National Ethics Teleconference

*Practicing Medical Procedures on the Newly Dead*

## November 19, 2003

# INTRODUCTION

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health
Care and a physician at the VA NY Harbor Healthcare System. I am very
pleased to welcome you all to today\'s National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of important VHA ethics
issues. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# ANNOUNCEMENTS

Remember, CME credits are available for listeners of this call. To get
yours go to <http://vaww.ees.aac.va.gov/ethics>.

Ground Rules: Before we proceed with today\'s discussion of practicing
medical procedures on the newly dead, I need to briefly review the
overall ground rules for the National Ethics Teleconferences:

-   We ask that when you talk, you please begin by telling us your name,
    location and title so that we continue to get to know each other
    better. During the call, please minimize background noise and PLEASE
    do not put the call on hold.

-   Due to the interactive nature of these calls, and the fact that at
    times we deal with sensitive issues, we think it is important to
    make two final points:

    -   First, it is not the specific role of the National Center for
        Ethics in Health Care to report policy violations. However,
        please remember that there are many participants on the line.
        You are speaking in an open forum and ultimately you are
        responsible for your own words, and

    -   Lastly, please remember that these Ethics Teleconference calls
        are not an appropriate place to discuss specific cases or
        confidential information. If, during the discussions we hear
        people providing such information we may interrupt and ask them
        to make their comments more general.

# PRESENTATION

In today's presentation we consider whether it is ethically permissible
for practitioners or trainee's to practice medical procedures, such as
intubation, on recently deceased patients, or as they are referred to in
the literature, the newly dead, and if so, whether it is ethically
necessary to obtain consent from the next of kin or prospectively, from
the decedent.

Joining me on the call today is Mary Beth Foglia. She has been a member
of the Ethics Center staff since 2002. Mary Beth is a registered nurse
with a master of science degree in nursing with an emphasis on health
services planning and evaluation, and socio-cultural anthropology. In
1999 Mary Beth obtained a Master of Art's in Bioethics from the
University of Washington.

The issue of practicing procedures on the newly dead came to the
attention of the Ethics Center through a consultation request from a
facility ethics committee.

The case went something like this: As part of a plan to remove a
patient, at his request, from mechanical ventilation, a senior resident
encouraged the more junior trainee's to practice intubation on the
patient after he had expired. Some members of the team questioned
whether this practice was ethically justifiable?

Mary Beth was the lead consultant in researching and responding to this
issue.

Mary Beth, could you start by telling us why some clinicians might want
to practice procedures on the newly dead.

**Ms. Foglia**:

Many clinicians and clinicians in training see practicing procedures on
the newly dead as essential to developing and maintaining their skills
in lifesaving procedures. These clinicians argue that alternative
methods, such as mannequins, animal laboratory training or computer
simulators, are insufficient or unavailable, and ultimately sacrifice
the interests of the living to the dead.

**Dr. Berkowitz:** Is this practice common?

**Ms. Foglia**:

The available evidence suggests that the practice of performing medical
procedures on the newly dead for skill development and to maintain
competence is relatively common. Le me give you some examples Ken.

-   A survey was conducted with directors of training programs in adult
    and pediatric critical care and emergency medicine programs within
    the United States. Of the 353 (353/449 or 79% response rate)
    responses, 39% (136/353) described using newly deceased patients in
    the teaching of resuscitation procedures. The highest proportion of
    respondents who permitted procedures to be performed on patients
    after their death was found among emergency medicine programs (63%).
    Only 10% (13/136) of the programs that used newly dead patients for
    teaching purposes required either verbal or written consent from
    patients' families. (Burns, 1994)

-   Another survey, by Fourre published in Academic Emergency Medicine
    in 2002 reported comparable findings. This survey queried department
    heads of emergency departments with emergency medicine training
    programs. 47% of responding departments (96/116) reported practicing
    medical procedures on the newly dead. Of the departments who
    practice on the newly dead three quarters stated that they "almost
    never" obtain consent from family members. Further only 4 of 96
    respondents have written policies governing this practice. (Fourre,
    2002)

**Dr. Berkowitz**:

What are health care professional's attitudes toward practicing
procedures on the newly dead?

**Ms. Foglia**:

Not surprising Ken, attitudes towards the practice are mixed and often
ambivalent.

Health care professionals involved in or aware that the newly dead were
being used for training without obtaining consent commonly express
discomfort with the practice. In spite of the discomfort experienced,
many view the practice as helpful when developing or maintaining
competence.

For example, one survey found that 53% of paramedics, 72% of nurses, and
97% of residents, believed that it is permissible to practice on the
newly dead without obtaining consent. In another study, 67% of nursing
students but only 30% of experienced nurses objected to the practice.

Some health care professionals report feeling angry, not so much by the
practice of training on the newly dead, but rather, that the practice of
training on the newly dead is concealed from families and the public.

Others believe as one young resident stated, "we are doing this to help
the next patient who comes through the door." (Wall Street Journal 2002)
Although, frankly, many critics of the practice believe it is damaging
for young physicians to develop habits of performing any procedures
without obtaining consent

**Dr. Berkowitz**:

I see really two different but related ethical questions here. One, is
it ethical to practice procedures on the newly dead at all; and two, if
it is ethical to practice procedures on the newly dead, do we need to
obtain the consent of the next-of-kin, or, prospectively, the decedent?
It can be difficult to separate these two questions but let's consider
the parallel example of organ donation. You can ask if it is ever
ethical, for instance, to remove organs from a person who has died, and
place them in a living patient, and then ask, what specific conditions
might make the procedure unethical. We would argue that it is ethical to
transplant organs from a person who has died with their consent, but
that that same procedure becomes unethical if it was done against the
will of a competent patient. I think we can separate the two questions
about practicing procedures on the newly dead in the same way, and ask
if it is an ethical treatment of the dead to use their bodies in this
way, and if it is, does the failure to obtain consent make it unethical.
If you do not mind, I would like to address those questions separately,
and start by asking if it is ethical to practice procedures on deceased
patients at all.

**Ms. Foglia**:

Let's think about this question in relationship to the history of
cadavers in research and training.

The use of cadavers in medicine has a long and sordid history, beginning
all the way back in the fourth century BC, the days of Aristotle and
Hippocrates. The Greeks actually had a very accepting attitude towards
the use of cadavers, because they believed that the soul and the body
were completely separate.

The coming of the Romans in the second century BC put an end to the use
of cadavers, because they believed that the treatment of the body had an
effect on the soul in the afterlife. As a result, Galen, the famous
Greek anatomist, relied almost entirely on pigs and monkeys for his
research.

The next shift in thinking occurred during the Renaissance, when
Leonardo da Vinci made use of cadavers for his anatomical drawings.
Andreas Vesalius, considered the father of modern anatomy, used cadavers
extensively in writing his 1543 treatise *De Humani Coporis Fabrica*.
But, the growing acceptance of cadaver dissections among researchers did
not correspond to a growing acceptance among the general public. The
cultural consensus was that violations of the body were also violations
of the soul.

For a long time researchers were forced to carry out dissections in
private, without public awareness, but in the 16^th^ century Henry VIII
publicly endorsed a policy to donate the bodies of executed criminals to
medical schools. This law remain unchanged until the 1830's when the UK
and many US states passed the Anatomy Act, making it unlawful to use
executed criminal's bodies for research.

Over time, a social consensus developed that use of the body for certain
circumscribed and altruistic purposes was permissible so long as consent
was obtained. This viewpoint is codified in the Uniform Anatomical Gift
Act of 1987. The Uniform Anatomical Gift Act allows citizens to give or
withhold consent to use their bodies for transplant, therapy, research,
and/or training after death.

**Dr. Berkowitz**:

Ok, let's go back to the second question that I asked, which is, is it
necessary to obtain consent from the next-of-kin or, prospectively, from
the decedent to ensure that practicing procedures on the newly dead is
done ethically. I know there is quite a bit in the literature on the
topic of obtaining consent for this practice, so maybe you could take us
through the arguments against, and then, the arguments for obtaining
consent.

**Ms. Foglia**:

There are a couple of different ways to argue that it is not necessary
to obtain consent for practicing procedures on the newly dead. These
arguments begin with the claim that practicing on the newly dead is the
only way that life saving skills can be developed or maintained. From
this beginning, a related argument states that limiting the availability
of bodies by requiring consent sacrifices the adequacy of clinical
training and the benefits of that training that accrue to the living.

Ken, as you know, we found no evidence to support the claim that
clinical training would be severely compromised if, in fact, fewer
corpses were available as a result of requiring consent. The majority of
authors publishing in respected journals concluded that the training
advantage of practicing on the newly dead is definable but limited.
There have been and continue to be technical innovations in mannequins,
computer simulators and more recently, interactive video disc
instruction, that are rapidly narrowing the relative advantages of using
the newly dead.

Plus, we know there are many training programs that simply don't
practice on the newly dead. No one has suggested that these programs
produce unqualified clinicians.

**Dr. Berkowitz**:

There also appears to be the opinion that most families or patients
would refuse to consent to such practices if they were asked. Is there
any evidence that families or nearly dead patients would refuse consent?

**Ms. Foglia**:

This belief is not supported in the literature Ken.

Studies of patient and family attitudes toward post-mortem procedures
indicate that in general, the public understands the benefit of
permitting practice on the newly dead. However, substantial majorities
believe that this practice should not occur without obtaining consent.
For example:

In a survey by Oman et al. of 100 older adults residing in a
metropolitan area, 54% thought that practicing life-saving procedures on
the newly dead is permissible. Of those who believed the practice was
permissible, 80% thought that obtaining consent should be required.
Believing that practice on the newly dead is permissible was correlated
with planning to donate one's organs and preferring an autopsy. (Oman,
2002)

Manifold et al. conducted a survey of 280 emergency department patients,
and found that 70% would agree to post-mortem procedures on themselves
or a family member, but only 40% thought it was allowable for a
post-mortem procedure to be performed without prior consent. (Manifold,
1999)

These same respondents thought that consent should be obtained either
through the advance care planning process or a wallet card format
similar to organ donation.

A study by Benfield suggests that social and cultural background may
influence one's perspective on practicing procedures on the newly dead.
For example

African-Americans were less likely to give consent for post-mortem
procedures, because of what the authors described as 'deep respect for
the body.' The percent of African-Americans who would consent was 33%,
compared with 83% of the general population. (Benfield, 1991)

However, in general we see willingness on the part of patients and
next-of-kin to allow post-mortem practice so long as consent is
obtained.

**Dr. Berkowitz**:

So what other sorts of arguments are being made that practice on the
newly dead should proceed without obtaining consent?

**Ms. Foglia**:

Well, Ken, some people argue that consent is not required to practice
procedures on the newly dead because the dead no longer meet an ethical
or legal definition of a person. Because the newly dead are not viewed
as persons they no longer have a claim to autonomy or the right to
determine what happens to their body.

Furthermore, some health care professionals argue that using the newly
dead for training purposes, regardless of pre-mortem preferences, is one
method of showing respect for the deceased. The argument runs something
like this: The dead may no longer determine what happens to their body
because they are not persons. But the dead deserve respect. One way of
showing respect is to use the body for altruistic purposes. Therefore,
by practicing on the newly dead with altruistic intent, that is, to
benefit future patients, health care professionals show respect for the
decedent.

It is worth noting Ken, that it is contrary to our common sense
understanding of a gift as codified in the Uniform Anatomical Gift act
for health care professionals to 'gift' someone else's body.

Another argument for not obtaining consent is that the next-of-kin have
only limited constitutionally protected property rights to the body of
the decedent. In this line of thinking, the next-of-kin have the right
to determine the disposition of the body, but their legal authority does
not extend to making decisions about practicing medical procedures.

Lawyers who have weighed in on this issue, argue that given even a
limited claim to the body of the decedent, it is legally prudent to
request consent from the next of kin.

A final argument used to justify practice on the newly dead is that of
implied consent. The argument is that if a patient chooses to be
admitted to a teaching hospital they are providing implicit consent to
be used for training purposes, including training that extends after the
patient's death. This argument is not very compelling. Many patients are
unable to choose where they receive care. This is dictated by insurance,
employment, socio-economics status, or other factors unrelated to
patient choice. Even if a patient chooses a teaching facility, this is
not carte blanche consent to make their living or dead body available
for any training purpose. The Veteran population may be particularly
vulnerable since many of our Veterans have no other options as to where
they receive care.

**Dr. Berkowitz**:

What really may be going on here is an attempt to avoid what could be a
very uncomfortable and emotionally difficult conversation with the
family about using their newly dead loved one for practice.

That could be a very uncomfortable conversation, but it is not that much
different from other conversations a clinician has to have with the
family, like breaking bad news, or requesting consent for autopsy or
organ donation. And developing good communication skills with patients
and family should be as important as developing life-saving skills.

**Ms Foglia:**

I think there is something to what you're saying Ken. Some clinicians
believe that by requiring consent, the clinician is subjecting the
patient or family to emotional distress that could be avoided. They
would forgo consent as a matter of justified paternalism. Most
commentators see this argument as very weak and out of step with ethical
norms.

**Dr Berkowitz:**

So, in general, we don't find the arguments for forgoing consent very
compelling. Could you take us through some of the ethical arguments for
obtaining consent for practicing procedures on the newly dead?

**Ms. Foglia**:

Sure Ken. First of all, there is a strong presumption on the part of
patients and families that health care professionals will tell them the
truth about what they are going to do to the patient. We saw this in the
studies I mentioned before---families expect to be asked about
practicing procedures on a recently deceased family member, and are
often willing to give consent when approached.

However, the practice as currently conducted, is often shrouded in
secrecy, known only to the clinicians engaging in it. This violates
tenets of professional ethics such as disclosure and truth telling and
can contribute to undermining public trust in the integrity of health
care institutions and providers.

Another argument for obtaining consent is related to respect for
persons. This may seem counterintuitive, since corpses are, by
definition, not persons. However, the notion of respect for persons does
not mean that at the moment of death we abruptly cease to attribute
moral force to any of the person's pre-mortem preferences and values. In
cases where the decedent's preferences are unknown, the family is often
in the best position to determine whether a particular use of the body
is consistent with the deceased's conception of respectful post-mortem
treatment. The family is already responsible for the disposition of the
body, and may carry an added responsibility for assuring the body is
treated with respect.

Finally, practicing medical procedures on the newly dead may violate
religious or cultural customs regarding respectful treatment of the
body. Although proponents of not obtaining consent argue that dead
bodies cannot be harmed, it is important to recognize that what
constitutes harm is in the eye of the beholder. For example, some
members of certain religious or cultural groups believe that the spirit
or soul is harmed if the body is not treated in accordance with custom
and tradition.

Let me give you a specific example: The Koran states, "Breaking the bone
of the dead is akin to breaking the bone of the living." Some religious
leaders have interpreted the text to mean that it may be possible for
the deceased to feel pain. This is one reason given for the reluctance
of some Muslims to allow post mortem examination. (Gatrad, 2001)

[]{.mark}

The bottom line here is that what post mortem procedures constitute
respectful treatment of the dead can vary, so obtaining consent ensures
that pre-mortem preferences are respected.

One final thought Ken, the question of whether procedures should be
practiced on the newly dead without obtaining consent is not one that
medical professionals should decide on their own. Rather the debate
should be subject to transparent deliberations with all interested
parties with an end result of policy formation.

**Dr. Berkowitz**:

The literature also suggests that some trainee's prolong resuscitation
efforts in order to practice medical procedures and that the code is not
called until the practice session is over. Can you tell me more about
this?

**Ms. Foglia**

Ken, there is evidence, both anecdotal and empirical that the practice
of prolonging the dying of nearly dead patients occurs. Some authors
claim that this practice will only increase, as more institutions
require consent prior to practicing on the newly dead.

A study by Kaldjian et al surveyed 234 internal medicine residents in 3
training programs and found that a third of house staff believed that
practicing procedures on imminently dying patients might be appropriate.
16% had actually done so. (Kaldjian, 1999)

The Wall Street Journal reported in 2002 that at one Midwestern
hospital, emergency room physicians established an unwritten policy that
they would no longer practice emergency procedures on the newly deceased
without obtaining consent. However, they now often use nearly dead
patients to train the hospitals residents, but don't inform the family
or ask for consent. (WSJ, 2002)

In light of this, I think when a facility sets policy regarding training
on the newly dead it needs to state unequivocally that unconsented,
unindicated training procedures on still-living patients is
unacceptable. There is really no way to defend the practice from an
ethical standpoint.

Finally, I want to note that some health care institutions are actually
billing insurance carriers for these procedures. Insurance carriers when
asked were unaware of the practice and in some jurisdictions this may be
considered fraud.

**Dr Berkowitz**

Now, to get back to the 'newly dead'. What are the accepted norms and
standards in this area?

Do any codes of professional ethics specifically address the issue of
obtaining consent for practicing on the newly dead?

**Ms. Foglia**:

Key professional associations have taken a position on the issue.

The American Medical Association's Council on Ethical and Judicial
Affairs weighed in on the issue by adopting a non-binding policy that no
training be performed on the newly dead unless the patient or family
members had given consent. (2000).

The Emergency Nurses Association endorses teaching skills and practicing
on the newly dead but only if consent is obtained.

The British Medical Association and Royal College of Nursing issued a
joint statement that practicing on the newly dead should be an
exceptional practice, and may only be justified if the body has severe
head, neck, or facial injuries, but the expectation is that even in that
case, consent will be obtained.

So far the American College of Emergency Physicians (ACEP) has not taken
an official position on the issue, but many of their constituents have
requested that they do so. Recently, the College posted an information
paper on their web site that called for additional research to help
inform policy regarding this issue.

**Dr. Berkowitz**:

Could you summarize the Ethics Center's position on this topic?

**Ms. Foglia**:

Sure, Ken

First, supervised and respectful training on the newly dead, with prior,
appropriate consent, is ethically acceptable.

Secondly, clinicians should not practice on the newly dead without
obtaining consent from the next of kin, or prospectively, from the
decedent.

Finally, extending resuscitation of a patient solely for the purpose of
training is ethically inappropriate and should not be done.

Although VHA does not have a policy that addresses this specific issue,
our mission is to create an environment that fosters collaborative
decision-making and promotes patient self-determination. One aspect of
promoting patient self-determination is to ensure that pre-mortem
preferences and values regarding the use and disposition of the body are
followed.

Our position is consistent with VA National Policy on Organ, Tissue, and
Eye Donation as well as the Uniform Anatomical Gift Act of 1987. We see
practicing on the newly dead to be ethically analogous to the situations
covered by UAGA.

Finally, in our view, clinicians can become competent in emergency life
saving procedures without sacrificing core ethical principles such as
consent.

Taken as a whole, the arguments against obtaining consent are not
ethically persuasive. They go against a strong ethical tradition that
consent be obtained for any procedure---pre- or post-death, and that the
next-of-kin is the proper decision-maker for any procedure after the
death of the patient.

# 

# MODERATED DISCUSSION

**Dr. Berkowitz**:

Thank you for that overview Mary Beth. Now we would like to turn to our
discussion, and I would like to know if our audience has any response to
the presentation or comments about the ethics of the position that Mary
Beth presented.

**Linda Williams, MD, Little Rock, AR**:

Was the data in the studies you mentioned on clinician attitudes toward
practicing procedures on the newly dead collected from practitioners who
do intubations or are required to learn intubation for their practice,
or was it collected from all clinicians in general?

**Ms. Foglia**:

Some studies looked at the attitudes of clinicians in general, and
others specifically looked at the attitudes of trainees in residency
programs. I should add that all the citations will be posted on the
summary of this call, so the reference materials will be available.

**Dr. Berkowitz**:

What was common to those studies, though, was that they surveyed program
directors to establish prevailing practice, so these are not just
disinterested parties.

Did you believe that would have a bearing on the results of the studies?

**Dr. Williams**:

Yes I do. I run a significant number of codes, and there are many
situations where intubation can be very difficult. I think clinicians
who are involved in codes have a higher interest in practicing and
developing this skill than people who have to think about it from an
empirical, historical, philosophical, ethical, moral viewpoint. The same
values are at stake, but I think how the various factors are weighted in
the decision-making process will be different for those more involved in
the actual life or death situations.

**Ms. Foglia**:

No one is suggesting that there is no benefit to practicing a procedure.
I think the issue, however, is whether or not consent is required, and
whether it should be incorporated into advance care planning.

**Dr. Williams**:

I think then this is analogous to decision-making capacity in that a
patient needs greater capacity to consent to a very involved procedure,
such as a coronary artery bypass graft with an aortic valve replacement,
and yet does not need the same level of capacity to consent to a tooth
extraction. When consent is given for one procedure that consent can be
extended to apply to the same procedure post-mortem. For instance, if
you have just been involved in a code, and you have been performing
procedures on the patient for 30 minutes before the patient is
pronounced dead, then some sort of consent is either implied or was
already obtained. The fact that the patient died does not negate that
pre-existing consent.

**Dr. Berkowitz**:

I think there is a difference between procedures performed for the
patient's benefit, and same performing the same procedure for the
purpose of benefiting others, like for teaching or research. Somehow the
reason for performing the procedure has to be figured into ethical
equation.

**Richard Frankel, MD, Honolulu, HI**:

I agree with that last comment. I think there is a difference between
asking someone to consent to practice procedures after death and an
autopsy, which may actually benefit the patient or family. Even then,
when approaching families to consent for autopsy, it is easy to blur the
line between asking to do an autopsy that might actually benefit the
patient or family, and one that will satisfy the clinician's curiosity.

On the other hand, practice procedures never benefit the patient. It
would be a very uncomfortable situation for any physician, particularly
a trainee, to ask permission to do that from a patient. It is more
appropriate to view it like organ donation and incorporate into the
admission process where the patient would automatically be asked, "If
you die are you an organ donor? If you die are you agreeable to having
trainees under appropriate circumstances practice certain procedures on
you?"

**Dr. Berkowitz**:

And that raises the question of how to operationalize obtaining consent
for post-mortem practice procedures. What you are suggesting is to do it
prospectively and consider doing it like organ donation or as part of an
advance directive. I do worry about the psychological consequences of
adding more questions to the general admission process like, "What do
you want us to do if you pass away? What are your wishes if you become
irreversibly ill? Can we have your organs? Can we use your body for
teaching purposes? This litany of questions could be potentially
traumatic for patients.

**Father William Wickham, Portland, OR**:

There are also the patient's religious values that need to be
considered. Will the chaplaincy be included in the decision-making
process to operationalize this to consider these religious values?

I would also like to add that I think consent has to be obtained if we
are going to respect the dignity of the deceased, unless the person has
given consent to donate his or her body to science.

**Dr. Berkowitz**:

I completely agree with you, and from an organizational ethics
standpoint the need to obtain consent and process for so doing needs to
be uniform throughout the system. The only way to develop good policy is
to base it on coherent information with all interested parties at the
table, and developing a fair way to apply throughout the organization. I
think that this question of post-mortem practice procedures is
definitely one that will touch on a patient's value system, and it would
be a mistake to develop policy without input from the chaplaincy.

**Ms. Foglia**:

Another issue is that the idea of harm itself is often at the heart of
an individual's cultural and religious beliefs. The medical conception
of harm, and the medical conception of respectful treatment is not
universally shared, and when a person's beliefs differ from the medical
norm, real tensions can surface.

**Chaplain Ron Stockhoff, Albany, NY**:

In terms of operationalizing this, I wonder if it could be treated as an
educational initiative. Brochures and handouts could be developed and
distributed along with information about organ donation and autopsy.

**Kathy Oman, RN, PhD, Denver, CO**:

I want to add my support to that idea. I am the author of the study with
the 100 older adults, and they were very surprised that post-mortem
practice procedures happened. They wanted to know more about it, and
wanted to be able to give consent in the form of an advance directive.

**Dr. Berkowitz**:

Before we would undertake a major educational effort to increase or
promote awareness and ultimately consent to do this, I think there needs
to be an assessment of how important is this as an educational activity.
Linda, you were arguing that it is very important, yet we know that half
or more than half of programs say they do not do it, and probably feel
they turn out competent clinicians. How do we then assess the
educational value of post-mortem practice procedures?

**Father Wickham**:

I think there should be a workshop on this. I would welcome a workshop,
if I could get funding to come.

**Chaplain Jack Klugh, Fargo, ND**:

I am hearing, what I think, are two different ideas. One is the idea of
donating to science or organ donation, and the second is the idea of
practicing. To me they give two different pictures. Now if you play
football, practice can be ten minutes or it could be five days. What is
the limit on the notion of practicing? For instance, what if someone
says, "Yes I'm open to practicing, but I'm not open to organ donation."

**Dr. Berkowitz**:

Most people are talking about practicing for less than half-an-hour on a
newly dead patient. The usual procedures practiced are intubation,
central line insertion, laryngoscopy, or that sort of thing. And, with
the exception of some needle sticks, they are not permanently
disfiguring or significantly disfiguring procedures.

**James Taylor, MD, New Orleans, LA**:

I was wondering if any consideration has been given to the forensic
consequences of these activities such as alteration of subsequent
post-mortem findings.

**Dr. Berkowitz**:

I think that's a good point. Certainly in some cases it would not apply,
but it certainly is an alteration.

**Maria Grenfell, RN, Iron Mountain, MI**:

I have a problem with some of this only because patients are already
overloaded with information on PAO, DNR, etc, when they are admitted. If
we start adding more to this, like consent to post-mortem practice
procedures, it will be even more difficult for patients to make
decisions.

**Dr. Berkowitz**:

I share your concern, and I think a process of giving all this
information to patients about post-mortem procedures and then asking for
consent can create the perception that there is an interest in the
patient dying so his or her body can be used for practice.

**Ms. Foglia**:

Again, the Oman study and some of the others say that people want the
opportunity. They want to be asked.

**Dr. Berkowitz**:

Does anyone on the line have a local policy that addresses this issue?

**Dr. Oman**:

We do in Colorado. We require the coroner release the body, and then we
require consent.

**Dr. Berkowitz**:

Is consent obtained at the time of death, or at some other point down
the line?

**Dr. Oman**:

At the time of death.

**Dr. Berkowitz**:

How would that work with the coroner needing to release the body?

**Dr. Oman:**

Frequently it is just a call to the coroner.

**Dr. Berkowitz**:

So the medical examiner has to sign off and say this is not an ME case.

**Dr. Oman**:

That's what we have in place for the past couple of years.

**Dr. Berkowitz:**

Has anyone had a case like this?

**Dr. Oman**:

That is how we got our policy. Someone was intubated in the field, and
then practicing occurred in the department. That prompted a two-year
look at practice, and then a policy.

# FROM THE FIELD

**Dr. Berkowitz:**

Now I want to turn to our "From the Field" segment, where we take
comments from our listeners on ethics topics [not]{.underline} related
to today's call. Please remember, no specific consultation requests in
this open format, but I invite you now to make your comments on other
ethics-related topics, or to continue our discussion on practicing
medical procedures on the newly dead.

**Dr. Williams**:

I just wanted to re-emphasize that there is a distinction between
post-mortem procedures that require consent and those that do not. It is
very different if you are going to practice line insertion or another
procedure that was not done in the code. For example, if there was a
very difficult intubation and the patient died, and now you want to find
out why you had trouble with that intubation. I think that is a
different thing that might not require consent. There are degrees of
what you can restrict and what you should not restrict, and I hope you
will take that into account.

**Dr. Berkowitz**:

The actual facts of the case and what you know about the patient should
also be considered. In the case that came to the Ethics Center, I found
it personally compelling that what they were going to practice was
exactly what the patient had asked them to stop doing. The patient was
being extubating, by the patient's request, and the proposal was to
practice putting the tube back after the patient died. I found that to
be particularly compelling fact of that case.

**Dr. Williams**:

I would certainly agree that it should not be done if it is a clear
violation of the patient's wishes.

**Dr. Berkowitz**:

And I think what you were saying before is that only the involved
parties are the ones who know the true value of what it is they are
going to practice, and that really needs to be considered. Oftentimes
people closest to the actual activity perceive more value than people
who are more removed from it. This is similar to organ donation, where
transplant surgeons are the most vocal proponents of presumed consent
for organ harvesting.

**Dr. Williams**:

I think that is certainly true. Again, organ donation is such a
magnitude removed from what is a routine CPR procedure of intubation
that I don't think the two are equivalent.

**Stuart Selikowitz, MD, White River Junction, VT**:

I have a background in both transplant surgery and research, and I do
not think that most of the procedures being discussed need to be
practiced on human beings. My research experience has shown me that
intubating a very large dog is almost the same as intubating a human.
Why we have to traumatize patient's families and patients with the
notion that somebody is going to intubate them if they die does not make
sense to me.

**Dr. Berkowitz**:

That gets back trying to objectively assess the value of this as an
educational activity.

**Dr. Selikowitz**:

There are some differences between a large animal and a human being, but
one can extrapolate from one to the other pretty easily. Virtual images
and computer models can also pretty well approximate a human being.

**CONCLUSION**

**Dr. Berkowitz:**

Well, as usual, we did not expect to conclude this discussion in the
time allotted, and unfortunately we are out of time for today\'s
discussion. We will post on our Web site a very detailed summary of each
National Ethics Teleconference. So please visit our Web site to review
today\'s discussion. We will be sending a follow up email for this call
that will include the links to the appropriate web addresses for the
call summary, the CME credits, and the references referred to.

I would like to thank everyone who has worked hard on the development,
planning, and implementation of this call. It is never a trivial task
and I appreciate everyone\'s efforts, especially, Mary Beth Foglia, and
Mr. Leland Saunders, other members of the Ethics Center and EES staff
who support these calls.

-   Let me remind you our next NET call will be on Tuesday, December 16,
    2003 at 12 noon. We are scheduled to consider whether separate
    signature consent should be considered for anesthesia as part of
    operative procedure. Please look to the Web site at
    vaww.va.gov/vhaethics and your Outlook e-mail for details and
    announcements.

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-   I will be sending out a follow-up e-mail for this call with the
    e-mail addresses and links that you can use to access the Ethics
    Center, the summary of this call and the instructions for obtaining
    CME credits, and the references that I mentioned.

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-   Please let us know if you or someone you know should be receiving
    the announcements for these calls and didn\'t.

-   Please let us know if you have suggestions for topics for future
    calls.

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-   Again, our e-mail address is: vhaethics@hq.med.va.gov.

Thank you and have a great day!

**References:**

Burns JP, Reardon FE, Truog RD. Using newly deceased patients to teach
resuscitation procedures. *N Engl J Med*. 1994; 331(24): 1652-5.

Fourre MW. The performance of procedures on the recently deceased. *Acad
Emerg Med*. 2002; 9(6): 595-8.

Doctors Question Use of Dead Or Dying Patients for Training. Paul
Glader. Wall Street Journal. November 12, 2002.

Oman KS, Armstrong JD, Stoner M. Perspectives on practicing on the newly
dead. *Acad. Emerg. Med*. 2002; 9(8):786-90.

Manifold CA, Storrow A, Rodgers K. Patient and family attitudes
regarding the practice of procedures on the newly dead. *Acad. Emerg.
Med*. 1999; 6(2):110-5.

Benfield DG, Flaksman RJ, Lin TH, Kantak AD, Kokomoor FW, Vollman JH.
Teaching intubation skills using newly deceased infants. *JAMA*. 1991;
265(18): 2360-3.

Gatrad AR, Sheikh A. Medical ethics and Islam: principles and practice*.
Arch Dis Child*. 2001; 84(1): 72-75.

Kaldjian LC, Wu BJ, Jekel JF, Kaldjian EP, Duffy TP. Insertion of
femoral-vein catheters for practice by medical house officers during
cardiopulmonary resuscitation. *N Engl J Med*. 1999; 341(27): 2088-91.