Volume 165 Issue 8

Major depression and refusal of life-sustaining medical treatment in the elderly Stuart C Hooper, Kevin J Vaughan, Christopher C Tennant and Janette M Perz MJA 1996; 165: 416-419 Abstract - Introduction - Methods - Patients and assessment - Follow-up - Statistical analyses - Results - Patients - Intensity of depression - Desire for life-sustaining treatment - Discussion - Acknowledgements - References - Authors' details Abstract Objective: To examine the effect of improvement or recovery from major depression in elderly patients on their desire for life-sustaining treatments. Design: Prospective case survey. Setting: Psychogeriatric Service of Hornsby Ku-ring-gai Hospital & Community Health Services and Ryde Hospital & Community Health Services (a community-based service serving an urban population with over 29 000 elderly people). Subjects: All patients referred with major depression (diagnosed by DSM-IV criteria) and no significant cognitive impairment between October 1994 and January 1995. Outcome measures: Number of life-sustaining treatments desired before and after treatment of depression in two hypothetical acute life-threatening illnesses (one with a good and the other with an uncertain prognosis), and intensity of depression on the Geriatric Depression Scale (GDS). Results: 22 subjects completed both stages of the study. Initial depression was severe in five, moderate in 16 and mild in one. GDS scores decreased in 18 subjects after treatment. Mean number of life-sustaining treatments desired by these patients increased significantly from 4.0 to 6.1 (out of seven possible treatments) in the "good prognosis" illness and from 6.4 to to 9.6 (out of 14) overall. The increase in the "uncertain prognosis" illness (2.3 to 3.4) was not significant. Conclusions: Moderate or severe major depression in the elderly is associated with a high degree of refusal of life-sustaining treatments. Treatment of the depression leads to increased acceptance of these treatments, particularly if prognosis is good. MJA 1996; 165: 416-419 Introduction Decisions about withdrawing or withholding life-sustaining medical treatments have become problematic in recent decades. Dramatic advances in medical technology enable many severely ill patients to remain alive, yet the decision to prolong life is tempered by the finite nature of resources, economic rationalism and the patient's quality of life. In the United States, it is estimated that decisions to limit medical treatment are made for about 70% of patients who die in hospital.1 In many cases, this is due to patient refusal of further medical treatment and is part of the strong shift towards respecting patients' autonomy and right to self-determination. In all Australian States, there is a common-law right for competent patients to refuse medical treatment, including life-sustaining treatment. In Victoria, South Australia and the Northern Territory, this right has received statutory recognition. In these States, legislation also permits competent individuals over 18 years to make advance directives ("living wills") specifying that in the event of a terminal illness the individual does not wish to be subjected to extraordinary life-prolonging measures.2 However, the potential influence of depressive illness on patients' refusal of life-sustaining treatment is often neglected. In the elderly (who are disproportionately represented among those who have life-sustaining treatment withheld or withdrawn), depression is often not recognised by primary care physicians.3-7 Misdiagnosis is especially likely in the elderly if symptoms are atypical (e.g., cognitive deficits [pseudo dementia], somatisation or anxiety). Further, with depression impairments in decision-making may be under-recognised, as the cognitive aspects of competence (which are emphasised by doctors and courts) may remain intact, while more subtle abilities (such as the ability to assign realistic values or meanings to the risks and benefits of prospective treatments)8,9 may be impaired. Depressed patients may undervalue potential positive outcomes and predict negative outcomes.9 These "affective" aspects of clinical competence are generally not considered as important as the "cognitive" aspects and can be more difficult to detect.10 The negative outlook disappears after recovery from depression, suggesting that it is specific to the illness phase and not a trait of depression-prone individuals.11,12 Case reports have highlighted patients who have initially refused, but later accepted, life-sustaining treatment after recovery from depression.9,15-18 Longitudinal studies of male Veterans Administration patients in the United States found that desire for life-sustaining treatment was not increased by recovery from major depression of mild to moderate severity,13,14 but was significantly increased if the major depression was severe.14 However, the extent to which results of these case reports and longitudinal studies can be generalised is uncertain. We therefore investigated the effect of recovery from major depression on preferences for life-sustaining treatments in a group of patients referred to an Australian community psychogeriatric service. Methods Our study was approved by the Ethics Committee of the Hornsby Ku-ring-gai Hospital & Community Health Services and Ryde Hospital & Community Health Services. Patients and assessment Subjects for the study were drawn from consecutive patients referred to the Psychogeriatric Service of Hornsby Ku-ring-gai Hospital between October 1994 and January 1995. The Psycho geriatric Service is a community-based service with inpatient facilities, serving an area with over 29 000 elderly people. Inclusion criteria: Diagnosis of DSM-IV major depression,19 made by clinical interview with the consultant psychiatrist and senior psychiatric registrar of the Psychogeriatric Service, according to DSM-IV criteria (Box 1). Severity of depression (mild, moderate, severe) was also assessed clinically with DSM-IV criteria; Mini-Mental State Examination score (MMSE) > 17.20 This was used to screen out patients with significant cognitive impairment; and Informed consent given. Intensity of depression was assessed with the Geriatric Depression Scale (GDS). This is a rating scale (not a diagnostic instrument) that provides a numerical index of intensity of depression and was designed exclusively for use in elderly patients. It contains 30 questions requiring a yes or no answer, which can be either self- or observer-administered. One-week test-retest reliability of 0.85 and criterion validity of 0.82 have been recorded.21,22 Desire for life-sustaining treatment was assessed by a questionnaire adapted from Lee and Ganzini,13 with simplification of the hypothetical scenarios. Patients were asked to "imagine that you developed a sudden life-threatening illness with an uncertain chance of recovery". They were then asked, "Would you want the following procedures should they be needed?". These comprised intravenous fluids with medication, nasogastric tube, blood transfusions, intensive care, kidney dialysis, mechanical ventilatory support, and cardiopulmonary resuscitation. The question was repeated for a similar illness with a good chance of complete recovery. Desire for life-sustaining treatment was quantified by assigning a point for each treatment desired. Follow-up After standard treatment for major depression (including pharmacological agents in all cases and electroconvulsive therapy in two), clinical assessments, GDS and questionnaires were repeated. At least six weeks was allowed before follow-up as the elderly may take longer to respond to antidepressant treatment. Recovery (remission) from major depression was diagnosed clinically at follow-up interview if patients no longer met the DSM-IV criteria for major depression. Statistical analyses The paired t test was used to compare initial and follow-up GDS scores. The Wilcoxon signed-rank test (a non-parametric test) was used to compare initial and follow-up scores for the life-sustaining treatment questionnaire, scoring 1 for any increase and 0 for any decrease and ignoring patients who did not change. The binomial distribution was consulted, with parameters 0.5 and the number of people who changed preferences. Results Patients Of 25 consecutive patients referred with major depression to the Psychogeriatric Service during the study period, 22 were included in the study. Two failed to meet the inclusion criteria (one did not give informed consent and the other did not score sufficiently on the MMSE) and a third died before follow-up. Demographic characteristics of the 22 who completed the study are shown in Box 2. A notable feature was the very high proportion of women in the group (82%). All but four of the patients were new referrals to the service and 10 (46%) were reporting their first depressive disorder. None had a history of previous prolonged psychiatric hospitalisations or previous suicide attempts. Twelve patients (55%) were treated in their homes, eight (36%) were treated predominantly in an inpatient psychiatric unit and two (9%) predominantly in a medical ward. Follow-up after a mean of 88.5 days (SD, 26.3) showed no significant changes in the number of medical illnesses or in demographic variables. Intensity of depression Severity of the depression was classed as moderate for 16 patients (73%), severe for five (23%) and mild for one (5%). Mean GDS score for the group was 24.4 (SD, 3.3) and decreased significantly on follow-up to 16.7 (SD, 8.0) ( P < 0.0005). Individual GDS scores decreased ("improved") in 18 patients, and 12 of these (55% of the total number) were diagnosed clinically as recovered from major depression, according to DSM-IV criteria. Desire for life-sustaining treatment Changes in desire for life-sustaining treatment among those whose depression improved or recovered are shown in Box 3. There were significant increases in the number of interventions desired overall and for the "good prognosis" illness among both the 12 patients who recovered from depression (according to DSM-IV criteria for remission) and the 18 whose GDS scores improved (including six who were not classed as recovered by DSM-IV criteria). There were also increases in the number of interventions desired for the "uncertain prognosis" illness, but the change was significant only in the "recovered" group. Of the 12 patients who recovered, nine had had major depression of moderate severity. The number of interventions desired among these nine also increased significantly overall ( P = 0.05) and for the "good prognosis" illness ( P = 0.04), but not for the "uncertain prognosis" illness. Discussion We found that remission of major depression in the elderly was associated with a significant increase in acceptance of life-sustaining treatments. This increase occurred for both moderate and severe forms of major depression. However, our study has limitations which should caution against drawing firm general conclusions. The main limitations are the relatively small sample size and the possibility of a gender bias caused by the high proportion of female patients. We also do not know the correlation between responses to hypothetical questionnaires and actual decisions when confronted with an "end of life" situation. However, indicating preferences to hypothetical scenarios is similar to executing a "living will" (also, in effect, hypothetical). The hypothetical scenarios examined only acute, not chronic, illnesses, and the findings of this study cannot necessarily be generalised to patients who have coexisting life-threatening medical conditions. In addition, the word "uncertain", used to describe prognosis in one of the scenarios, may have been ambiguous, as all prognoses are uncertain. It was chosen to enable comparison with Lee and Ganzini's studies,13,14 but "poor" or "unfavourable" would have been less ambiguous. A further limitation involved the diagnostic assessments, which did not use structured diagnostic instruments. Our results vary from those of other longitudinal studies.13,14 Ganzini et al.14 found that recovery from major depression was associated with change in preferences for life-sustaining treatments only if the depression was severe. Lee and Ganzini13,14 concluded that, in major depression of mild to moderate severity, "patients should not be discouraged from completing advance treatment directives and that choices by these patients to limit treatment should be respected". However, our finding of a significant increase in the number of life-sustaining treatments desired by nine patients who recovered from major depression of moderate severity suggests that doctors should be cautious about adopting such an approach in the elderly with moderate major depression. Differences between the results of our study and those of Ganzini et al.14 may have been caused by differences between samples and methods. Their sample had a higher proportion of men (81% versus 18% in our study) and their questionnaire about life-sustaining treatments was more complex, possibly affecting subject comprehension and reducing the sensitivity of the instrument. They used DSM-III-R criteria to diagnose major depression, but the differences between these criteria and the DSM-IV criteria that we used are minor. However, neither set of criteria precisely defines the boundaries between mild, moderate and severe forms of major depression, allowing the possibility of diagnostic bias in classifying severity. Further, in analysing their data, Ganzini et al.14 defined a clinically evident increase in preference for medical therapy as an increase in desire for a mean of three or more of the 14 possible interventions. A different cut-off (e.g., two or more of the 14 interventions) would have led to different results. In addition, we allowed a longer time before follow-up than Ganzini et al.14 (mean, 88.5 days versus 24.5 days), and, although we found that degree of recovery measured by GDS was no greater, it is possible that preferences for life-sustaining treatments may take longer to improve than depression. Another possibility is that the longer follow-up period in our study allowed factors other than changes in level of depression to affect preferences. These studies highlight the potential for depression to influence patient desire for life-sustaining treatments, suggesting that clinicians would be wise to take into account patients' mental state when assessing refusal of life-sustaining treatments. If doubt exists about a patient's decisional capacity, or whether major depression is present, psychiatric consultation is indicated. In the absence of an advance directive (completed before the onset of depression), severely depressed patients' wishes to forgo life-sustaining treatments should not be respected until an attempt is made to treat the depression. In contrast, it appears reasonable to respect the wishes of mildly depressed patients, whereas in moderate major depression consensus is lacking. It would be prudent (until further studies clarify this question) to err on the side of preserving life and to treat moderate major depression of moderate severity before respecting a refusal of life-sustaining treatments. Furthermore, patients with moderate or severe major depression who are planning to write advance directives should be encouraged not to do so until their depression has been treated. In our patients whose depression "improved", we found no significant increase in number of life-sustaining treatments desired for an illness with uncertain prognosis. Although the lack of significance may have been due to the small sample size, it suggests that the prognosis of the illness should also be considered in clinical settings. When prognosis is so poor that treatment becomes futile, refusal of life-sustaining treatments should be respected regardless of the presence of major depression, in accord with the ethical and legal principle that doctors are not required to administer futile treatments. The ethical dilemma presented by a depressed patient with dubious decisional capacity who refuses life-sustaining treatments has received little attention. The physician who complies faces the prospect that the patient's decision was biased by the depression and would have reversed on recovery. The physician who does not comply faces the possibility that the request was authentic and the patient's life has been prolonged against his or her wishes. In resolving the dilemma, careful consideration should be given to the severity of the depression, the prognosis of the illness and whether treatment would be deemed futile, and also to any previous directives made by the patient when their decisional capacity was clearly intact. Acknowledgements We acknowledge the generous support of Dr R Russell (Psychogeriatrician, Royal North Shore Hospital), and Dr W Jenneke (Staff Specialist Psychiatrist, Hornsby Ku-ring-gai Hospital). References Greco P, Shulman K, Lavizzo-Mourey R. The patient self-determination Act and the future of advance directives. Ann Intern Med 1991; 115: 639-643. CCH Australia. Death with dignity. Australian Health and Medical Law Reporter. Sydney: CCH Australia Ltd, 1995: paragraph 22-360. Regier D, Hirschfeld R, Goodwin F. The NIMH depression awareness, recognition, treatment program. Am J Psychiatry 1988; 145: 1351-1357. NIH Consensus Development Panel on Depression in Late Life. Diagnosis and treatment of depression in late life. JAMA 1992; 268: 1018-1024. Eisenberg L. Treating depression and anxiety in primary care -- closing the gap between knowledge and practice. N Engl J Med 1992; 16: 1080-1084. Nielson C, Williams T. Depression in ambulatory medical patients: prevalence by self report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psychiatry 1980; 37: 999-1004. Rapp S, Walsh D, Parisi S. Detecting depression in elderly medical inpatients. J Consult Clin Psychol 1988; 56: 509-513. Appelbaum P, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med 1988; 319: 1635-1638. Gutheil T, Bursztajn H. Clinicians' guidelines for assessing and presenting subtle forms of patient incompetence in legal settings. Am J Psychiatry 1986; 143: 1020-1023. Bursztajn HJ, Harding HP, Gutheil TG, Brodsky A. Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment. Bull Am Acad Psychiatry Law 1991; 19: 383-388. Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill. Am J Psychiatry 1995; 152: 1185-1191. Wilkinson IM, Blackburn I. Cognitive style in depressed and recovered depressed patients. Br J Clin Psychol 1981; 20: 283-292. Lee M, Ganzini L. The effect of recovery from depression on preferences for life-sustaining therapy in older patients. J Gerontol 1994; 49: M15-M21. Ganzini L, Lee M, Heintz R, et al. The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy. Am J Psychiatry 1994; 151: 1631-1636. Salzman C. ECT and ethical psychiatry. Am J Psychiatry 1977; 134: 1006-1009. Weitzel W, Purtilo R. Aggressive treatment of geriatric depression: what limits on intervention? Psychiatr Opin 1979; 160: 9-14. Swartz C, Stewart C. Melancholia and orders to restrict resuscitation. Hosp Community Psychiatry 1991; 42: 189-191. Baile F, DiMaggio J, Schapira D. The request for assistance in dying. Cancer 1993; 72: 2786-2791. American Psychiatric Association diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington DC: APA, 1994. Folstein M, Folstein S, McHugh P. "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-198. Yesavage J, Brink T, Rose T. Development and validation of a geriatric depression screening scale: a preliminary result. J Psychiatr Res 1983; 17: 37-49. Koenig HG, Meador KG, Cohen HF, Blazer DG. Self-rated depression scales and screening for major depression in older hospitalized patient with medical illness. J Am Geriatr Soc 1988; 36: 699-796. (Received 30 Oct 1995, accepted 3 Jun 1996) Authors' details Department of Mental Health, Hornsby Ku-Ring-Gai Hospital, Sydney, NSW. Stuart C Hooper, FRANZCP, Senior Psychiatric Registrar in Psychogeriatrics; now Consultant Psychiatrist, Sydney, NSW; Kevin J Vaughan, FRANZCP, Staff Specialist. Department of Academic Psychiatry, Royal North Shore Hospital, Sydney, NSW. Christopher C Tennant, FRANZCP, MD, Professor. Department of Psychology, Faculty of Arts and Social Sciences, University of Western Sydney, NSW. Janette M Perz, BA(Hons), Research Psychologist. No reprints will be available. Correspondence: Dr S C Hooper, 11 Clanalpine Street, Eastwood, NSW 2122.

Stuart C Hooper · Kevin J Vaughan · Christoper C Tennant · Janette M Perz

Research Evaluation of the PAPNET system in a general pathology service Annabelle Farnsworth, Fay M Chambers and Colin S Goldschmidt MJA 1996; 165: 429-431 Abstract - Introduction - Methods - Results - Discussion - References - Disclaimer of conflict of interest - Authors' details - - More articles on Obstetrics & gynaecology and women's health Abstract Objective: To compare the results of an automated rescreening device (PAPNET) with manual screening of Papanicolaou (Pap) smears. Design: All normal or technically unsatisfactory smears and a random sample of abnormal smears on manual screening were submitted for PAPNET rescreening. Setting: Large general pathology laboratory in Sydney between January and September 1995. Results: Of 54 658 PAP smears classified on manual screening as normal, 266 were reclassified as abnormal after PAPNET screening (32 atypical squamous cells of uncertain significance, 217 low-grade squamous intraepithelial lesions and 17 high-grade intraepithelial lesions). Of the random sample of 1022 smears classified on manual screening as abnormal, all high-grade intraepithelial lesions (122 smears) and squamous cell carcinomas (2 smears) were also detected by PAPNET, and 112 were reclassified as normal by PAPNET (14 atypical squamous cells of uncertain significance and 98 low-grade squamous intraepithelial lesions). Histological follow-up confirmed 15 of the 17 smears classified as high-grade intraepithelial lesions on PAPNET screening and detected a further seven that had been classified by PAPNET as either atypical squamous cells of uncertain significance or low-grade squamous intraepithelial lesions. Conclusions: When used as a quality-control measure in a general pathology laboratory, the PAPNET automated screening system detects higher numbers of abnormal PAP smears than manual screening. Introduction Papanicolaou (Pap)-smear examination has been shown to lower mortality and morbidity from cervical cancer,1 but the screening test itself is imperfect. False negative results (when a smear is reported as normal but has been taken from a woman with a high-grade lesion in her cervix) have been reported to be between 10%-20%.2The failure of Pap smears to detect some high-grade abnormalities is the result of either sampling or laboratory error.2 Sampling error occurs when the person taking the smear fails to collect the abnormal cervical cells because of either poor technique or the small size or localised nature of the lesion.3 Laboratory error is usually caused by the screening cytologist failing to detect the abnormal cells on the slide. Screening of Pap smears is a labour-intensive task requiring a high degree of skill and concentration. Even in laboratories using well-recognised quality control measures and staffed by highly trained cytologists, many high-grade abnormalities remain undetected by routine manual screening. These may also be missed on a manual rescreen.3 PAPNET is an automated interactive system for analysis of Pap smears which has been shown to detect abnormalities that were repeatedly missed on manual screening.4,5 We introduced the PAPNET system into our laboratory in January 1995 as a quality-control measure for rescreening of all negative (normal) smears. Here, we compare the detection of abnormalities by PAPNET with those detected by manual screening in our laboratory, and report on the histological follow-up of the PAPNET cytopredictions and the work practices of cytologists using this system. Methods Our laboratory is a large general practice in Sydney with a referral base covering metropolitan and country areas of New South Wales. During the period of our survey (23 January to 30 September 1995), all Pap smears were screened manually using routine methods. Quality assurance measures used in the study (e.g., rescreening and follow-up of abnormal smears) were routine procedures used in our laboratory. All smears considered "normal" (negative) and "technically unsatisfactory" on routine manual screening, together with a random sample of smears considered "abnormal" on routine screening during the same period, were submitted for PAPNET analysis. Smears were considered technically unsatisfactory when a confident report could not be given because of scanty material, or obscuring of cellular detail by blood, inflammation, cellular degeneration or air drying. The abnormal smears were randomly selected from the recent file of atypical smears. The PAPNET rescreening was undertaken blind to the results of manual screening. (See Box 1 for a description of the PAPNET technology.) Interim reports were generated for smears considered normal and technically unsatisfactory, and, after the slide review was completed in the laboratory, a final report was issued incorporating the PAPNET findings. Reporting terminology was based on the Bethesda system of reporting cervical/vaginal cytological diagnoses.6 A record was kept of the number of cases each cytologist was able to review per day with PAPNET. The number of slides that required manual rechecking and complete rescreening was also recorded. This involved the cytologists using the light microscope to recheck individual abnormal cells that were tagged on the PAPNET monitor. If these cells were considered to be significantly atypical, the whole slide was rescreened. If any degree of abnormality was found after rescreening, the slide was submitted to the cytopathologist for checking. To test the specificity of PAPNET, histological follow-up was performed for all patients who had an additional lesion predicted by PAPNET and were recommended to have colposcopy for this lesion. As follow-up of cytological predictions can take many months, the process was expedited and, where possible, histology results are given. In some cases, follow-up was still pending or the referring doctor had decided to follow-up by repeated observation and Pap smears. These are designated as "follow-up to come". In some cases, follow-up was unavailable; the referring doctor had been unable to contact the patient, the patient had moved or had decided to proceed no further with management. These cases are designated as "lost to follow-up". Results During the 10-month period of this survey, 60 317 Pap smears were submitted to the laboratory for examination. These smears are categorised in Box 2 (cytopredictions). The results fall within suggested National Cervical Screening Programme standards for reporting categories of technically satisfactory smears. PAPNET screening was performed on 54 658 smears classified on manual screening as negative (or within normal limits) and 1819 smears classified as technically unsatisfactory. Of the 3840 smears classified on manual screening as abnormal, 1022 smears (27%) were randomly selected and submitted for PAPNET screening: 807 low-grade squamous intraepithelial lesions, 122 high-grade squamous intraepithelial lesions, 91 atypical squamous cells of uncertain significance, and two cases of squamous cell carcinoma. Manual screening compared to PAPNET screening Of the smears classified as negative on manual screening, 266 were reclassified as abnormal after PAPNET rescreening, including 17 reported as high-grade squamous intraepithelial lesions (Box 3). This represents a 7% increase in abnormal smears after PAPNET rescreening. All of the 122 smears reported as high-grade squamous intraepithelial lesions and both squamous cell carcinomas detected on manual screening were also detected by PAPNET (Box 3). Fourteen (15%) of the 91 smears reported as atypical squamous cells of uncertain significance and 98 (12%) of the 807 reported as low-grade squamous intraepithelial lesions were reclassified as negative on PAPNET rescreening (Box 3). Histological follow-up of PAPNET cytopredictions Histology confirmed an abnormality in 28% of smears reported as atypical squamous cells of uncertain significance and 61% reported as low-grade squamous intraepithelial lesions (Box 4). Of the 17 smears reported as high-grade squamous intraepithelial lesions on PAPNET rescreening, 15 (88%) were confirmed on histology (Box 4). Three of the 32 cases reported as atypical squamous cells of uncertain significance and four of the 31 reported as low-grade squamous intraepithelial lesions (where colposcopy was recommended) were also shown to have a high-grade lesion on histological biopsy. In total, there were an extra 22 histologically confirmed high-grade lesions not detected on manual screening, of which 15 were detected by PAPNET. Cytologists' work practices In our laboratory, cytologists manually screened between 25 and 50 slides (mean, 42; standard deviation [SD], 6) per day. The large SD reflected the range of experience among the laboratory's cytologists, who alternate between gynaecological and non-gynaecological cytology. PAPNET rescreening was included in this rotation. After training, cytologists performing PAPNET rescreening were able to screen between 100 and 160 slides (mean, 126; SD, 15) per day. This included loading and unloading the tapes, viewing and assessing the images on the PAPNET screen, documentation and generating patient reports. The number of cases submitted for limited rechecking varied between 10%-90%, depending on the cytologist. The number requiring complete rescreening by a senior cytologist varied between 0 to 10 per cytologist per day and averaged five per day. The number of cases submitted to a cytopathologist by each cytologist averaged one per day. Discussion Pap smears remain the highest-volume pathology test that is not automated. Attempts have been made to automate this complex process for nearly 40 years, but it is only recently that advances in the development of automated systems have occurred which offer practical advantages in a laboratory. Although the detection rate of abnormalities on manual screening was well within normal standards in our study, PAPNET rescreening was able to detect an increased number of abnormal Pap smears. This increase was not associated with a loss of specificity, as often occurs with increased detection by manual screening.3 Many studies have shown the ability of PAPNET rescreening to detect a significant number of abnormal Pap smears when compared with manual screening, but these have been predominantly smaller studies using archived material.8,9 Our study was undertaken as part of the routine workflow in a laboratory processing a large number of smears and is the first Australian study to compare the two screening systems. The reported increase in detection of abnormalities in other studies has been as high as 16%,10 and the company which developed PAPNET (Neuromedical Systems Inc., New York, USA) claims increases of up to 30%. The increase in our study was much smaller (7%), with most detected abnormalities being low-grade lesions. However, we believe this increase was worthwhile given the reasonably high rate of detection on manual screening and the large volume of routine smears processed. Boon et al. reported the results of a large series of smears that were not double-screened, but had been either manually screened or PAPNET screened. Higher detection rates of abnormalities were found in the PAPNET group. Our study is the first report of a large series in which all negative smears were screened both manually and by PAPNET. Our study showed that the PAPNET system could be feasibly integrated into a routine working laboratory situation. It was a valuable educational and quality assurance tool. Cytologists found it easy to use and were able to review slides at three to four times their manual-screening rate. From our experience, cytologists did not become complacent in their manual screening, but rather became more cautious knowing that all the negative smears would be examined by a computerised device. The additional work for cytopathologists and senior cytologists was not great. PAPNET is only one of a number of automated cytology systems currently available as an additional test for routine Pap-smear screening. We did not undertake a comparison of other automated systems or their cost-effectiveness. Further studies on the cost-effectiveness of PAPNET testing and its efficacy for use in public health screening programs are needed. It may be that automated testing technology will replace current screening methods in the future. Disclaimer of conflict of interest This work was conducted independently. Neither Douglass Hanly Moir Pathology nor any of the individual authors has any financial or other association with the suppliers of the PAPNET service, Neuromedical Systems Inc. References Mitchell HS, Giles GG. Cancer diagnosis after a report of negative cervical cytology. Med J Aust 1996; 164: 270-273. Koss LG. The Papanicolaou test for cervical cancer detection. A triumph and a tragedy. JAMA 1989; 261: 737-743. Boscha MC, Rietveld-Scheffers PEM, Boon ME. Characteristics of false negative smears tested in the normal screening situation. Acta Cytol 1992; 36: 711-716. Koss LG, Hin E, Schreiber K, et al. Evaluation of the PAPNET cytologic screening system for quality control of cervical smears. Am J Clin Pathol 1994; 101: 220-229. Boon M, Kok CP. Neural network processing can provide means to catch errors that slip through human screening of Pap smears. Diagn Cytopathol 1993; 9: 411-416. The Bethesda system of reporting cervical/vaginal cytologic diagnoses: revised after the second National Cancer Institute Workshop, April 29-30, 1991. Acta Cytol 1993; 37: 115-124. Royal College of Pathologists of Australasia. Performance Standards for Australian Laboratories Reporting Cervical Cytology. Sydney: RCPA Quality Assurance Programs, 1995. Rosenthal DL, Acosta D, Peters RK. Computer-assisted re-screening of clinically important false negative cervical smears using the PAPNET testing system. Acta Cytol 1996; 40: 120-126. Sherman ME, Mango LJ, Kelly D, et al. PAPNET analysis of reportedly negative smears preceding the diagnosis of a high grade squamous intraepithelial lesion or carcinoma. Mod Pathol 1994; 7: 578-581. Elgert PA, Suhrland MJ, Re E, et al. Prospective quality control of cervical smears using the PAPNET system [abstract No. 5]. In: Abstracts of the Scientific Session of the 42nd Annual Scientific Meeting of the American Society of Cytology; 1994 Nov 1-6; Chicago. Acta Cytol 1994; 38: 793-805. Boon ME, Kok LP, Beck S. Histologic validation of neural network assisted cervical screening: comparison with the conventional procedure. Cell Vision 1995; 2: 23-27. (Received 10 Jan, accepted 14 Aug 1996) Authors' details Douglass Hanly Moir Pathology, 95 Epping Road, North Ryde, NSW. Annabelle Farnsworth, MB BS, FRCPA, Cytopathologist. Fay M Chambers, MB BS, FRCPA, Cytopathologist. Colin S Goldschmidt, MB BCh, FRCPA, Cytopathologist. Reprints: Dr A Farnsworth, Douglass Hanly Moir Pathology, 95 Epping Road, North Ryde 2113. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> We appreciate your comments. 1: The PAPNET system. PAPNET consists of a scanning apparatus and a review station.4 In Australia, the cervical slides are sent to Hong Kong for the initial scanning. The scanning apparatus includes an automated microscope with an attached video camera which transmits images to a primary classifier. Selected images are then passed into a neural net computing unit which chooses the 128 highest-ranking images for storage on an optical disk or digital tape, which is sent back to Australia for display at the review station. The review station is located in the cytology laboratory where manual screening takes place. The 128 recorded images are displayed in panels on a high-resolution colour monitor and are reviewed by a cytologist. If an abnormality is suspected, the original slide is manually checked and, if necessary, manually rescreened. Back to text 2: Categories of Pap smears on manual screening (23 January to 30 September 1995). CytopredictionNumber of smearsNegative*54 658 (90.6%)Low-grade squamous intraepithelial lesions 2974 (4.9%)High-grade squamous intraepithelial lesions 432 (0.7%)Atypical squamous cells of uncertain significance434 (0.7%)Technically unsatisfactory1819 (3%)Total60 317 (100%)* Cellular appearance was within normal limits. Back to text 3: PAPNET rescreening of PAP smears classified as normal and abnormal on manual screening. CytopredictionNormal smears: manual screeningPAPNET rescreeningAbnormal smears: manual screeningPAPNET rescreeningNegative*54 65854 359--112Atypical squamous cells of uncertain significance--329177Low-grade squamous intraepithelial lesions--217807709High-grade squamous intraepithelial lesions--17122122Squamous cell carcinoma--022Technically unsatisfactory18191852---- * Cellular appearance was within normal limits. The 112 negative smears on PAPNET screening had been classified on manual screening as atypical squamous cells of uncertain significance (14 smears) and low-grade squamous intraepithelial lesions (98 smears). Back to text 4: Histological follow-up of PAPNET cytopredictions. Histological follow-up PAPNET-detected abnormalitiesNegative/inflammation*Low-grade squamous intraepithelial lesionsHigh-grade squamous intraepithelial lesionsFollow-up to comeLost to follow-upTotalAtypical squamous cells of unknown significance66371032Low-grade squamous intraepithelial lesions21544631High-grade squamous intraepithelial lesions 01150117 *Cellular appearance was within normal limits. Back to text

Annabelle Farnsworth · Fay M Chambers · Colin S Goldschmidt

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

Corinne Ginnifer · Anne-Maree Kelly