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Apr. 23, 2003 - It’s a typical day in the ER when Carter finds out he has been assigned to precept a new group of excited medical students assigned to their ER rotation. The students are awaiting their patient assignments when a paramedic crew bursts through the door with a middle-aged man complaining of chest pain. Carter turns immediately to the patient, firing off questions about his cardiac risk factors. When asked how many heart attacks he has had in the past, the patient responds, “you mean including the one I’m having right now?” The patient is medically stabilized with nitroglycerin and oxygen and the students scurry off to interview their patients.

Carter’s shift doesn’t go very well despite help from the eager students. He is urgently summoned back to the room of the chest pain patient who has a code blue (cardiopulmonary arrest). He begins to resuscitate the patient only to be interrupted by Carrie who has taken a phone call in Carter’s absence relaying the news of his grandmother’s death. She tries to get his attention but Carter intensifies his activity. Eventually Carter looks up at Carrie and she says, “I’m sorry, it’s your grandmother, she died.” Without missing a beat, Carter deftly moves around the patient giving medication orders and firing up the defibrillator. The medical students watch in awe but one remarks, “if you don’t get him back after 3 shocks, his chance of survival is zero.” Carter responds, “well watch me” and attempts defibrillation again, this time with the return of the patient’s heart beat. A nurse observes that the patient’s pupils are “fixed and dilated” indicating likely brain death after a prolonged resuscitation. He issues a few final orders and then leaves the room abruptly to deal with his own emotional anguish.

Carter tries to disentangle himself from his ER responsibilities so he can deal with his own grief and see his family members. He reassigns the medical students to Romano. On his way out of the ER, Carter walks past the resuscitation room where the students have suited up in sterile gowns and are practicing invasive procedures on the resuscitated patient who remains on life-support. Romano is barking from the sidelines, “If you don’t learn to do this now, you’ll never be able to save anyone.” Carter is furious and orders them to stop. “This is not a cadaver lab” he shouts. Romano retorts that the patient will die anyway but he leads the sheepish students out of the room. The cardiac monitor shows that there is no longer a heart beat and a dejected and exhausted Carter turns off the life support systems.

Without adequate training opportunities, medical students and resident physicians cannot become competent in performing medical procedures. This is especially true in the case of life-saving procedures during a medical resuscitation where the opportunities for practice may be few and far between and the highest level of skill is needed to provide the best chance for success and to minimize any harm to the patient. Life-saving procedures which commonly fall into this category are endotracheal intubation, central venous catheter placement, venous cutdown, pericardiocentesis, intraosseous catheter placement, thoracostomy tube placement, cricothyrotomy, and thoracotomy with cross-clamping of the aorta. The latter two procedures are never performed on a non-emergent basis. Certain medical specialties such as emergency medicine, critical care, and neonatology, have the greatest need for practice opportunities due to the likelihood of having to perform these procedures in practice.

In some situations, residents and medical students may learn to perform life-saving procedures on a person who has died very recently (newly deceased), perhaps immediately after an unsuccessful resuscitation when the patient has been pronounced dead. This training method has been proposed by some medical educators as optimal for several reasons. First, after death, the patient is no longer exposed to additional harm or risk. Second, before rigor mortis sets in, the tissues of the body will remain pliable and best approximate the conditions under which the procedure is normally done. This has been argued to be especially true for the skill of endotracheal intubation, where cadaver and manikin models for training have not been found to be as useful. Finally, the supervision and teaching of the procedure can be done under less stressful conditions so the chance for success is maximized.

Currently, there are many training institutions which allow the practice of life-saving procedures on the newly deceased. A 1994 survey of emergency medicine and adult and pediatric critical care training programs indicated that 39% used this method for teaching resuscitation procedures. Emergency medicine and neonatology programs used it most commonly and tracheal intubation was the most common procedure performed. This practice is not, however, without significant controversy and has been discussed at length in the medical literature particularly with regard to the issue of informed consent. Should survivors (family members, next of kin) be asked for permission before a procedure is performed on a newly deceased person?

Arguments in favor of practicing procedures on the newly deceased without prior consent cite substantial benefit to society without risk to the dead person. In addition, it is felt that seeking consent from families during the initial grief process would represent an additional burden for them increasing the amount of emotional stress when the medical staff should be taking steps to reduce stress and suffering. Are these reasons strong enough to make this practice ethically justifiable?

Many physicians have disagreed with the premises outlined above and advocate informed consent be sought in all circumstances prior to the use of newly deceased patients for procedural training. Society is already mistrustful of the medical community and frowns upon actions which operate under a veil of secrecy. To perform invasive procedures on a dead body without prior permission can easily be interpreted as being disrespectful to the dead. Although most procedures are minimally invasive and do not result in obvious disfigurement, families may indeed worry that this might interfere with funeral procedures. In addition, individual religious and cultural beliefs surrounding the handling of a dead body should be highly respected and preserved, and the process of requesting permission allows for family to object to the procedures on these grounds. Other members of the health care team, who do not use cadavers during training, may find it objectionable to perform procedures on the newly deceased without the express consent of the family. The process of seeking permission is respectful for these individuals as well.

The feasibility of obtaining informed consent from families who have just lost a loved one has been seriously questioned and used as a rationale for avoiding consent altogether. An important study by McNamara et al. demonstrated that obtaining informed consent from family members for the practice of procedures on newly deceased adults in the ED is indeed feasible. Consent for learning or practicing a specialized form of intubation (retrograde tracheal intubation) on patients who were dead less than 3 hours, was requested from the nearest relative of the patient either in person or on the telephone. Included in the consent discussion was the statement that there was no direct benefit to the deceased, and only a potential benefit to future patients. Families were also told that disfigurement would consist of a small hole in the anterior neck. If consent was obtained, an emergency medicine resident or student nurse anesthetist was permitted to learn the procedure under the supervision of the investigators with the prerequisite of having attended a classroom overview and demonstration.

Results of the McNamara study showed that 59% of the families approached agreed to the procedure. Consent was obtained more frequently for deaths in the ED as well as for deaths which were unexpected, surprising findings in light of the lack of prior relationship between families and physicians in these circumstances. Common explanations for refusal were that the patient had suffered enough or would not have wanted invasive procedures done. Reasons cited for granting permission were usually for potential benefit to other patients. In a similar study on consent for trainees to practice intubation in recently deceased neonates, rates of consent were as high as 73%. They may have been higher in this study due to the family’s long-term relationship with the medical staff. Surveys of the general public have also revealed that there is general support for using this technique in training settings with the less invasive procedures correlated to higher support for doing the procedure.

To date, there is no known legal statute which specifically limits or forbids teaching procedures on the newly deceased with or without consent. However, there are many compelling reasons why consent should routinely accompany this practice. In this episode of ER, the issue of consent was not even explored and the viewer was not aware of any family members being present in the ER. In reality, family members are often present during or shortly after the death of a loved one, and are the central focus of all post-mortem activities in the ER or other setting. Teaching procedures on the newly deceased helps to establish greater technical proficiency which may not otherwise be gained with respect to certain life-saving procedures, and clearly benefits physicians in training. This benefit may extend to society when another individual’s life can be saved by such a procedure. Asking for permission shows respect for the patient, the patient’s family and their values and may be the most ethical way to incorporate this practice into medical education. Carter’s dismay at finding his medical students practicing procedures on his patient with a failed cardiopulmonary resuscitation was obviously colored by the loss of his own grandmother, but highlights the inner conflict that physicians may experience as well.

References:

1. The Council on Ethical and Judicial Affairs of the American Medical Association. Performing procedures on the newly deceased. Academic Medicine. 77(12 Pt 1):1212-1216.
2. Oman KS. Armstrong JD 2nd. Stoner M. Perspectives on practicing procedures on the newly dead. Academic Emergency Medicine. 9(8):786-90.
3. Burns JP, Reardon FE, Truog RD. Using Newly Deceased Patients to Teach Resuscitation Procedures. NEJM 331(24): 1652-1655.
4. McNamara RM, Monti S, Kelly JJ. Requesting Consent for an Invasive Procedure in Newly Deceased Adults. JAMA 273(4): 310-312.
5. Brattebo G, Wisborg T, Oyen N et al. Using Newly Deceased Patients in Teaching Procedures. [Correspondance] NEJM 332(21): 1445-1447.
6. Benfield DG, Flaksman RJ, Lin T-H et al. Teaching intubation skills using newly deceased infants. JAMA 265:2360-2363.
7. Brattebo G, Wisborg T. Consent for Invasive Procedures in the Newly Deceased. [Letters] JAMA 274(2): 128-129.