Correspondence
Using Newly Deceased Patients in Teaching Procedures
N Engl J Med 1995; 332:1445-1447May 25, 1995
- Article
To the Editor:
In their Sounding Board article on the use of newly deceased patients in teaching resuscitation (Dec. 15 issue),1 Burns and colleagues conclude that permission must be obtained from the next of kin. This is in contrast to the position of Orlowski et al.2 We believe that it is appropriate to make a clear distinction between intubation techniques, which require lax neck tissue, and the other resuscitation techniques, which can easily be practiced on a body with rigor mortis.3
The key question is whether the public accepts the use of newly deceased patients to teach intubation. In our study of a random sample of the general population in Norway, a majority of the 971 respondents (58 percent; 95 percent confidence interval, 55 to 61 percent) said they would allow the body of a close relative to be used for teaching intubation techniques.4 The fact that some U.S. hospitals have been using newly deceased patients to teach emergency procedures without obtaining consent is consistent with the results from Norway.5 There is a need for a clear and open policy on these matters.
As Orlowski et al. stated, an exception to informed consent must be permitted for the teaching of intubation. With open disclosure that this practice is both necessary and important, patients will have the opportunity to refuse the procedure by advance directive.2
We strongly disagree that a request for consent to use a deceased patient in teaching resuscitation procedures should be made when the relatives are confronted with the death. This practice would only add to the family's stress. The points made by Burns et al. apply to the more mutilating procedures, which we agree should be performed only after informed consent has been obtained.
5 ReferencesGuttorm Brattebø, M.D.
Haukeland Hospital, N-5021 Haukeland, NorwayTorben Wisborg, M.D.
Hammerfest Hospital, N-9601 Hammerfest, NorwayNina Øyen, M.D., M.P.H.
Haukeland Hospital, N-5021 Haukeland, Norway1
Burns JP ,Reardon FE ,Truog RD . Using newly deceased patients to teach resuscitation procedures. N Engl J Med 1994;331:1652-1655
Full Text | Web of Science | Medline2
Orlowski JP ,Kanoti GA ,Mehlman MJ . The ethics of using newly dead patients for teaching and practicing intubation techniques. N Engl J Med 1988;319:439-441
Full Text | Web of Science | Medline3
Brattebo G ,Seim SH . Teaching and training of invasive procedures on cadavers. Lancet 1988;2:1078-1079
CrossRef | Web of Science | Medline4
Brattebo G ,Wisborg T ,Solheim K ,Oyen N . Public opinion on different approaches to teaching intubation techniques. BMJ 1993;307:1256-1257
CrossRef | Web of Science | Medline5
Brattebo G ,Wisborg T . Instruksjon og øving av akuttmedisinske prosedyrer på nylig avdøde. Tidsskr Nor Laegeforen 1990;110:1380-1381
Medline
To the Editor:
Three facts justify using the dead to practice and teach nonmutilating procedures.1-3 First, a corpse merely symbolizes the person who once occupied that shell.4 Unlike the living patient, a corpse cannot be physically harmed. Many clinicians learn and practice lifesaving medical procedures on the living, often in operating rooms or intensive care units.3 These patients can be harmed and are often placed in harm's way without their knowledge or consent. Beneficence and nonmaleficence, as well as a basic respect for persons, suggest that practicing on the newly dead represents a much better alternative.
Second, corpses rarely remain in the hospital unit — especially the emergency department, where Burns et al. found the practice most common — very long after death.1-3 Logistics do not allow a delay in the removal of a body.
Third, experience shows that the requirement for consent often prevents postmortem practice and teaching.5 Physicians find it stressful to discuss death, especially unexpected death, with families. They only reluctantly request consent for autopsies and organ or tissue donation. This stress is compounded if the physician has never before interacted with the family or the patient.
If clinicians must either abandon learning or practicing on new corpses or obtain permission before doing so, I fear one of two alternatives will occur. New clinicians will not learn how to perform lifesaving procedures or practice on living patients will increase. Using the newly dead offers our best hope of teaching lifesaving skills to clinicians while doing the least harm to our patients.
5 ReferencesKenneth V. Iserson, M.D.
University of Arizona Health Sciences Center, Tucson, AZ 857241
Iserson KV . Life versus death: exposing a misapplication of ethical reasoning. J Clin Ethics 1994;5:261-264
Web of Science | Medline2
Iserson KV. Death to dust: what happens to dead bodies? Tucson, Ariz.: Galen Press, 1994.
3
Iserson KV . Postmortem procedures in the emergency department: using the recently dead to practise and teach. J Med Ethics 1993;19:92-98
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Feinberg J . The mistreatment of dead bodies. Hastings Cent Rep 1985;15:31-37
CrossRef | Web of Science | Medline5
Perkins HS ,Gordon AM . Should hospital policy require consent for practicing invasive procedures on cadavers? The arguments, conclusions, and lessons from one ethics committee's deliberations. J Clin Ethics 1994;5:204-210
Web of Science | Medline
To the Editor:
I do not agree with Burns et al. that “permission must be obtained to use newly deceased patients in teaching resuscitation.” I cannot see how such permission can truly be secured without tarnishing the rapport between doctor and patient. I see no adequately sensitive way that such an awkward issue can be raised.
I particularly take issue with the proposal that informed consent be required. Practicing lifesaving procedures on humans is very helpful. As a resident, I frequently witnessed and participated in such practice after unsuccessful resuscitations. That experience improved my ability to intubate live patients.
I favor the “Don't ask, don't tell” practice of resuscitation techniques behind closed doors. This approach educates physicians. Without it, fewer young doctors will learn how to intubate patients, because they will not wish to go through the difficulties of obtaining informed consent.
Jeffrey M. Bloom, M.D.
San Luis Medical Clinic, San Luis Obispo, CA 93401To the Editor:
When I first heard of the value of using newly dead patients to train physicians in resuscitation techniques, I thought of incorporating permission for such training in my living will, but did not know how to do so. The state I live in has recently legalized living wills, and Burns et al. provide a policy for practice on the newly dead. As a layperson, I think that the provision in a living will for such training is a natural extension of the provision for organ donation or an autopsy and that disfigurement is a trivial concern (provided that facial features are undisturbed out of respect for the next of kin). The authors should suggest suitable wording to add to living wills, which could include a provision for the use of the body for any other techniques and procedures that would be of value.
Leonard Finegold
Drexel University, Philadelphia, PA 19104To the Editor:
Burns et al. mention that “no state statutes . . . specifically prohibit the teaching of procedures with the use of newly dead patients.” A review of Canadian law reveals legal statutes that suggest family consent is required before a resuscitation procedure is practiced on a dead body. The Human Tissue Gift Act of Ontario states that consent is required in order for “the person's body . . . [to] be used after the person's death for therapeutic purposes, medical education, or scientific research.”1 Ontario law also requires the medical examiner's agreement to “alter the body” of a person who has died.2
As the authors state, the use of newly deceased patients to teach procedural skills “must be the culmination of a structured learning sequence.” Thus, candidates will have mastered the various steps that are part of the procedure and will have corrected any defective skills before actually performing the procedure.
The safest legal and ethical approach that addresses these concerns is a policy that meets the needs of each institution and training program while ensuring that the newly deceased are treated with respect. Certainly, the various restrictions suggested by the authors as part of their proposed guidelines must be examined by policy makers before they adopt any regulations.
2 ReferencesChristopher M.B. Fernandes, M.D.
St. Paul's Hospital, Vancouver, BC V6Z 1Y6, CanadaAuthor/Editor Response
The authors reply:
To the Editor: We appreciate the comments of Drs. Bloom and Iserson, which underscore our point that newly dead patients can offer “opportunities to practice resuscitation techniques that are difficult or impossible to learn in other ways without exposing living patients to additional risk.” We also share the concern expressed by Brattebø et al. that seeking permission from family members to practice resuscitation procedures may generate additional stress, “adding to the family's emotional trauma at a time when medical staff should be most concerned about reducing it,” as we note in our article.
Two of us, as practitioners responsible for patient care and the training of residents and fellows in busy pediatric intensive care units, have found that there is never a good time to approach a family for permission to perform an autopsy or remove organs for donation. Yet, just as one would never perform an autopsy or remove organs without the family's permission, regardless of the benefit to others, one should not teach resuscitation procedures without the family's permission.
There is no evidence to support Dr. Iserson's statement that seeking permission to practice procedures on newly deceased patients “prevents postmortem practice and teaching.” Indeed, the two studies in the literature that examined this issue found just the opposite. McNamara et al. recently reported the results of their study in which consent was requested from 44 families of newly deceased patients to perform wire-guided retrograde intubation; 26 families (59 percent) gave permission. The authors note that consent was obtained “despite the lack of a prior relationship with the family by the persons requesting consent.” In addition, the authors noted that consent was obtained more frequently in unexpected than expected deaths (77 percent vs. 41 percent, P = 0.03).1 These results are similar to those reported by Benfield et al., who found that 73 percent of parents gave permission for the use of their newly deceased children in teaching intubation skills in a neonatal intensive care unit, including several parents who consented to the intubation procedures but not to an autopsy.2
Although we have not previously considered the viewpoint expressed by Mr. Finegold, a statement allowing the performance of nonmutilating resuscitation procedures for training purposes in an advance directive would be in accordance with the recommendations outlined in our article.
Dr. Fernandes's comments are very informative. We were unaware of the specificity of the Canadian statute and believe that it provides additional support for the policy we have put forth. We reiterate that resuscitation procedures should be taught on newly deceased patients only when other options are inadequate and should be subject to the restrictions outlined in our policy proposal.
2 ReferencesJeffrey P. Burns, M.D.
New England Medical Center, Boston, MA 02111Frank E. Reardon, J.D.
Hassan & Reardon, Boston, MA 02116Robert D. Truog, M.D.
Children's Hospital, Boston, MA 021151
McNamara RM ,Monti S ,Kelly JJ . Requesting consent for an invasive procedure in newly deceased adults. JAMA 1995;273:310-312
CrossRef | Web of Science | Medline2
Benfield DG ,Flaksman RJ ,Lin T-H ,Kantak AD ,Kokomoor FW ,Vollman JH . Teaching intubation skills using newly deceased infants. JAMA 1991;265:2360-2363
CrossRef | Web of Science | Medline
- Citing Articles (4)
Citing Articles
1
Georgene W Hergenroeder, Bettina C Prator, Alice F Chow, David J Powner. (2007) Postmortem intubation training: patient and family opinion. Medical Education 41:12, 1210-1216
CrossRef2
Joal Hill. (2003) Consent for teaching procedures. The Lancet 362:9387, 924
CrossRef3
Mark W. Fourre. (2002) The Performance of Procedures on the Recently Deceased. Academic Emergency Medicine 9:6, 595-598
CrossRef4
Craig A. Manifold, Alan Storrow, Kevin Rodgers. (1999) Patient and Family Attitudes Regarding the Practice of Procedures on the Newly Deceased. Academic Emergency Medicine 6:2, 110-115
CrossRef
