Teaching resuscitation on the newly deceased: do we want to know?

Time for public scrutiny and debate

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Using the newly deceased for the teaching of resuscitation techniques has been debated in the mainstream journals and medical ethics literature overseas for more than a decade, but in this issue of the Journal (page 445) Ginifer and Kelly bring the subject into the public domain for the first time in Australia.

In their survey of selected Australian emergency departments, the practice of teaching resuscitation techniques using the bodies of newly deceased patients was found to be widespread but relatively infrequent. Consent from relatives was rarely obtained, and most emergency departments had no written policies governing this practice. Ginifer and Kelly question the educational need for such experience and raise ethical and legal issues.

In considering the need for teaching of resuscitation techniques, it is important to distinguish between minimally invasive procedures such as endotracheal intubation (by far the most commonly practised procedure), central venous cannulation and pericardiocentesis and more extensive procedures such as tracheostomy or emergency thoracotomy. The performance of emergency thoracotomy for any reason in the emergency department is exceedingly rare, typically being undertaken only by surgeons on patients with penetrating chest trauma with profound shock or recently lost vital signs. When it is performed in these circumstances in the hope of restoring life, the procedure is outside the terms of this debate.

Endotracheal intubation is a lifesaving procedure. The need for certain clinicians to be skilled in the technique is unequivocal, but at present there is no adequate animal model or manikin that can satisfactorily substitute for training in the skill; it can be gained only on human subjects with typical neck tissue resilience (that is, the newly deceased or patients anaesthetised for surgery). ¹ It is self-evident that the former cannot be harmed, while the latter, even with the closest supervision, may potentially suffer from any of the complications of the procedure.

It is pertinent to note that the need for clinical training in resuscitation techniques, its benefit to society and the educational value of practice on the newly deceased have not been seriously questioned in the medical literature.

However, legal and ethical issues will inevitably arise. If law reports are any guide, this issue is not one of great public, judicial or coronial concern. In Australia, and even in the litigious United States, I have been unable to find a single successful criminal or civil prosecution of a doctor or hospital for permitting or performing a minimally invasive resuscitation technique on a newly deceased person. In Australia, coroners in several jurisdictions have raised no objection to the practice, provided such events are noted in the patient record.

In both law and ethics, consent for clinical interventions is central to most arguments. If an advance directive has been made and is known, the situation is clear, but this circumstance is rare. Typically, death has been sudden and unexpected and relatives are often not available for some time. Obtaining consent from relatives is therefore frequently impractical, and indeed it has been suggested that, because of the additional stress and psychological harm that might result, it may be unethical to seek consent to procedures from relatives just confronted with the sudden death of a loved one.

The literature provides little guidance in the analysis of this debate, but Bratteb¿ et al. showed, in a random public survey in Norway, that 70% of people would consent to being used for teaching intubation during anaesthesia and 60% would consent to the procedure being performed on a newly deceased relative.² In this study, only four of 971 respondents considered these practices "unethical". Most other published studies on this subject have reported similar results, but the views of Australian society have never been surveyed and extrapolation of information from other cultures and legal systems may be inappropriate.

Our society needs to consider three possible options if it believes that there is a benefit to having doctors skilled in resuscitation. The first is to create a requirement for explicit proxy consent from the next of kin. This would be frequently impractical, might cause psychological distress for some people, and might not represent a true substituted judgement of the deceased.

The second option is for the States and Territories to legislate to sanction a range of procedures on the basis of presumed consent. Here, society would be agreeing, through its elected representatives, that the net benefit of the educational practice is significant, and would assume that its members wish to act beneficently in death. At least 15 countries currently have presumed-consent laws.

The final option is to maintain the status quo, but with more explicit arrangements. For this option, institutional guidelines and review of practice are mandatory. The public must be assured that the deceased will always be treated with respect and that their known wishes will be followed. The procedures practised on the deceased should be those required to save lives in emergency situations, and should be conducted in a defined educational program by medical or paramedical personnel under specialist supervision. The supervisor should be responsible for the sensitive and appropriate selection of both clinical material and procedure, having regard to such matters as the circumstances of death, any religious considerations, forensic relevance and the voluntarily expressed views of any relatives or staff present.

Informed consent from the senior available next of kin should be obtained for any procedure to be performed after the deceased has been removed from the resuscitation area. Proxy consent would not need to be obtained for the performance of minimally invasive procedures undertaken in accordance with institutional guidelines in the immediate postresuscitation period. Also, the supervisor would not need to specifically inform relatives unless directly questioned, but all procedures should be recorded in the patient record, and these should be routinely reviewed for appropriateness as part of clinical audit and quality management processes.

Teaching resuscitation on the newly deceased is an important educational tool in medicine, but there are complex social issues involved. It is therefore inappropriate and unnecessary for the practice to be hidden from public scrutiny and debate. It is equally inappropriate for the practice to occur other than in the context of strict institutional guidelines and review. This is a matter which could be addressed by many Australian hospitals immediately.

1. Orlowski JP, Kanoli GA, Mehlman MJ. The ethics of using newly dead patients for teaching and practising intubation techniques. N Engl J Med 1988; 319: 439-441.
2. Brattebo G, Wisberg T, Solheim K, Oyen N. Public opinion on different approaches to teaching intubation techniques. BMJ 1993; 307: 1256-1257.

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