Correspondence
Insertion of Femoral-Vein Catheters for Practice during Cardiopulmonary Resuscitation
N Engl J Med 2000; 342:1368-1370May 4, 2000
- Article
To the Editor:
Kaldjian et al. (Dec. 30 issue)1 raise a much more important question than whether residents in internal medicine should “practice” the insertion of central venous catheters without consent. Consider the training of emergency-medicine physicians in the performance of cricothyrotomy. This rarely performed, moderately difficult surgical procedure is truly lifesaving, but only if accomplished within seconds of the failure of other attempts to establish an airway.
Although there is evidence that the families of more than one third of patients who have recently died in the emergency department will consent to the performance of this procedure for practice,2 emergency physicians are reluctant, for many good reasons, to ask families for consent at that time.3 The result is that the procedure is not performed on those who have just died. Training relies on expensive and inferior animal models and usually one or two clinical experiences during an emergency-medicine residency. In general, the skills needed to perform this lifesaving procedure are deficient.
When I renewed my driver's license, with a simple signature I agreed to be an organ donor. Had I been asked whether I would like to be a cricothyrotomy-training model, I would have agreed without hesitation. Thus, my license could bear a second round, orange sticker. Next to the one saying “organ donor” would be another saying “airway trainer.” Then, if I should suddenly die, my wife (who presumably would be distraught) would not have to be asked for permission. I could help others not only by donating organs but also by having an emergency physician practice cricothyrotomy (under appropriate supervision, with respect, and with preservation of my dignity). Then, on some future shift, that physician might be better able to provide a surgical airway quickly and skillfully. And that might save someone's life. Maybe even, say, my son's.
For that I would like to give my consent — the next time I renew my license.
3 ReferencesStephen J. Playe, M.D.
Baystate Medical Center, Springfield, MA 011991
Kaldjian LC ,Wu BJ ,Jekel JF ,Kaldjian EP ,Duffy TP . Insertion of femoral-vein catheters for practice by medical house officers during cardiopulmonary resuscitation. N Engl J Med 1999;341:2088-2091
Full Text | Web of Science | Medline2
Olsen J ,Spilger S ,Windisch T . Feasibility of obtaining family consent for teaching cricothyrotomy on the newly dead in the emergency department. Ann Emerg Med 1995;25:660-665
CrossRef | Web of Science | Medline3
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 | Medline
To the Editor:
Kaldjian et al. state, “The performance of involuntary, nontherapeutic invasive procedures, including those performed during CPR [cardiopulmonary resuscitation], should be recognized as an unacceptable departure from a system of medical ethics that emphasizes the centrality of the patient's well-being and the need for informed consent.” But the patient's well-being is not an issue: the outcome is already determined. The insertion or noninsertion of a central venous catheter has no effect either way. And whose informed consent is needed? Do they mean the contemporaneous consent of the patient — clearly an impossibility since the patient is effectively, if not quite legally, dead — or the consent of the family? Even assuming that the next of kin is available, do the authors imagine that consent (or refusal of consent) given during resuscitative efforts to practice on a dead or moribund family member would ever be “informed”? And how is consent central to the issue when there is no risk or benefit to the patient involved but potentially very great consequences for other patients in the future?
With respect to any ethical question on which opinions are divided (as in this case), it is proper to conclude that no one should feel compelled to participate. It is not proper to act as a self-appointed authority to dictate what is “unacceptable” for others to do. If Kaldjian et al. are offended by the prospect that an insentient patient, soon to be dead, might be used for practice, perhaps they should consider the possibility that an all-too-sentient patient will die or suffer needlessly because his or her physician was denied the chance to attain maximal proficiency in a lifesaving procedure.
Michael Heller, M.D.
St. Luke's Hospital, Bethlehem, PA 18015To the Editor:
We have proposed that clinicians seek permission from family members to practice procedures on newly deceased patients.1 After the publication of our article, we heard reports that this proposal was often being circumvented by delaying the declaration of death in patients receiving CPR so that practice procedures could be performed by trainees. This may explain, at least in part, the finding by Kaldjian et al. that a quarter of all house officers surveyed at three internal-medicine residencies reported that they had observed the placement of nontherapeutic central venous catheters for practice during a resuscitation.
There is no evidence of a crisis in medical education with respect to the teaching of resuscitation skills that justifies practicing procedures without permission for the greater good of our society. Those who have studied the responses of families to requests for permission to practice procedures on newly deceased relatives have found that a substantial proportion will give their permission.2,3 Finally, the haphazard exposure of a few trainees to the practice, as described by Kaldjian et al., is an inadequate method for teaching and reinforcing procedural skills in training programs.4 Procedural skills are best learned through a structured training sequence that allows all trainees ongoing opportunities to enhance their technique and their confidence.
The loss of trust by the surreptitious use of the dying or the dead to practice nontherapeutic procedures will lead to further regulation of practices that will diminish our profession and damage the public good far more than the loss of a few haphazard teaching opportunities.
4 ReferencesJeffrey P. Burns, M.D., M.P.H.
Robert D. Truog, M.D.
Children's Hospital, Boston, MA 021151
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
Benfield DG ,Flaksman RJ ,Lin TH ,Kantak AD ,Kokomoor FW ,Vollman JH . Teaching intubation skills using newly deceased infants. JAMA 1991;265:2360-2363
CrossRef | Web of Science | Medline3
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 | Medline4
Walker A . Teaching junior doctors practical procedures. BMJ 1991;302:306-306
CrossRef | Web of Science | Medline
To the Editor:
How should the issue be resolved if the 66 percent of residents who oppose practicing femoral-vein catheterization on nearly dead patients during CPR cannot dissuade the 34 percent who favor it? I believe that a hospital policy banning such a practice is the only realistic solution. Such a policy would provide explicit institutional support for respecting patients and their bodies. A policy would also act as an important check on the temptation to practice procedures in a crisis. And, with the weight of senior faculty experience, authority, and consensus behind it,1 a policy would establish a high standard for physicians' behavior and thus guide residents during their early professional development. But resolution through policy would require strong, consistent faculty leadership.2 With this issue in medical ethics, as with many others, the first 95 percent of resolution is deciding what is right; the other 95 percent is doing it.
2 ReferencesHenry S. Perkins, M.D.
University of Texas Health Science Center at San Antonio, San Antonio, TX 78284-78791
Engelhardt HT. The foundations of bioethics. New York: Oxford University Press, 1986:39-49.
2
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
Author/Editor Response
The authors reply:
To the Editor: Our survey was not specifically designed to determine whether house officers considered the patient in the hypothetical scenario, 20 minutes after the start of CPR, to be dead or alive. However, 10 of the 234 participants expressed, unsolicited, a belief that the patient was already dead. That so few expressed this belief may imply that most house officers believe that patients receiving CPR are still alive or should be treated that way until they are declared dead. This conclusion is supported by the reasons offered by the majority of house officers (66 percent) who opposed the insertion of femoral-vein catheters for practice during CPR. Heller maintains that patients who do not have a response to CPR are, practically speaking, already dead and therefore no longer susceptible to harm or benefit. Whether a patient is considered alive or dead 20 minutes after the start of CPR, the purpose of CPR is to sustain or restore life. We believe that until death has been declared, a patient should be accorded the dignity and protections due to a person, not a corpse.
What happens after a declaration of death is another matter — one that involves respect for a corpse. Burns and Truog emphasize reasons for requesting permission to practice procedures on newly deceased patients, and Playe offers a practical way to circumvent physicians' reluctance to request consent from grieving relatives. Although requesting permission can be awkward and emotionally difficult, it need not be substantially different from requesting organ donation. The rationale is very similar in these two situations: it is to allow other patients to benefit from the life and death of the newly dead. If it is agreed that practicing procedures on the corpses of patients who have recently died is educationally valuable and constitutes good public policy, a request for consent could be included as part of the well-established postmortem dialogue that includes requests for organ donation and autopsy.
Lauris C. Kaldjian, M.D.
Yale University School of Medicine, New Haven, CT 06520Eric P. Kaldjian, M.D.
Parke-Davis Pharmaceutical Research, Ann Arbor, MI 48105Thomas P. Duffy, M.D.
Yale University School of Medicine, New Haven, CT 06520
