much
conflict that no matter how the case is resolved, there will be negative
residue. These residual negative feelings and perceptions are damaging to
the everyday functioning of the hospital and need to be prevented by
avoiding or reducing the originating conflict.2
Howe EG. Preventive ethics and alleviating care
providers' stress. The Journal of Clinical Ethics
1993;4(4):283–6; Forrow L, Arnold RM, Parker LS. Preventive ethics:
Expanding the horizons of clinical ethics. The Journal of Clinical
Ethics 1993;4(4):287–93; McCullough LB. Practicing preventive
ethics—The keys to avoiding ethical conflicts in health care.
The Physician Executive 2005;31(2):18–21.
Conflict is at the heart of ethics committee consultation, and
conflict resolution is the anticipated product of the consult. Sometimes,
however, the consultation exacerbates the conflict through its values
clarification process. Even when the consult does result in tempers being
calmed and making recommendations that seem to all to be a fair and
appropriate compromise, hard feelings can linger. If hospital staff
and/or community clinicians have been embarrassed, intimidated, or
felt “ratted on” in the consult process, these outcomes will
further reduce the respect and prestige of the committee throughout the
hospital. The consult may leave a bad taste in the mouth of patients
and/or surrogates, as well, reducing their trust and respect for the
hospital, its clinicians, and for the medical profession.
Attempting to address weaknesses in the ethics committee model, a
variation on committee consultation called mediation has been gaining
attention.3
Dubler NN, Liebman CB.
Bioethics Mediation: A Guide to Shaping Shared Solutions. New
York: United Hospital Fund of New York; 2004.
The notion here is
that formalized due process is lacking in the ethics consultation model
and that this is a serious missing piece that mediation adds back into the
equation on behalf of the patient. Nonetheless, mediation suffers from the
same central weakness as a standard ethics committee consultation.
Mediation is a retrospective, conflict-centered process. In fact, it is
just mediation's focus on due process that may make it an even less
useful conflict resolution method in everyday practice than is standard
ethics committee or subcommittee consultation. Mediation distances the
process even further from the bedside and adds more layers of review and
greater delays to case resolution.
The weaknesses in ethics committee consultation and mediation of their
retrospective nature and their resulting inability to prevent serious
conflict from arising in the first place, however, do not undermine the
importance of either service. Rather, they underscore that clinical ethics
has matured to a point at which it should be refining its own
methodologies and applying the full panoply of bioethics services in more
targeted ways.4
Wolf SM, Kahn JP. Bioethics
matures: The field faces the future. Hastings Center Report
2005;35(4):22–4.
That is why we recommend using ethics
committee consultation in only the truly dilemmatic case. Mediation, too,
can be expected to have high utility in certain kinds of situations. One
can imagine instituting a process at a hospital where any time a case
moves toward litigation, the parties are encouraged to try mediation
first. Such a process could save untold distress and dollars. Neither
committee consultation nor mediation, however, are practices well suited
to advancing goals of ethics training and consultation in the everyday
activities of a hospital. On a routine, day-to-day basis, rounding is a
better fit.
“Walking” Rounds as the
Preferred Model for Routine Ethics Case Consultation and Professional
Training
Going from bed to bed, presenting each patient's case, seeing
each patient, and setting the care plan is how hospital clinical medical
care is routinely coordinated and delivered. The addition of an ethicist
to this process of rounds is a natural enhancement to this normal daily
activity.
The purpose of rounding is to enhance the quality of clinical care.
That is, like everyone else employed by a hospital, the bioethicist is
there to serve the good of the patient. Our experience has taught us that
the most effective way for the rounding bioethicist to serve the patient
is by serving the team, most notably the attending physician, in thinking
through the various ethical issues relevant to a particular patient's
care within the time frame optimal to the patient's needs. Having the
bioethicist see her/his role as serving the patient by serving the
clinicians also sets what we consider the optimal psychological framework
for the bioethicist—that the bioethicist is there to assist others
in thinking through the issues, not there as judge or ethics expert.
Accordingly, the concept of “train the trainer” is an ideal
filter for conceptualizing the bioethics service of rounding. If a
physician, particularly a unit attending, increases her/his skills in
ethical analysis, then the rounding bioethicist will have succeeded in
advancing the ethical care of the hospital's and unit's
patients.
Another way in which having a bioethicist join regular unit work
rounds enhances clinical care is by clarifying that rounds is an
appropriate place for moral discourse, contributing to strengthening the
moral climate of the unit.5
Walker MU.
Keeping moral space open: New images of ethics consulting. Hastings
Center Report 1993;23(2):33–40; DeRenzo EG. Individuals,
systems, and professional behavior. Organizational Ethics: Healthcare,
Business, and Policy 2005;2(1):44–58.
Hospital units
are organismic. They respond to changes in activity level, personnel mix
and other staffing pattern characteristics, and personality dynamics. Each
unit will have its own culture and feel. Much of the emotional climate of
a unit will be attributable to the degree to which a unit is a morally
safe environment. That is, the degree to which all members of a unit, from
desk clerks to clinicians, feel comfortable enough to speak up and raise
difficult and/or complex ethical issues will contribute to the moral
climate of a unit. Where clinicians are disinclined to speak up, errors
are more likely to occur.
That is the second way in which the rounding bioethicist fulfills the
purpose of enhancing the quality of clinical care, by modeling behavior
that strengthens the moral courage required to speak up. Medical hierarchy
based on knowledge and ethical and legal obligation is appropriate. But
because medicine is so hierarchical, it is often difficult for clinicians
to learn that optimal moral discourse requires flattening traditional
power hierarchies during moral discussion and ethical argumentation. This
may be the most important lesson the advent of ethics committees has to
teach. One of the primary reasons the ethics committee has become such a
ubiquitous addition to the medical terrain is the appreciation,
articulated or intuitive, that diversity of views and voices in the
consideration of complex medico-moral discussions is an ethical advance
over outdated practices of medical paternalism. But because the care of
most hospitalized patients does not involve ethics committees, this notion
of diversity of moral perspective needs to be brought to the patients. By
having a bioethicist articulate a reasonably complete range of ethically
permissible actions, offer ethical justifications for various points along
that continuum, and then, as appropriate, make and justify recommendations
for one or more of the ethically acceptable options, the bioethicist
models how to engage in ethical argumentation without being argumentative.
As the clinicians perfect this skill, the level of moral discourse in the
unit is elevated, moral distress declines, and patients can be expected to
receive better and safer clinical care.
Adding a bioethicist to regular work rounds can—and ultimately
should—have profound effects on unit processes around medico-moral
decisionmaking. This prospect, however, should give the bioethicist pause.
Because the environment of any hospital unit is fragile and susceptible to
responding to subtle changes, one wants to be careful that the
introduction of the bioethicist to rounds produces positive and not
negative outcomes. Thus, we underscore our recommendation that the
bioethicist who rounds see him/herself as one who serves and educates.
Being perceived as a “know-it-all” in ethics will be the kiss
of death.
This is especially critical to the success of the rounding bioethicist
who is trained (and perhaps still licensed) as a clinician, particularly a
physician bioethicist. For the clinician–bioethicist, especially the
physician–bioethicist, it is all too easy to fall back on old habits
and slide between roles of bioethicist and clinician. Whether the
bioethicist was originally trained as a philosopher, social scientist, or
physician, the bioethicist function is not responsible for direct patient
care. This is a fact that must always be front and center in the rounding
bioethicist's self-awareness.
Also, timing is everything. A bioethicist joins rounds by invitation
of the unit chief. Invitations can be extended more or less
enthusiastically. Once on rounds, unless the bioethicist gains credibility
as a useful member of the group, the invitation will not last long. It is
important that the bioethicist learn to negotiate the fine line between
raising ethical issues that need attention and knowing which ethical
issues are better postponed. The rounding bioethicist must learn to
disagree forcefully if need be, but simultaneously in a way that builds
trust and respect, without embarrassing or intimidating
others—including, and sometimes especially, the attending
physician.
Take, for example, the problem of informed consent. It is difficult to
know how much a patient and/or his/her family has actually
absorbed. Often patients and their families build walls of psychological
denial to protect themselves from the misery and sadness that information
about poor health brings. To expect perfect understanding is unrealistic.
Where ethical judgment is needed is to determine at what point one's
obligation to make an ethically acceptable effort has been met. Finding
this set point for each patient every time requires thought and may
produce disagreement among the team. Ethically and legally, what is enough
informing and enough understanding for satisfactory consent is going to be
a moving target; there is no formula for finding just the right spot to
call the job well done. But the skilled bioethicist can facilitate a
discussion on rounds detailed enough to produce a reasonable level of
confidence that a good faith effort has or has not been made. Ordinarily,
handling these routine ethical aspects of care on rounds will prevent this
kind of situation from going from bad to worse, resulting in so much
conflict that an ethics committee consultation is called to handle a
problem that, if it had been handled early on, might not have become a
problem at all.
To master the art of ethical negotiation, the bioethicist has to build
the respect and trust of the team while allowing the morning's set of
regular work rounds to progress in a timely manner. In the consent example
just given, the skilled bioethicist will be able to quickly elicit from
various members of the team whether or not there is consensus that the job
has been done satisfactorily or if there is more work to do and with whom.
Sometimes it will emerge that the work left to do is primarily with the
patient and/or with the family. Just as often, however, it will become
explicit (perhaps for the first time, although it may have already been
well recognized in silence or in hushed tones) that the senior treating
physicians still need to work out their own judgments so a clearer message
can be given to the patient and family. This requires give and take, and
most likely it is the rounding bioethicist who serves as traffic cop in
the intersection.
This default position as ethics discussant fulcrum has its own set of
justifications and benefits. The group will naturally and appropriately
look to the bioethicist to model refined communication skills in ethical
analysis, especially in discussions that might be a bit uncomfortable. In
addition to neutral facets of these interchanges, such as communication
skills, this process involves more emotionally charged undercurrents, most
notably power issues. To do this in a way that not merely surfaces
disagreement, but also makes everyone feel respected and more comfortable
working together after the discussion is over is the key to the rounding
bioethicist's success. Being successful at this kind of communication
interchange and power differential management requires that the
bioethicist has already built strong trusting relationships. The rounding
bioethicist must be a moral model in bringing up the difficult issues and
challenging barriers. Success requires that the rounding bioethicist, over
time, be seen as someone who provides wise and practical counsel in
nonpunitive ways and, when the situation calls for it, acts with moral
courage.
Practical Considerations
Personnel
We recommend that only well-qualified and experienced persons
participate in clinical ethics rounds. Because bioethicists who round are
going to have to earn the trust and respect of the most senior physicians,
and be able to do so in a reasonably short time frame (or the bioethicist
will be labeled unhelpful and quickly marginalized), we recommend that the
rounding bioethicist have a terminal advanced degree, that is, Ph.D., MD,
or JD, to better ensure developing the trusting relationships with the
attendings that are critical to success. We recommend also that the
bioethicist be highly experienced in the clinical medical setting. That is
not to say that the rounding bioethicist needs to be a trained and/or
licensed clinician. Sometimes it is to the rounding bioethicist's
advantage not to be a clinician by previous training. But the rounding
bioethicist must be knowledgeable of the clinical setting and understand
enough medical terminology to grasp what is going on with the patient. On
rounds, discussions of a patient's condition will be presented fast,
in technical, medical language. There is no time for translation. Slowing
down rounds is something to be avoided. Having a substantive ethical
discussion about a particularly complex medico-moral aspect of a
patient's care that has immediate relevance for medical
decisionmaking is the only acceptable reason to slow down rounds. A
bioethicist's ignorance of the medical facts is never acceptable.
Logistics
The logistics of rounding will have to be worked out in ways that are
most appropriate to each practice setting in which they arise. There may
be minimum requirements, however, to assure that the purposes of having a
bioethicist can be achieved through the means proposed in this paper.
Concerning where in the hospital to start rounding, we recommend intensive
or critical care units (ICUs or CCUs), medical and surgical, adult,
pediatric, and neonatal, first, covering geriatric and obstetrical units
next. These are the busiest, have the sickest patients, and present the
most ethically complicated cases in the hospital. Decisions often have to
be made hourly because the patient's clinical status is changing that
fast or faster.
Frequency of having the bioethicist on rounds should be at least once
a week. Attending regular unit rounds once a week assures that the
bioethicist gets to know everyone. Familiarity with unit processes assures
comfort but, by being there only weekly, assures, also, that nobody
becomes dependent on the bioethicist for routine ethical analysis. Being
available by beeper increases unit comfort. Also, it does not appear
necessary to set a rigid schedule as to what day of the week the
bioethicist will round. In fact, it may be better to set a default day but
run a schedule where some weeks the bioethicist rounds on a nondefault
day, rounding occasionally on each day of the week, including weekends.
That way the bioethicist learns how the unit's functioning fluctuates
throughout the week and, as long as the bioethicist is faithful to once
weekly, the staff grows comfortable with him/her coming on and off the
unit.
Being there when rounds start is the goal. But because different
attendings have differing schedules and emergencies occur regularly,
making a good faith effort to be there when rounds start, and hitting the
mark with reasonable frequency, is an acceptable standard to set. But once
there, the bioethicist needs to stay through rounds. Ordinarily, there is
a rhythm to rounds and one can estimate what the general length of rounds
is going to be. But codes and other interruptions will simply mean that
rounds will last longer. The bioethicist will need to keep her/his
schedule flexible on the day she/he rounds so that once on rounds, the
bioethicist stays to the bitter end.
Costs
Rounding is not going to be cheap. Hospitals have been trying to
shoehorn the costs of ethics services into invisible crevices since ethics
services started appearing in hospitals. Often there is no explicit line
item in a hospital's budget for an ethics committee. They are a
virtually unfunded mandate.
Although we strongly urge not connecting cost cutting with quality in
healthcare, we recognize that for non-income-generating activities to be
sustainable, they need to contribute to sound resource management. We
predict that having a bioethicist on rounds will make this kind of
contribution.6
Schneiderman LJ, Gilmer T,
Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics
consultation on nonbeneficial life-sustaining treatments in the intensive
care setting: A randomized controlled trial. JAMA
2003;290(11):1166–72.
That we predict having rounding bioethicists will save costs does not
mean that the service will be inexpensive. Bioethicists should be paid
respectably. If one calculates the salary for one bioethics FTE (full-time
equivalent position) at 40 hours per week for 52 weeks per year, that
equals 2080 hours annually. The time for bioethics professionals as
voluntary addendums to a clinical ethics service is over. Less than fair
compensation will inevitably result in undercutting the professional
standing of the bioethicist as an integral part of the team.
Limitations of the Rounding Model
Having a bioethicist on rounds is not, however, a panacea. Perhaps the
most obvious and significant limitation of the rounding model is that it
is heavily skewed towards physician training. In the standard process of
rounds, the case is presented to the supervising attending by the
responsible resident (or other clinician in hospitals without resident
training programs). Thus, the bioethicist's focus is most heavily on
the clinician presenting the case and the attending. Depending on
institutional custom, rounding may or may not include
clinicians/managers from nursing, social work, and other disciplines.
If not, supplemental ethics education by other mechanisms designed to
engage these disciplines will be needed. A related point is that this
model does not include much, if any, interaction with patients and/or
surrogates. This may or may not be a limitation of the activity.
Another limitation is the prospect for having the rounding bioethicist
co-opted by the clinicians, that is, simply becoming a parrot of the
recommendations and decisions most preferred by some or other members of
the team. This is akin to the problem that the mediation model of
consultation is designed to avoid, that the process lacks formalized due
process and is therefore open to problems of bias of the rounding
bioethicist. Having the bioethicist co-opted by the physicians and/or
perceived by others (patients, families, other providers) to have been so
co-opted will be damaging to the credibility of the bioethicist and have
negative spillover onto other bioethicists and/or bioethics activities
in the hospital. Also, were co-opting to occur, problems such as the
bioethicist being used as a front for shielding sub rosa fiscal
reasons for limitations of care could emerge. Relatedly and more commonly,
however, is the concern that having a bioethicist on rounds is biasing in
the same way as having a “lone ranger” ad hoc clinical ethics
consultant can be biasing. Any time only one voice is heard the potential
for swaying others based on bias rather than well-articulated and full
argumentation is a disturbing possibility.
The final limitation we readily see, however, will come out of an
embarrassment of riches rather than as a result of flaws in the model,
itself. That is, if, as we suspect, rounding becomes a more widely offered
and utilized clinical ethics consultation and training service, there may
not be enough bioethicists to go around.
Next Steps
It will be important to begin shaping the model so it can be
replicated and tested. To do so, we recommend placing it into the context
of the notion of treatment fidelity.7
Bellg
AJ, Borrelli B, Resnick B, Hecht J, Minicucci DM, Ogedegbe G, et al.
Enhancing treatment fidelity in health behavior change studies: Best
practices and recommendations from the NIH behavior change consortium.
Health Psychology 2004;23:443–51.
Shaping the
rounding model in this direction requires decisions about its
“active ingredients” or core elements, and their dosage, that
is, what elements of rounding, in what amounts, are optimal for producing
the desired outcomes? Components thought to be important include (1)
regular consideration of routine ethical issues; (2) goals of care
congruent with a patient's clinical status and prognosis; (3) ability
of caregivers to identify, analyze, and address situations that are
potentially or actually ethically problematic; (4) follow-up and revision
of previous plans as conditions dictate; and (5) reflection as a team on
the accumulating consensus in the unit for handling ethical issues. Dosage
refers to the number, frequency, and length of contact. Weekly rounding
assures that most patients will be seen and most residents will be exposed
to explicit ethics discussions. Amount of discussion on each patient will
reflect time needed to resolve medical and ethical questions for a
satisfactory plan of care.
Much work remains to be done to optimally develop
“rounding” as an ethics service and to test the most efficient
use of resources to yield important outcomes. For example, more work is
needed to fully flesh out the outcomes so that they can be better
quantified and evaluated. These are anticipated to include the following:
- Ethical conflict avoided as evidenced by decreased numbers of
nondilemmatic ethics committee consults, legal actions, and reduced moral
distress
- Ethically appropriate care of patients—such outcomes as having
reasonable patient preferences actually enacted and consent be
informed
- Ethically appropriate involvement of patients'
families/significant others—their understanding of surrogacy
sufficient to play supportive role to patient
- Development of ethical analysis skills in staff
- Ethically supportive institutional policies and climate, and
self-efficacy on the part of all parties in carrying out their
practice
- A sense of shared history in consensus about appropriate resolution
of paradigm cases and accumulation of resolutions reflecting reasonable
laws and institutional policy/practice.
In summary, we have argued that it is now time to focus more attention
on rounding as the preferred model for routine ethics case consultation
and professional training for a number of reasons. Having bioethicists
integrated into regular unit rounds can be expected to (1) advance the
goals of the field to strengthen ethical patient care practices; (2) teach
bioethics to clinical professionals more effectively on a routine,
day-to-day basis, than does the ethics committee case consultation model;
(3) avoid or reduce the conflict that is the trigger for most ethics
committee consultations; and (4) allow the present model of ethics
committee consultation to be applied more judiciously, targeting full
committee and/or subcommittee case consultation to only the most
complex cases. Rounding is tied to the care of real patients in real time
and promises to address routine ethical issues early in a patient's
stay, well upstream of problems that could generate the kind of conflict
resulting in downstream logjams of repetitive, after-the-fact, less than
effective ethics committee consults.
