Teaching resuscitation skills using the newly deceased

Corinne Ginifer and Anne-Maree Kelly

In many hospital emergency departments doctors learn life-saving technical skills on patients who have recently died. This longstanding practice is justified as providing training that cannot be offered in any other way. But can it continue without the informed consent of relatives and the general approval of the public? (MJA 1996; 165: 445-447)

For editorial comment, see Ashby

Introduction - The overseas experience - The Australasian experience - Ethics - Law - Public debate - References - Authors' details

Make a comment - Register to be notified of new articles by e-mail - Current contents list - ©MJA1996

Introduction

Patients today are educated, informed and active in decisions concerning their health. Much of the awe and mystery that once surrounded the practices of doctors has been dispelled and some longstanding practices are now being questioned. One such practice is the use of the bodies of newly deceased patients to train staff in specialised emergency procedures, a practice that has been criticised on ethical, religious and legal grounds.¹

Aside from these arguments, it may be argued that the practice is outdated, as there are now alternative teaching tools -- but do the alternatives offer the same quality of training?

The overseas experience

Reports from the United States suggest that the practice is widespread, occurring in up to 39% of hospitals.² It is considerably more common within certain departments, occurring in 54%-63% of emergency departments and 58% of neonatal critical care programs,^2,3 with nearly equal rates in both teaching and non-teaching hospitals.³

Few departments (only 7% in the United States) ³ have a written policy regarding the practice. Less than half of these policies required notification of the next of kin. None the less, reports indicate that in 10% of cases where recently deceased patients were used for this purpose consent was obtained. ²

Endotracheal intubation is the most commonly practised procedure. Other procedures include placement of central venous catheters, surgical venous cutdown, thoracotomy, pericardiocentesis, cricothyrotomy, liver biopsy and intraosseous needle placement. ²

Although there is widespread agreement (even in hospitals that do not teach using recently deceased patients) that the practice has educational value, objections on religious, ethical and legal grounds have been raised in up to 25% of institutions where it is practised. ³ Many members of staff, particularly nurses, find the practice distressing because it appears to conflict with their primary duty of care -- not only to the patient now deceased, but also to the relatives, whom they wish to protect from any further grief.

Approaching relatives for consent to perform certain procedures on the recently deceased patient has been an issue much discussed. Many believe that relatives should not be approached for such consent as this would only cause them further distress. ⁴ However, a Norwegian study found that 58% of people surveyed would allow the body of a close relative to be used for teaching intubation techniques, ⁵ and a US study found that 39% of families consented to cricothyrotomy on deceased relatives. ⁶ Success rates for obtaining consent have been reported to be as high as 59% for invasive procedures in adults ⁷ and 73% for endotracheal intubation in deceased infants. ⁸ Success in obtaining consent depends upon providing adequate information and explanation to relatives and the opportunity to establish a relationship with the family before the patient's death. ⁶

The Australasian experience

Our search of the Australasian literature ( Medline search using the keywords "newly", "deceased", "teaching" and "resuscitation", limited to the last 10 years) did not find any discussion of this issue, although we thought it likely that the practice is as common in Australia and New Zealand as it is overseas. In April 1995 we surveyed all 55 emergency departments in Australia and New Zealand accredited for training by the Australasian College for Emergency Medicine. The survey asked whether the department used the newly deceased to teach resuscitation skills and, if so, how frequently this practice occurred, which procedures were performed, whether consent was obtained from relatives of the deceased and whether the department had a policy about the practice. Respondents were invited to express their opinions on the legal, social and ethical issues involved.

Forty-eight responses were received (response rate, 87%). Twenty-two respondents (46%) indicated that resuscitation skills were taught using the bodies of newly deceased patients in their emergency department. These data are comparable with those reported in the United States. ^2,3 Further similarities exist: no department which practised such procedures obtained consent from relatives and only one of the 48 respondents had a written policy governing the practice. The procedures undertaken and their frequency are summarised in the Box.

Concerns centred largely on legal and ethical issues, although 73% of respondents believed the practice to be ethical.

Ethics

The ethics of this practice have been debated in the international literature.^1,4,9,10 The central issue is whether the need for training and the benefits resulting from access to the bodies of the recently deceased outweigh any possible harm to individuals and society.

The need for highly trained doctors skilled in resuscitation techniques is undisputed. To produce such doctors there must be the means to teach resuscitation skills in a realistic manner. For many years, this was accomplished using recently deceased patients, upon whom an experienced member of staff demonstrated and taught junior members and medical students. Generally, the relatives of the deceased were not informed and, on the whole, only non-invasive procedures were undertaken. Such teaching involved only a few students at a time and was carried out in a sensitive manner with respect for the deceased. It did not present any risk of harm to the deceased while offering an educational opportunity without risks to living patients.

However, it may be difficult to justify the use of recently deceased bodies for training if new teaching models and techniques are accepted as adequate alternatives. Sophisticated and realistic manikins can provide practice in endotracheal intubation, venous cannulation, external cardiac compression and so forth. Intubation experience may be gained using patients who are anaesthetised for surgery. Preserved cadavers and anaesthetised animals have also been used to teach various procedural skills. More recently, interactive videodisc instruction has gained recognition as a suitable tool for teaching endotracheal intubation. ³

Whether these alternatives are adequate remains contentious.

The British Medical Association and the Royal College of Nursing, while adamantly rejecting the routine use of recently deceased patients for teaching purposes, do accept that it may be acceptable in exceptional circumstances when patients have suffered major trauma resulting in a disturbance to the normal anatomy of the face, neck and upper trunk: "Practising intubation on recently deceased patients who have suffered such injuries affords experience not obtainable in any other way." ¹¹ This position suggests that, in general, the use of recently deceased patients in training can be justified if it is superior to the alternatives available. If so, then perhaps the "harm" we inflict can be justified for the "greater good" to society gained from such access.

Would this practice be more acceptable if the consent of relatives was sought? Seeking consent may inflict further grief on those who are already distressed, but this may be the price we pay for the opportunity to access this valuable resource for teaching purposes.

Law

Laws regarding this practice differ around the world. Burns et al. have reviewed the relevant legislation and test cases in the United States, ² where there are no state statutes that specifically prohibit the teaching of procedures using recently deceased patients. It has been established by various state courts that the patient's constitutional right to privacy that protects him or her from non-consensual invasion of the body terminates at the time of death. In addition, state courts in Michigan, Georgia and Florida hold that the constitutional rights to privacy and property are personal and cannot be claimed by the next of kin. In contrast, the US Appeals Court for the Sixth Circuit held that the next of kin had a constitutionally protected property interest in the patient's remains. Furthermore, the next of kin could have a legal claim against the hospital for negligent or intentional infliction of emotional distress if procedures were performed on the patient after death without the family's consent.

Some countries (including Belgium, France and Israel) have adopted a "presumed consent" policy for organ donation. ^2,9,10 This places the onus on the family to raise objection to organ donation; in the absence of specific objection, and with no obligation on the doctor to ask for permission, organ donation may proceed. In these countries the number of kidney transplants is well ahead of many other European countries and no one would doubt the benefits to society. Possibly, the same principle could be applied to the use of newly dead bodies for teaching purposes.

What are the Australian laws on these matters? Currently, the coroners and human tissue Acts of the various Australian States do not deal specifically with this issue. Neither do the equivalent New Zealand Acts. There is no doubt that it is unlawful to interfere with coroner's cases, but there is no law preventing the use of bodies to teach minimally invasive and non-invasive procedures during the first few minutes after death in cases that are not required to be reported to the coroner. In Western Australia this may soon change. A new Coroners Act has recently been passed in the Lower House and is now before the Upper House of Parliament. This new Act deals specifically with the use of newly deceased patients for teaching purposes, requiring consent from the coroner together with either prior written permission from the deceased or permission from the senior next of kin in the absence of prior objection from the deceased. Other Australian States may follow suit.

It is possible that the performance of such procedures could be considered a trespass under tort law, the principle being that people "should . . . be prevented from touching corpses whether by way of an unauthorized post-mortem examination or for other purposes". ¹² This has not been tested in the Australian courts (Dr H Aders, legal adviser to the Medical Defence Union, Sydney, personal communication).

Public debate

Does the need for training and the benefits arising from access to the bodies of the recently deceased outweigh any possible harm to individuals and society? Progress in the debate has been slow, perhaps because of a reluctance to seek guidance from the community about a practice that has been occurring covertly for many years.

References

1. Iserson KV. Postmortem procedures in the emergency department: using the recently dead to practise and teach. J Clin Ethics 1993; 19: 92-98.
2. Burns JP, Reardon FE, Truog RD. Sounding board: Using newly deceased patients to teach resuscitation procedures. N Engl J Med 1994; 331: 1652-1655.
3. Morhaim DK, Heller MB. The practice of teaching endotracheal intubation on recently deceased patients. J Emerg Med 1991; 9: 515-518.
4. Orlowski JP, Kanoti GA, Mehlman MJ. The ethical dilemma of permitting the teaching and perfecting of resuscitation techniques on recently expired patients. J Clin Ethics 1990; 1: 201-205.
5. Brattebo G, Wisborg T. Teaching procedures on the newly dead [letter]. Ann Emerg Med 1995; 26: 242.
6. 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.
7. McNamara RM, Monti S, Kelly JJ. Requesting consent for an invasive procedure in newly deceased adults. JAMA 1995; 273: 310-312.
8. Fernandes CMB. Practice of procedures on the newly dead [letter]. Ann Emerg Med 1995; 26: 1.
9. Iserson KV. Law versus life: the ethical imperative to practice and teach using the newly dead emergency department patient. Ann Emerg Med 1995; 25: 91-94.
10. Goldblatt AD. Don't ask, don't tell: practicing minimally invasive resuscitation techniques on the newly dead. Ann Emerg Med 1995; 25: 86-90.
11. Royal College of Nursing. Intubation training: An ethical practice? Nursing Standard 1993; 7: 38-39.
12. Trindade F, Cane P. The law of torts in Australia. 2nd ed. Melbourne: Oxford University Press, 1993.

Western Hospital, Melbourne, VIC.
Corinne Ginifer, MB BS, DA(UK), DipRACOG, Emergency Medicine Registrar;
Anne-Maree Kelly, FACEM, Staff Specialist, Emergency Medicine.
No reprints will be available. Correspondence: Dr C Ginifer, Emergency Department, Western Hospital, Footscray, VIC 3011.

<URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.
We appreciate your comments.