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:
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: