Medical ethics, patient agency and clinical excellence

  • 19 November 2024
  • 4 minutes

“The three are completely symbiotic,” says Gonville & Caius College Fellow Dr Zoë Fritz (Medicine 1995) and a Wellcome Fellow in Society and Ethics at The Healthcare Improvement Studies (THIS) Institute.

Zoë is a consultant in Acute Medicine 40% of her time, working as a diagnostician, and spends 60% of her time as a researcher in Applied Clinical Ethics, as well as directing studies at Caius, and teaching. Her research is prompted by observations from clinical practice. 

She adds: “I look at the way that doctors and patients interact and some of the systems that we have in hospitals in particular. I work to try to identify problems with clinical practice and conduct research  to develop better ways. By which I mean more ethical, more autonomy respecting, more equitable. I then test them using empirical methods to assess the impacts of the change, looking for the desired improvements, but also checking for unintended negative consequences.

“I combine applied clinical ethics research with clinical work. That means I keep on seeing how we're doing things and keep on coming up with new ideas of what needs to be challenged. I also teach, and I find the medical students are brilliant instigators of  questioning medical practice because they're not inured to the way we do things.”

The incoming perspectives of medical students, questioning established processes, combined with clinical work and empirical research, has proved invaluable in putting the patient experience first. Zoë’s work has spanned  examining do not attempt cardio pulmonary resuscitation orders (DNA CPRs), how recommendations are made on referrals to intensive care, new approaches to transplant donations, communicating uncertainty in diagnosis and recording the medical history, all of which have implications on patient agency and trust between the patient and the doctor. The progression to a digital age and use of Artificial Intelligence (AI) in diagnosis is another area of interest.

No matter the subject or application, the ethical questions are of paramount importance, and work in collaboration with colleagues in Philosophy and Law supports Zoë’s research and any recommendations made. 

A clear example of Zoë’s work, and its impact, is with ReSPECT, which stands for Recommended Summary Plan for Emergency Care and Treatment. When she was a registrar, Zoë noticed patients who had DNA CPRs “were being unofficially triaged to ‘do not bother’”. Zoë adds: “We found lots of evidence that patients with DNA CPRs weren't getting treatment that they might benefit from. This was clearly an ethical problem.”

Rather than a red DNA CPR form in a patient’s notes, an alternative approach was devised.

Zoë adds: “I introduced this idea that instead of just thinking about CPR, we should be changing the focus of the conversation and the documentation to overall goals of care. The most important thing in recommending what treatments a patient might benefit from is understanding what outcomes the patient values, and what outcomes they fear. We can respect those preferences, and then provide our clinical judgement about treatments to align with those goals.”

Proposing and delivering change can be challenging. The initial research study was received coolly, with medical professionals hesitant about time constraints. When it ended, and medical professionals at the hospital where the project took place were told they could go back to the former method, the reaction spoke volumes. “I got a flood of emails – totally abandoning all the anonymity we had carefully preserved – from clinicians saying going back to the old way would be a retrograde step,” Zoë says. 

Zoë worked with Resuscitation Council UK, presented to the Parliament Health Select Committee, the British Medical Association and the General Medical Council as ReSPECT was developed.

She adds: “It was a reasonably simple change, but it changed the nature of the labelling and it changed the treatment that the patients received from both nurses and doctors. The number of objective harms to the patient were dramatically reduced, nearly halved.

“This was an important empirical finding, and we then had to work with patients, doctors, nurses, resuscitation officers, everybody who might be involved, to try and iterate it to make it an acceptable practice that wouldn't have negative unintended consequences.”

ReSPECT is now in 70% of integrated care boards in England, is being introduced in Northern Ireland, has a presence in Scotland, and is being translated into Danish and Czech.

Zoë’s research sometimes explores less obvious medical matters. A student who volunteered at food banks applied to do a project with her.

“We did a project looking at whether doctors, as part of their history taking, should ask about food,” she says. “We ask about alcohol, we ask about drugs, and we ask about smoking, but should we be asking whether people have enough food? Asking when you discharge a patient whether they have food in their fridge is one of the best indicators of whether they will end up being readmitted. 

“That was an excellent example of a student finding a question that was really important and we've published a paper together on that.”

It was also an excellent example of why Zoë benefits from her multi-faceted career.

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