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Tue 19 Nov, 2002 08:43 am
I found this in The Tampa Tribune today. I could not find the link on the online edition. It was originally written in the Wall Street Journal. I found it in the WSJ. The reason I printed the article instead of a link on this long story, is because if you are not a subscriber to the WSJ, you will not be able to access the story.
I believe that it is a VERY important story, and needs to get wide coverage.
"Doctors Question Use of Dead
Or Dying Patients for Training
By PAUL GLADER
Staff Reporter of THE WALL STREET JOURNAL
Unbeknownst to the vast majority of family members, after a patient dies in the emergency room of many hospitals, a senior physician draws a curtain and supervises young doctors practicing several rounds of emergency medical techniques on the deceased.
In addition, several hospitals permit young doctors to practice on patients who are nearly dead, that is, who are technically still alive, but beyond the help of even extraordinary measures.
The procedures include inserting needles into major veins, drawing body fluids and performing endotracheal intubation, a technique for opening a person's airway. Though rarely discussed, the practices have been standard at many teaching hospitals, and some other hospitals, since the 1970s. Furthermore, hospitals sometimes bill the nearly dead patients' insurance company for the procedures performed for medical training.
The medical community is increasingly divided on the ethics of such practices. Two years ago, medical-student members of the American Medical Association asked the AMA's Council on Ethical and Judicial Affairs to study the issue and develop ethical guidelines for using newly dead patients for training purposes. As a result, the AMA adopted a nonbinding policy that no training be performed on newly dead patients unless the patient or family members had given consent. Since then, several of the nation's 1,100 teaching hospitals have stopped using newly dead patients for training or have implemented new rules regarding consent. The AMA didn't address the practice of doing medical training on nearly dead patients.
There are no hard numbers on how many hospitals engage in these practices and the ethical policies governing such training vary widely between hospitals, at times even among departments within a single hospital. "There is no consistency on this," says Jessica Berg, an assistant professor of law and biomedical ethics at Case Western Reserve University, Cleveland, who supports the AMA's calls for consent.
A paper published in the Journal of General Internal Medicine this month shows that controversy has surrounded the practice at least since the 1970s. "Physicians have a sense that this is not completely appropriate, and much of the practice flies under the radar," says Dr. Jeffrey Berger, one of the paper's authors, who practices at Winthrop University Hospital, Mineola, N.Y., and is Assistant Professor of Clinical Medicine at State University of New York at Stony Brook.
In a survey of 96 emergency-room directors, published in Academic Emergency Medicine in June, about half the directors said they were training residents on newly dead patients in their hospitals. Only four of the respondents said they had written policies requiring family members' consent for performing intubations on patients, while 76% said they "almost never" ask for such consent.
Doctors who support the practice say it is the best way to learn life-saving emergency procedures. "We don't get a magic wand," says Kenneth Iserson, a professor of emergency medicine and director of the bioethics program at the University of Arizona who uses newly dead ER patients to train his students. He defends teaching students on fresh corpses without consent. "We have to actually learn these procedures," he says.
"[The AMA's nonbinding ban is] a bad position. It's a bad policy," says Dr. Iserson, who also is head of the ethics committee at the University of Arizona Medical Center, "If the doctors in the emergency room units don't know how to do these procedures, these patients die," he says.
Catherine A. Marco, chairwoman of the ethics committee of both the Society for Academic Emergency Medicine and the American College of Emergency Physicians, said the college's committee had discussed the issue at length some years ago but didn't reach a decision "because there are so many divergent opinions" about the practice.
CONTROVERSIAL PRACTICE
In a survey, 45 emergency programs said they trained on newly dead patients. A breakdown:
Procedure Programs Using Procedure
Endotracheal intubation (opening airway with tube through mouth and into trachea) 42
Central line (drawing blood from major vein) 16
Cricothyrotomy procedures (inserting needle or knife and tube into neck) 11
Thoracotomy (opening chest wall) 3
Other 6
Source: Academic Emergency Medicine
An emergency room physician at St. Vincent Mercy Medical Center in Toledo, Ohio, Dr. Marco says the 14 emergency doctors there decided on an unwritten policy in the past five years that they wouldn't perform medical training on the newly deceased without consent. Instead, she says they often use nearly dead patients to train the hospital's 36 residents, but don't specifically tell family members or ask for consent.
Although training procedures on nearly dead are in the medical record, families of deceased patients are sometimes unaware of medical teaching, she says. "I'm not sure it is beneficial to explain that to grieving families," Dr. Marco says. "It would be kind of cruel to tell a grieving family we could have pronounced him dead five minutes earlier."
The patients' insurance companies can get billed for procedures used for training purposes in clinical settings, which can amount to hundreds of dollars, Dr. Marco says. These procedures fall into a gray area, she says: "Suppose in a resuscitation scenario we realize that the outcome is unlikely to be successful. We may perform a few more procedures that have a limited chance of benefiting the patient, but also serve a teaching function. The issue is not entirely clear since it is impossible in many cases to clearly separate the two objectives."
The idea of using dying patients for medical training shocks other experts. "I can't see how you would justify that ethically or legally, no matter what," says Case Western's Ms. Berg about the practice in general.
Representatives for insurance companies Aetna Inc., Hartford, Conn., and Philadelphia's Cigna Corp. said the companies weren't aware of such practices or that insurers were being billed for them. Susan Pisano, vice president of communications for the American Association of Health Plans in Washington D.C. said, "If this is a process largely hidden below the surface, it does need to be discussed in a very explicit and aboveboard way."
Then there are religious questions about these kinds of medical training. Some cultures and religions, such as Orthodox Judaism, believe the spirit of a newly dead person could be disturbed by postmortem medical practice. "This is something they should not be doing," says Rochelle Silberman, an administrator of the National Institute of Judaism and Medicine, in New York. "It's not right. It is unethical."
Dr. Paul Wolpe, a fellow at the Center of Bioethics and the University of Pennsylvania in Philadelphia, believes the AMA policy, though not binding, will serve as a "gold standard" for hospital ethics boards. He says the recommendation "is going to shut down an enormous number of procedures that are now being done without anyone's consent."
Doug Smith, a third-year medical resident at the University of Arizona's Medical Center in Tucson, says he agrees with Dr. Iserson that young residents learn best from newly dead patients. Board certification through the American Board of Emergency Medicine involves written and oral exams, but no physical demonstrations. "I think it is just like many ethical issues. There are definitely two sides to it," Dr. Smith says. " We are doing this to help the next patient who comes through the door."
Dr. Wolpe and other critics of the practice say it is damaging for young physicians to develop habits of performing procedures without consent. Dr. Leonard Morse of the AMA council and the University of Massachusetts, thinks the answer could be a simple consent form on admission to a teaching hospital to perform. "So many questions are asked when you enter the hospital, this would be another good one," he says.
Dr. Iserson says if residents can't train on newly dead patients, more emergency departments would resort to prolonging life support for nearly dead patients. In a study, published in 1999 in the New England Journal of Medicine, of 234 internal medicine residents in three training programs at hospitals affiliated with Yale University, a third of the residents said prolonging the life of patients for practice is appropriate and 16% had done so.
As an alternative, some hospitals such as Yale-New Haven Hospital in Connecticut, Stanford University Medical Center and the University of Pittsburgh Medical Center are using a combination of hands-on training on real patients and practice on the corpses of people who donated their bodies to science, on mannequins and, in a few cases, on animals. Some believe virtual reality, fiber-optic and mannequin technology will continue to improve as an alternative.
"There has been absolutely no motivation in the medical community, up till now, to find alternative training methods or to gain consent, because there has been tolerance of doing these procedures on newly deceased patients," says Dr. Wolpe. "I think the patience with that method has ended."
There are a number of important issues that need to be considered here.
Is it ethical to conduct procedures on patients who are almost dead, when it will do them no good?
Is it ethical to conduct procedures ondying or newly deceased patients without their families' permission, or knowledge?
Is it ethical for hospitals to charge the patient's health insurance for procedures that are not dome for the benefit of the patient?
Is it ethical to conduct procedures on newly deceased patients, when the procedure runs counter to the patient's religious beliefs?
Does the learning that a medical student derives by conducting the procedures outweigh any other ethical considerations?
Phoenix
Probably like most of us reading this, I had no idea such practices were in place. I am short of time this morning, but very much want to return here later and take up these questions.
Gawd.
Well, first off (sorry to take your questions out of order), the billing of insurance companies has got to stop. When insureds purchase a medical policy, it is for their care, not to pay for medical training. This is not only unethical but I am surprised insurance companies haven't sued over it. I bet they will, and then this practice will cease, post haste.
Secondly, the religious question is of some significance, and I think that's at least partially bound up with the question of consent. Hospitals have gone to court to try to, for example, have Jehovah's Witness parents consent to medical intervention for their minor children. While this may be a difficult process, it's open to all. Circumventing consent isn't open; it's underhanded. Patients' families have the right to feel betrayed - and those with religious considerations have probably had their civil rights violated.
The next question is, is it ethical to perform procedures that will do no good? Yes, I think it is, so long as there is consent and so long as said procedures do not create or prolong pain in the patient. Plenty of procedures are performed daily which will do no good or have a rather slender chance of doing good, such as providing blood transfusions to dying patients with uncontrolled bleeding. I don't have a problem with this so long as the above conditions re pain are met.
Finally, there is a definite benefit to having interns and residents practice on the newly dead and nearly dead. After all, in med school they only use cadavers and lab animals, and there are more and more restrictions on said usage all the time. Doctors need to learn somehow. I'd be pretty upset if my doctor was denied learning experiences which might help her save my life - but at the same time I wouldn't want those experiences to have come at the expense of a grieving family's consent or a dying patient's last wishes or last experience of suffering. I believe there is a benefit to this so long as it is done in the context of informed consent. I agree with the statement that permitting these procedures without consent may be sending a message to newly minted doctors that consent is some sort of unfair obstacle which patients and their families toss up just to be obstructionist to doctors. This is a dangerous way to think - it's the kind of thinking which results in overly paternalistic doctors who do things like tie the tubes of mentally disabled women 'for their own good' or put scarcely viable preemies through all sorts of medical hoops to 'save them' even when they can't be saved.
Oh - on a housekeeping note - Phoenix, can you please move this topic to Medical News? Thanks.
Oh my. This is a sticky issue.
A topic so important should be included in every health care directive so that each person can make their own decision instead of expecting their family to give consent in a time of grief.
Obviously, billing insurance companies for these experiements is wrong. I'll have to think a bit on the other issues as I'm not at all sure how I feel about this.
I spent three years in the Army Medical Corps, and so, after being separated from the services, spent another three years working in civilian hospitals, before giving up i disgust. By that, i do not mean that i had any knowledge of such specific actions, although it does not surprise me. I worked in one of the state-designated regional trauma centers in a midwestern state, and saw many things which appalled me. A man came into the ER once, dying (as it proved) from coronary failure. I called the man's physician of record, who was obviously very intoxicated. Although i told him i would call someone else, he came in anyway. It was necessary for nurses to physically block his access to the patient and his family. Fifteen minutes later, he was in my office, weeping and apologizing--then, eventually, snoring. This is an extreme case, but alcohol and drug abuse was common.
Medical students often preformed routine procedures--intubation, suturing, applying plaster casts--without the patient or family being specifically informed that the patient was not being treated by an MD. Doctors would privately discuss the failings of their fellows, but close ranks when outsiders were about. The same things can be said of nurses and nursing students.
By and large, doctors and nurses are a good lot, but there are two significant considerations in this special case. The potential for harm by bad practitioners is truly frightening. The arrogance and hubris of a few make hospitals and clinics unnecessarily stressful environments, while impeding any efforts at reform of the professions. This last reason is what eventually lead me to get out and stay out of "ancillary services" work. This is another aspect of the profession--those legions of aides, dietetic workers, clerks, warehousemen, all of those who support the "professional" efforts (as though their own efforts were not professional) are generally underpaid and overworked, and subject to daily verbal abuse by "professional staff." Nevertheless, doctors routinely pass off their duties in direct patient care to nurses, and nurses often pass off their duties in direct patient care to aides and orderlies. The notion that medical students need to practice many of these procedures is absurd--they may very likely go through their entire professional lives without ever again performing these procedures. I'd much rather have a nurse "stick" me than some arrogant and inexperienced doctor.
The problem is in part from the public, who treat MD's as infallible oracles. But this could qualify as blaming the victims. MD's themselves often quietly encourage this attitude--and humility and perspective are almost unknown in their ranks. To give some perspective, consider if you will that the human race has thrived and prospered for many, many millenia without "competent medical professionals." In the last 200 years, doctors and nurses have only gradually developed scientifically replicable and reliable procedures, and yet, the human race has witnessed an unparalelled (sp?) population explosion--the reasons? The automobile, and competent civil engineers and plumbers--pile all the doctors and nurses in the last two centuries in one big heap, and they have done less for human life expectancy than a handfull of engineers who have produced reliable automotive and train transportation--eliminating the human race's most chronic disease vector, horse manure in the streets. Clean water and efficient sewage removal and treatment rank second only to the elimination of the ubiquitous horse in society. Tell that to most MD's, and you'll be laughed at or get a patronizing response. Nonetheless, public and private non-draft animal transportation (i should work for the government) and clean water and reliable sewage systems are far more important to good public health than is the medical profession--who would still like you to believe that society owes them a great debt.
And this brings me to the final rub--by far, the majority of medical and nursing students whom i have known in my life calmly assert that, given how hard they've worked and sacrificed (although their spouses don't get a mention), and given how crucial they are to good public health (not true, see above)--society owes them a generous living, and a respect equivalent to that once reserved for an aristocracy.
OK, rant over.
I read this article in the WSJ, the other day. Imagine, keeping a patient on life-support for experimentation purposes and
NOT requiring a consent form.
My opinion is that any form of experimentation on the human body, without informed & signed consent is immoral and unethical and shoud be illegal.
I likewise agree that most if not all of these procedures DO NOT have to be learned on a human body. Many medical schools do not teach conventional gross anatomy anymore. They rely on computer simulation excercises and the use of dummies to simulate a human.
New Haven- Absolutely agree. I think that the findings in this article clearly illustrate the cavalier attitude of not only the medical profession, but society at large, as related to the aged, infirm, dying and simply vulnerable human beings.
The sad part of this is, that I don't think that the plight of these patients will engender much change in the way the medical profession does "business", as well as the attitudes of doctors towards dying patients. I think that what WILL bring about reform is when the insurance companies get wind of this. And to me, that is very sad!
Another situation, you'll commonly see in a Teaching Hospital is the performance of the
unnecessary autopsy.
Someone dies in the hospital , at the age of 90 years of heart failure, which is strictly due to old age, there's absolutely no reason to autopsy the body.The attendings encourage the autospies so that the residents get
TRAINING.
Insurance companies plus the lawyers!
New Haven- Amen to that. Usually, I am not crazy about lawyers building cases from out of nowhere. In this instance though, I would like to see the guilty doctors and hospitals sued up the wazoo!
Re: Doctors Question Use of Dead or Dying Patients For Train
Phoenix32890 wrote:
Is it ethical to conduct procedures on patients who are almost dead, when it will do them no good?
If it will do them no harm either, then I really dont see a problem with it, if that is the only concern. If a patient can lend some information in their state without harm, I dont think there is anything wrong with getting that information.
Phoenix32890 wrote:
Is it ethical to conduct procedures ondying or newly deceased patients without their families' permission, or knowledge?
Unfortunately, usually the time at which a family can be interviewed regarding these procedures usually is one in which they may not be able to make a decision of that nature. However, I dont think that it should be done without permission, I can very well understand why some of these procedures are done, and the fact that a recently deceased patient can provide the best learning environment for residents. Think of it this way, if you were in the hospital, would you want someone doing one of theese procedures if they had never tried it before? Still, I can understand why many people would be put off by the idea, and especially considering the timing of such a decision.
Phoenix32890 wrote:
Is it ethical for hospitals to charge the patient's health insurance for procedures that are not dome for the benefit of the patient?
It certainly is not. Since these procedures are done only for the information they provide, not for the care of a patient but, more for the care of physicians, the hospital should be paying for these procedures, and I cant think of how they could in any way get the health care industry to pay for it without some sort of violation.
Phoenix32890 wrote:
Is it ethical to conduct procedures on newly deceased patients, when the procedure runs counter to the patient's religious beliefs?
Certainly not. A patients rights/beliefs will certainly outweigh the fact that another patient may soon be there in which they can conduct procedures on.
Phoenix32890 wrote:
Does the learning that a medical student derives by conducting the procedures outweigh any other ethical considerations?
No, it does not. Doctors/students should carry themselves to the highest ethical levels possible, which in my opinion would have to include consideration first hand for the patients considerations.
Part of the informed consent form involves the care of the patient at the end of life. How does the patient want to die? What does the patient want done to his/her body at the end of life.
Those of us, who've worked professionally in hospitals know some of the unpleasant things that go on there. Suffice it to say, on admission to any hospital for treatment and/or a procedure make sure your wishes are made known in writing and make sure, your wishes are part of your permanent MEDICAL RECORD.
Be sure to have an ethical and reliable witness to all of your medical decisions. If you consult with a lawyer, do so OUTSIDE of the hospital.
Very good advice, Boss . . . to which i would add, if you have a physician who hesitates in the least to keep you informed, find a different doctor . . .
In those hospitals associated with a religion, I believe there is a higher ethical standard, relative to medical care, in place.
Ya lost me with that one, y'all have fun
seeyahbye
Wow, Phoenix, this article left me astounded that such things were condoned in hospitals.
The fact that they were done without the patient's or family's permission is what I find so terribly objectionable. It would seem that a patient, or family member, should provide consent to this practice upon entering the hospital, when he or she can make an informed decision. If this were done, the question of religious beliefs would also be addressed.
Billing insurance companies for these procedures is just plain wrong.
Whether these procedures are helpful to the learning experience, is something I can't answer. The doctors obviously think so or it wouldn't be an accepted practice.
Phoenix, once again you've found a topic of the utmost interest.
I had an uncle who had early onset alziemers, before he lost his faculties he was able to donate his brain and body to SMU Med School thus saving the family from and trials of tribulations re what was to be done. The school will be able to use his brain for many years and we will all benefits from his desire to assist the medical community. Bob was diagnosed in 1985 and died December 1995.
Based on my professional experience, I've found that most of the Catholic Hospitals, staffed by nursing nuns, do have higher standards of patient care and with this, higher standards of ethical and moral concerns.
i'm speaking as an unacceptable organ donor (because of cancer and chemotherapy) whose remains have been demoted from "use organs and tissues" to "use whatever possible in medical research".
Personally, I would accept the usefulness of my just-dead or nearly dead body as a teaching tool. I've taught all my life and the thought of being able to continue to do so is appealing to me. I think my cadaver might benefit more people as a teaching tool than as an anatomy lesson.
My living will and the living wills of my loved ones indicate our willingness to be used for training and research when dead. If there is no discomfort involved, being used while dying would not be objectionable to me.
These are my choices, not a universal precedent. Other people are entitled to make their own decisions. Individual rights should continue until the beloved is decently buried.
If enough people volunteer as inert teachers, there would be no need to infringe on the beliefs of those who feel differently.
If I knew that Blue Shield of PA was being charged for procedures done to my body for the sole purpose of medical education, I'd be haunting the hospital corridors in the administrative section for a long, long time--and I would make a particularly powerful avenging spirit.
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