Should physicians be allowed to practice on dying patients?
Respect for dignity, family must be maintained
In the past, patients who died in the hospital often were considered the perfect opportunity for less-experienced physicians and interns to practice difficult medical procedures.
"The medical profession used to be a lot more aggressive with newly deceased patients because it was seen as a really good way for students to learn," says Jorge Martinez, MD, FACEP, director of emergency medicine services at the Medical Center of Louisiana in New Orleans. Martinez is chair of the Dallas-based American College of Emergency Physicians’ ethics committee.
"They used to practice invasive procedures, central lines, things like that," explains Martinez. With time and the evolution of medical ethics, however, deceased patients are no longer viewed simply as learning opportunities, but as patients. Although no longer living, patients have some remaining rights, even if they are not the same as those a living patient would have, he says.
The tension between permitting medical students and residents to learn complicated medical procedures while providing patients with the best possible medical care is present in almost every area of a teaching hospital, adds Arthur R. Derse, MD, JD, FACEP. Derse is an emergency physician and associate director for medical and legal affairs at the Medical College of Wisconsin’s Center for the Study of Bioethics in Milwaukee. The issue becomes particularly difficult, Derse notes, when talking about allowing students to perform procedures or examinations on recently deceased patients. (For more on the practice of teaching on recently deceased patients, see story, p. 41.)
Procedures such as intubations, central line placement, and femoral catheterization, to name a few, are complicated and difficult to learn to do well on a mannequin or lab animal. Recently deceased patients offer the best opportunity to perform the procedures on a human form, with no chance of a mistake harming a patient.
"But, there is a real practical problem with getting consent here," he says, "and if we believe that people’s consent should be obtained before doing something to them, then there ought to be consent for this as well. But, this is not like organ donation, it is unlikely that someone will sign an advance directive ahead of time, saying If I am dead, go ahead and practice on me.’ And, it would be difficult to disclose to family members that, Yes, as long as your loved one was dead, we let our medical students try to intubate him.’"
The alternative, says Derse, is worse. Residents would have to practice the procedures on living patients, who need a skilled provider.
"[Practicing on deceased patients] is an ethical violation, but I think the violation is less than a number of other violations, and the benefit is great," he says. "I am not justifying it. I am just saying that I am grateful that the first mistake I ever made in intubation was made on a dog. I learned a lesson from that that I will never forget and I have never made a mistake in that way again, and I am extremely grateful for it."
Invasive procedures require family consent
Most physicians now feel invasive procedures should be avoided on deceased patients, say Martinez and Derse.
"I definitely would draw the line at anything that would disfigure someone," Derse says. "For example, in intubation, there is no disfiguration. What usually happens is you have the [teaching] physician take out the tube that was placed in the patient during the resuscitation attempt, and show the resident how to put the tube back in. I think once a person has died, intubation is the only thing you can look at."
Martinez is more specific in saying that it is possible to allow residents to visualize the trachea and other anatomy before seeking consent from the family.
"In other words, if we have a major trauma or something like that and the patient died, we have no problem saying the medical students and residents can use the laryngoscope and look inside the mouth and at least see the anatomy of the patient," he notes. "We don’t do anything else; we don’t do chest tubes, or peritoneal lavage, or anything else that would cut the skin. If we cut the skin, we have to ask the family for permission to do that."
Asking for consent
Experts are divided on when, how, and whether to seek consent from surviving family members in order to perform procedures on the recently deceased.
Derse, who advocates only practicing intubation on deceased patients, says he recommends a policy of informing a patient’s family if they ask, but not necessarily seeking permission upfront. "Certainly, I think there should be full disclosure. That is, if someone asks if something has been done, they should be told. Maybe you want to have a general policy that it is known that it is done."
Lauris C. Kaldjian, MD, assistant clinical professor of medicine at Yale University in New Haven, CT, questions whether there is an appropriate way to approach a grieving family with this request. "Most families are not in the existential position when their loved one has just died to somehow switch gears and say, Oh, my loved one is no longer here; that could be anyone’s body.’ I do not think that is how we work as human beings."
Some physicians do advocate seeking permission from the family at the same time permission is sought to donate organs or perform an autopsy, he notes. "We already have protocols for that very difficult discussion, and there might be a way that we could, sensitively, incorporate this question into that protocol," he says.
However, waiting after informing the family of the patient’s death may work against the clinical educational value of any procedures, he adds. "After a certain amount of time, you have changes in the body, in the way the fluid settles and rigor mortis sets in, that will prevent certain procedures from being performed. But, you have to ask yourself, Is this really the only way to teach these procedures?’"
Martinez says physicians at his institution do, on occasion, ask family members for permission to practice procedures.
"First, you explain to them that their family member is deceased," he says. "There, the statement is, We would like to allow our student doctors and our residents to advance their knowledge by being able to do this procedure.’"
In many cases, the family is willing, and some have consented to further procedures. In some cases, the physician determines the family should not be approached with the request, he says.
"If you cannot get permission or, for some reason, do not want to ask, it is too difficult to walk in there and ask a family that has just lost someone that question," he says. "Then, what you do is just look at the [body] as a specimen and instruct the students about where the anatomy is, but you do not probe it in any way." (For more on emerging technology to assist in teaching, see story, p. 43.)
Teaching hospitals must pay special attention to the way in which physicians are allowed to treat deceased patients, because they are really learning more than just how to perform procedures, Martinez and Kaldjian state.
"The attitude the physician has to the patient is very important," Martinez says. "The way you deal with the deceased patients will reflect largely the way you deal with living ones."
For doctors in training, it is especially important that respect for the patient as an individual be reinforced, adds Kaldjian. "If you allow a time that patients are seen solely as vehicles for educational purposes, I think that is not helping the already challenging task of helping these students treat patients with full respect."
The strong foundation in medical ethics found at most medical schools will help prevent abuses of power related to practicing medical procedures on vulnerable patient populations, including deceased patients, adds Martinez. "The concept that the patient is a participant in their health care, and it is not just up to the physician, has really been emphasized in the medical literature and actively taught now in the medical schools," he says. "The younger students and residents tend to be much more aware than older doctors for whom that issue was not addressed as much."
Frequently, residents and students express a great degree of caution when he suggests examining the anatomy of a deceased patient. "It is almost at the point where every time we say, Why don’t you go ahead and take a look at the [vocal] cords,’ the student will look up and say, Is it OK?’"
Written protocols should not be necessary if the proper foundation of respect for patient autonomy, patient participation, and informed consent is communicated throughout the institution, Martinez says. "It’s like having a written rule that you don’t spit in a patient’s face or call them demeaning names. You have to communicate what behavior is immoral and reinforce that through [setting a personal example]."
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• Jorge Martinez, MD, FACEP, Medical Center of Louisiana, 1532 Tulane Ave., New Orleans, LA 70112.
• Arthur R. Derse, MD, FACEP, Center for the Study of Bioethics, 8701 Watertown Plank Road, Milwaukee, WI 53226-0509.
• Lauris C. Kaldjian, Yale University School of Medicine, 320 Temple St., New Haven, CT 06520.