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Medical Ethics Question

One of my jobs is acting as a supervisor / mentor to the next generation of doctors – medical students in the final phases of their training.

Recently one of my students  (Anton Lavell) posed an ethical question – I think I know what my “position” is on this question.  But, I want to know yours!

Anton is writing his final year Medical Ethics paper – so I thought rather than just write a dry discussion – why not poll the readers of Broome Docs to ask what their ethical position is on the following:

Ethics Case:

One morning in the emergency department, Mr Smith, a 90 year old retiree is brought in  by ambulance after being found to be unresponsive on his bathroom floor, by his daughter. He has a background of ischaemic heart disease, atrial fibrillation, hypertension and osteoarthritis. On arrival at the emergency, he was initially tachycardic and hypotensive with a low GCS of E2V1M2. But was soon found to have no pulse. Advanced life support and CPR was commenced. Up until this time Mr Smith was being ventilated with bag and mask  and endotracheal intubation is being considered and about to be performed. However, the CPR being performed is seeming futile. Ultrasound showed no cardiac activity. The senior consultant decided to cease CPR. 

Whilst Mr Smith’s death is still being confirmed and documented. The registrar who was present at the attempted resuscitation, is eager to complete to the endotracheal intubation. Additionally, there are two interns present, who have limited experience in endotracheal intubation are eager to have a shot afterwards.

These subsequent practices can serve as important practice opportunities, that can increase a junior doctor’s competence, which will better equip them future situations, and may even prove to be life-saving. Many would argue, that deceased patients offer a unique consequence-free environment, if you will, in which to practice intubation, as no further harm can be caused. Additionally, if survival had seemed likely, the responsibility of intubation would normally go to the most experienced doctor. Hence, intubation opportunities for the vast number of doctors in training can seem few and far between.

Practicing medical procedures, such as endotracheal intubation on newly expired patients has been a traditional activity among training doctors (Berger et al., 2002). Consent for these procedures by next of kin is not commonly sought, but rather performed surreptitiously out of site from family or friends of the deceased (Berger et al., 2002). Yet, consent is generally considered a mandatory requirement for all medical procedures to be performed. But now that the patient is dead, does autonomy become less of an issue? Some could argue that  because corpses can not have autonomy violated and families’ have only limited authority over the decedent’s remains, unconsented training is permissible. Furthermore, discussion with family members to obtain consent may cause additional emotional stress.

 The use of corpses for training purposes may provide benefits for other living patients, as more experienced doctors may be less likely to fail or harm future patients. Since the patient is already deceased, there is no risk associated with failing to secure the airway, and any physical harm is inconsequential. Thus in a purely secular sense, maleficence is not an issue. However, such actions may be in direct conflict with various religious, spiritual and cultural beliefs or customs. Additionally, it offers no direct patient benefit and may damage public trust in the medical profession. 

Thus if the decision were yours, would you allow the registrar and two interns to practice endotracheal intubation on the now deceased Mr Smith? 

Is endotracheal intubation of deceased patients in emergency departments an acceptable practice?

OK, now I want you to put yourself in the shoes of the supervising Senior Doctor in this ED.  If you have a few minutes please complete the following poll, so we can get an idea about the spread of opinion out there and gauge the current ethical landscape of this practice.

Thanks for your time.  Comments are usually better for this type of thing – so let me know your practice.  Casey

THE RESULTS ARE IN:

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Comments

  1. Roger Browning says:

    No

    Do the benefits really justify the potential harm?

    Potential benefits?
    Will attempting to intubate this recently deceased man increase the skill set of these junior doctors and perhaps save a future patients life? I think this is unfortunately probably not true…..
    My first issue with this that intubation is not a life saving skill, ventilation & oxygenation are, and I would like to state these are better accomplished by other techniques (bag / mask or supraglottic device e.g. LMA) by most doctors who aren’t regular intubation practitioners. The learning of procedural techniques of any sort inclduing endotracheal intubation are best done in a structured well designed situation with appropriate discussion of all the issues involved including potential complications / equipment / pharmacology etc etcsurrounding. Perhaps this poorly structured quick surreptitious intubation will give these junior doctors a false impression of the ease of this procedure and actually cause harm to future patients in their care. Edentulous deceased 90 yr olds are usually pretty easy to intubate. What if in the future based on their newly found confidence at intubation they decide to skip bag mask ventilation or LMA and go straight for the gold standard “ETT”. For example the next weekend in the ED an apnoiec unconscious young adult who has overdosed on alcohol and GBH is brought in. Not surprisingly this young adult with teeth who hasn’t had muscle relaxants is actually a bit difficult, they think they can see the cords and so go for it but actually accidentally intubate the oesophagus. The capnography is not immediately available and as the resuscitation worsens they aren’t initially aware of their mistake and by the time they realise it is misplaced soem time later the patient has suffered irreversible hypoxic brain injury………

    Potential Harm:
    As above. Erosion of family and public trust I suspect if they became aware of it many would not approve.

    What if we changed the postulated question to:
    After the decision to cease CPR is made the junior staff ask if they can “practice” chest compressions on a real person as they have never done it before? I think I would probably support that for sure. Correct chest compression technique definitely improves outcomes and is a skill every health care worker should aim to be competent at….The patient has already been getting CPR and I think the family and public would just view this as a continuation of the resuscitation which was already occurring….

  2. Short answer -- no.

    Want to learn the motor skill of intubation -- then mannikin, elective cases in OT and then emergency cases/unsupervised lists to mastery

    It’s more than passing the plastic -- the learners need to understand the cognitive steps around airway planning and RSI…not intubating corpses

  3. Good question, but in my opinion, the answer is clear. Flat no.
    In the “old days” when sim, manikins, airway courses, other medical short courses, cool toys like VL’s and the internet/YouTube didn’t exist, maybe, but nowadays there’s no need. Whilst I only qualified as a specialist 3 years ago, and my training was seriously diminished by lack of real-world airway experience, (I blame that on being shunted through an 3-month anaesthetic rotation at a peripheral hospital where I only intubated about 10 patients, the rest were fasted elective cases with LMA’s), I would never let a trainee perform a procedure on a newly deceased patient.
    Anyone who would hasn’t been the first degree relative of someone who’s died in front of them. I have, twice, (and 2 x second degree relatives as well), and the shock, grief and emotion involved are overwhelming. To even consider interfering with a body in this setting, in the modern educational age defies any reasonable explanation.
    If I found out that some gung-ho ED doc tried to intubate my still warm but dead parent, while I was made to wait outside, then I’d take the tube and place it firmly into one of their non-respiratory orifices, with no lube. If anyone was insensitive enough to dare “ask for consent”, I’d do the same.
    The death of a relative, especially a parent as in this case, is a profound, life-changing event, no matter their age. To even consider disrupting the family’s experience of this is completely unnecessary, selfish, and pointless, when there are so many other avenues to learn practical skills.
    To anyone who thinks they’ve constructed a philosophical argument that says it’s OK, I say “ethics schmethics”, wait til your parent actually dies in front of you, then tell me you’d be happy to let a Registrar practice on their corpse while you and your family were made to sit in the hallway. No amount of philosophising can prepare you for reality.

  4. David Berger says:

    Time has moved on and what was once acceptable is no longer. The Alder Hey Children’s Hospital scandal in Liverpool has shown that it is no longer acceptable to retain the tissue of dead children for research or teaching purposes without parental consent and in the same way it is not acceptable to perform such procedures on a newly deceased individual without relatives’ consent, if indeed it is acceptable at all. Arguments as to how valuable the training could be are not relevant. Exactly the same issues pertain to the outmoded practice of medical students lining up to do VEs on anaesthetised patients without their consent.

    You could ask ‘Well, who is harmed by it?’ However, the answer to that question is not the doctor’s to give. We cannot second guess whether a relative may or may not be outraged or offended by it and the philosophy of ‘what you don’t know can’t hurt you’ has been shown to have been conclusively superseded by the new policies of open disclosure, where medical errors are to be disclosed, even if no evident harm has occurred.

    I would say this is less now an ethical question than a medico-legal / professional conduct question. I think anyone doing this these days could find themselves on sticky ground if they got found out. The autonomy of the individual is now paramount, in life and in death, and rightly so if the profession wishes to retain the trust of the public, so watch out!

  5. I would not let this happen on my watch. There are better opportunities out there through simulation and supervised practice in elective theatre settings.

    It’s also a whole team issue. The nursing team would need to be involved in the decision to proceed just as much as the docs (not alluded to in the text). Family would need to be informed as well at a time when it’s not really ideal.

    So, basically no.

    S

  6. Michelle Johnston says:

    A categorical no from me also, Casey. For the reasons already cited; rich other training situations now abound, but also as time goes on, I have realised that we exist in a time of critical care whereby numerous and varied external forces all contrive to reduce the human side in what we do. We need to somewhere be the last guard against reducing patients to numbers, or times, or training materials, and give them the most valuable care of all -- compassion.

  7. Airell Hodgkinson says:

    Thanks for posing an interesting question which has stimulated a lot of discussion in our department.
    The resounding answer, from an ethical point of view has been “NO”. Most of our thoughts have already been mentioned above, from BVM ventilation being of higher priority than intubation to emotional thought of “assault” on a newly deceased.
    In 20 years of medicine in Australia I have never seen this done, and only one colleague reports being present when it was done on ONE occasion.
    Given the overwhelming negative resonse, both professional and emotional to the matter, I would want to be absolutely clear on the Legality of the practice. If a peson present did not agree and reported it, then there could be ramifications.
    Times have moved on since the casual use of deceased remains were used for practicing procedures. Simulation, mannikins and supervised clinical attachments now fulfil the role. Whatever happened to the mandatory twenty intubations (not LMAs) that every intern was required to perform to complete their contract at one Perth hospital? No interns in theatre with me this afternoon, with four intubations on the list…..
    Would it be different to allow the junior staff to intubate DURING the resuscitation, which would appear fruitless anyhow…hmmm.

    • Kate johnson says:

      I agree tubing a dead person for practice is ethically wrong. I’ve never seen that scenario.

      However, as an RMO i have seen “grey areas” a few times in tertiary hospitals. For example, during one if my ed terms a patient is wheeled in with cpr in full swing by the paramedics…it is the early hours of the morning when the ed is only staffed by rmos and a couple of registrars. The pt is 90 years old with a complex cardiac history and his prognosis is looking pretty dismal with PEA, but no-one has “called it” yet. So the cpr is still in full progress when the junior registrar who would like some more experience volunteers to tube the pt, although the tube is unlikely to improve the patients outcome. A decision to stop cpr and call the pt dead occurs about 5 minutes after the tube. Its unlikely the tube would have helped the pt, but the pt was not officially dead at that point and active measures being continued briefly.

  8. I have never actually heard of this practice before now. My answer is ‘no’ as in the rare case where intubation is life saving over and above ventilation/oxygenation, the ‘occaisonal’ intubator will struggle regardless of whether they have a few post mortem intubations under their belt or not. The more important skills include mask ventilation and LMA insertion. My two cents.

  9. Easy
    It’s a straight NO -- its not OK.
    The procedural sequence/motor skill of intubating is only 5% of what makes it a challenging procedure. That can be practised on mannequins or in elective patients in OT with supervision.

    The decision making around airways is the real skill. That is not going to benefit from sticking plastic into a dead guy. So -- I see no benefit, I only see lack of dignity, breaching trust, ignoring consent, and disregarding humanity as a core tenet of what we do. Additionally I’d apply the the “would you want it done to your mother?” test. Again, it s a no for me.

    There is in my mind, no dilemma. Straight NO. 

    • David Berger says:

      There’s a saying in aviation: “A superior pilot uses his superior judgement in order not to have to use his superior skill.”

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