Is it OK to 'practice' on patients who have just died?
From the April ACP Observer, copyright © 2003 by the American College of Physicians.
By Christine Kuehn Kelly
The headline in The Wall Street Journal last fall was designed to send a shiver down patients' spines: "Doctors Question Use of Dead or Dying Patients for Training." Similar media coverage, most of it prompted by a journal article that focused on the topic, bluntly asked whether doctors were abusing corpses.
When a patient codes, housestaff often perform medical procedures such as intubation and central line insertion. But when physicians try to resuscitate a patient, educators believe that giving trainees an opportunity to hone their resuscitation skills is a legitimate reason to continue working on the body—even after the patient has died.
Educators believe that giving trainees an opportunity to develop their resuscitation skills is a legitimate reason to continue working on patients' bodies after they die.
"Medical students have to learn lifesaving resuscitation skills somewhere," said Kenneth Iserson, MD, professor of emergency medicine and director of the bioethics program at the University of Arizona in Tuscon. "If they don't learn on cadavers that cannot be harmed, they will learn on the living, who can."
"Everyone agrees that procedural skills are an essential aspect of training," said Catherine Marco, MD, an emergency room physician at St. Vincent Mercy Medical Center in Toledo, Ohio, and chair of the American College of Emergency Physicians' ethics committee.
Young physicians need to be proficient in lifesaving skills such as endotracheal intubation, central venous catheter insertion and pericardiocentesis, she said. And interns and residents who haven't yet demonstrated skill in using the needle and syringe need to practice these lifesaving procedures.
"When I go into a code blue, I always try to involve the less experienced residents," said J.B. Svoboda, ACP Associate, a chief resident in the internal medicine program at the University of Missouri-Columbia. "I have medical students do compression or have interns put in a femoral line." These procedures take place only toward the end of the code after the team has done everything it can to save the patient, he said. "And I never do unnecessary things or re-do procedures."
A gray area
Increasingly, however, physicians and institutions are questioning the ethics of using the nearly or newly dead for training, especially when the patient has not given explicit prior consent. While consent is commonly required for most medical procedures, emergency resuscitation is the exception.
In general, families have legal rights to the corpse after death. Trainees might therefore risk legal trouble by performing procedures that are not medically necessary, such as removing and reinserting an endotracheal tube. And payers could view unnecessary procedures that increase hospital bills as fraud.
"This is a gray area that should get further attention," said Jeffrey T. Berger, FACP, director of clinical ethics at Winthrop University Hospital in Mineola, N.Y. Dr. Berger and colleagues looked at the ethical issues raised by training strategies in an article published in the October 2002 Journal of General Internal Medicine.
In the article, Dr. Berger and his colleagues concluded that "unconsented, unindicated training procedures on still-living patients are ethically unacceptable." The article also stated that current ethical norms do not support performing invasive procedures on the newly dead without prior consent.
Physician organizations have begun taking a hard look at the ethics of using patients' bodies for training purposes without consent. ACP and the American College of Emergency Physicians, for example, both plan to develop guidelines on the issue.
Pressure from student members led the AMA several years ago to adopt a policy stating that no one should perform training procedures on the newly dead without consent. The policy does not, however, prohibit training on the dying.
Some educators think the AMA policy goes too far. Dr. Iserson, for example, said that interns and residents—who may be the last line of defense for patients on their unit—need these lifesaving skills. And because many internists go on to practice in small communities where they often insert central lines and endotracheal tubes, he continued, residents must be able to competently perform the procedures before they leave training.
The AMA policy has already had a "chilling effect" on training, Dr. Iserson claimed. Some teaching institutions now prohibit using newly dead patients for training, while others have adopted more restrictive guidelines.
In some cases, policies have led to prolonged resuscitation of the dying, he pointed out. "It's horrific," Dr. Iserson said. "A team may be able to bring back the heart for a period of time, but it prolongs a patient's dying process."
While educators can teach lifesaving procedures without touching a human body, most physicians consider alternatives a poor substitute.
Winthrop University's Dr. Berger predicted that training opportunities could disappear if teaching hospitals toughen their consent requirements—leaving training programs searching for other ways to help residents learn resuscitation skills. While there are other options for teaching the procedures, most educators consider them a poor substitute for hands-on experience with the human body.
"Mannequins are far too expensive or aren't always available," Dr. Iserson explained. "The tough intubations cannot be learned on a mannequin. Variations in anatomy are difficult for even the most experienced physicians."
Some programs plan to use more bodies donated to science for training, but corpses do not demonstrate physiological responses such as fluid return. And although virtual reality computer models—like those used to train pilots—will eventually be good enough to train physicians, Dr. Iserson said, right now they're not an option.
Issues of respect
Because many educators believe practicing on the dying and dead is still the best way for residents to hone their resuscitation skills, some programs are looking for ways to continue using the training technique.
Raising trainees' consciousness is a first step. "Most housestaff don't even perceive these as ethical issues," said Dr. Berger. "To keep the public's trust, programs and residents need to be proactive and think about ethical implications."
Maintaining a respectful attitude can go a long way. Patients and their families need to know that physicians see them as people, not specimens or interesting clinical puzzles. Educators say it helps to consider how you would want you own relatives to be treated in a similar situation.
"Keep the body covered appropriately during procedures," suggested Harmon H. Davis II, FACP, a pulmonologist in Cheyenne, Wyo., member of the College's Ethics and Human Rights Committee and Governor for the College's Wyoming Chapter. Make sure procedures don't disfigure the body or further distress the family, he said.
It's also important to respect patients' spiritual beliefs. Most physicians are aware that Jehovah's Witnesses will not accept blood products and that Orthodox Jews believe the body should not be invaded postmortem. The religious convictions of many other patients, however, may not be apparent to a resident rushing to a code.
"We try to honor the patient's cultural and religious beliefs, but we don't always know what they are," said St. Vincent's Dr. Marco. Physicians have to be flexible if the family provides more information, she added.
Many educators, however, say that the most important change programs can make is to require consent.
"Unauthorized use of the recently dead is desecration," said David A. Fleming, FACP, director of the center for health ethics at the University of Missouri-Columbia and a member of the ACP Ethics and Human Rights Committee. He suggested that trainees do procedures only if patients have given approval in advance to donate their bodies to science or to allow their bodies to be used in resuscitation training procedures. In lieu of prior consent, physicians should get approval from the patient's family following a death.
While families may be supportive of training, they want to know what is going on—so don't practice procedures secretly or without consent. "Never make the assumption that the family will want training to continue," said Dr. Fleming. "Don't get ahead of the family on this issue."
How do you go about getting consent? Most residents don't feel comfortable asking for permission, but studies have found that patients understand that physicians need to learn how to do emergency procedures on the dying or newly dead.
Open, honest communication can help, Dr. Fleming pointed out. When you are withdrawing care, you should already be in touch with the family.
If the situation seems appropriate, respectfully ask if the family would allow physicians in training to learn how to perform certain procedures as safely as possible. Explain that their loved one cannot be harmed at this point. If the patient has already died, express your condolences and explain the sequence of events.
You might say something like, "Your mother has gone, but there are other people she can help even now. There are certain procedures we use to help save lives. We would like to take this opportunity to do these procedures better. Would you agree to let her body be used to help train young physicians? Do you think your mother would mind?"
Dr. Fleming pointed out that families naturally tend to say, "She's been through enough." Before he gets such a response, he tells families exactly what the procedures would be, such as intubation. "And I tell them they would be welcome to be there with their loved one as we do this, so they will know she is being treated with respect."
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
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