Introduction

Training in procedural skills is an essential aspect of emergency medicine education. One approach to providing this training in the emergency department is to use the bodies of patients immediately after the pronouncement of death. This approach raises complex ethical issues.

Several principles regarding procedural skills training enjoy wide acceptance. Medically appropriate, compassionate care of all patients, including dying patients, is of paramount importance. Medically appropriate procedures should be performed on all patients, including dying patients, should be documented in the medical record, and should be appropriately billed. All procedures performed by learners should be appropriately supervised by qualified emergency physicians. Caregivers should respect the dignity of each patient until the time of death and should show respect for the body of the patient after death. Teaching procedural skills must not interfere with family visitation, autopsy, or forensic evidence collection.

At this time, opinions on some of the moral issues regarding the use of the newly dead to teach procedural skills are divided within the medical community.

1. Is teaching procedures using recently deceased bodies acceptable?

Several studies have demonstrated that practicing procedures on the newly dead is perceived to be an acceptable practice among the general public. ^i,ii Proponents of this practice assert a moral imperative to adequately train health care professionals in procedural competency. Allowing procedural skills training on newly dead bodies may be preferable to providing this training on living patients, since there is no risk of harm to a living patient, and there is no financial cost to the patient or family.

Although technologic advances may soon lead to realistic and practical alternatives to training on real patients, at this time such options are not widely available. The evolution of technologic alternatives for training in procedural skills, including mannequins, virtual reality, and similar devices, will be important to the development of additional educational approaches in the future.

2. Is teaching procedures using recently deceased bodies currently practiced?

Several studies have attempted to quantify the utilization of recently deceased bodies for teaching procedural skills. In one recent study, 47% of EM training programs reported the use of recently deceased for teaching purposes. ⁱⁱⁱ Another recent study showed that approximately 27% of teachers in emergency medicine had used recently dead patients to teach learners procedural skills, mostly without consent. ^iv Although intubation was the most commonly taught technique in this study, the practices of teaching other procedures such as central line placement, chest tube placement, cricothyrotomy, venous cutdown, and thoracotomy were also identified.

3. Should Consent Be Obtained?

The recent literature demonstrates that most adults believe that consent from family members prior to practicing procedures on the newly dead is appropriate. ^{v, vi, vii, viii, ix} Other options for the future may include a pre-morbid consent to use the body for teaching procedures, similar to an advance directive. Identification of such patients who have previously consented may be done with identification documents, wallet cards, or an accessible registry of patients who have consented. The AMA recently instituted a nonbinding policy regarding procedures on recently deceased patients, which states that consent should be obtained. ^x However, there is no consensus regarding this issue.

Several studies have demonstrated the feasibility of obtaining consent for postmortem procedures from family members. ^{xi, xii} In another recent study, however, only a minority of families consented to a postmortem procedure. ^xiii

Some commentators argue that obtaining consent is not feasible, may increase distress to the grieving family, and may inhibit the utilization of the educational practice. ^{xiv, xv} Anecdotal experience at some institutions with a policy that consent must be obtained suggest that required consent inhibits or eliminates the practicality of the teaching experience. Some advocate that a "don't ask, don't tell" approach may be appropriate. Some physicians believe that procedures may be taught using recently deceased patients without obtaining consent. Variations of this position include the view that procedures may be taught using recently deceased patients unless there is a previous refusal from the patient or family, and the view that consent from family should be obtained if family members are available, but teaching may proceed if the family is unavailable to consent.

4. Is additional research needed?

Additional research into the ethical ramifications, public opinion, and feasibility and consequences of familial consent in this setting, as well as other teaching settings, is needed. There are many unanswered questions in this setting, including the impact of policy on the feasibility of teaching procedures, the impact of requesting consent from grieving families, the significance of who requests consent, and public opinion regarding disclosure, etc. Unbiased data from well-designed research will prove helpful in the future development of policy that will serve the functions of guiding ethical and practical teaching methodology.

References

1. Oman KS, Armstrong JD 2nd, Stoner M: Perspectives on practicing procedures on the newly dead. Acad Emerg Med 2002; 9:786-90.
2. Tachakra S, Ho S, Lynch M, Newson R: Should doctors practice resuscitation skills on newly deceased patients? A survey of public opinion. J R Soc Med 1998 9:576-8.
3. Fourre MW: The performance of procedures on the recently deceased. Acad Emerg Med 2002; 9:595-8.
4. Denny CJ, Kollek D: Practicing procedures on the recently dead. J Emerg Med 1999; 17:949-52.
5. Goldblatt AD: Don't ask, don't tell: practicing minimally invasive resuscitative techniques on the newly dead. Ann Emerg Med 25:86-90, 1995.
6. Moore GP: Ethics seminars: the practice of medical procedures on newly dead patients - is consent warranted? Acad Emerg Med 2001; 8:389-92.
7. Berger JT, Rosner F, Cassell EJ: Ethics of practicing medical procedures on newly dead and nearly dead patients. J Gen Intern Med 2002; 17:774-8.
8. Manifold CA, Storrow A, Rodgers K: Patient and family attitudes regarding the practice of procedures on the newly deceased. Acad Emerg Med 1999; 6:110-5.
9. Kerns AF: Better to lay it out on the table rather than do it behind the curtain: hospitals need to obtain consent before using newly deceased patients to teach resuscitation procedures. J Contemp Health Law Policy 1997; 13:581-612.
10. http://www.ama-assn.org/apps/pf_online/pf_online?f_n=browse&doc=policyfiles/CEJA/E-8.181.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/CEJA/E-7.05.HTM&nxt_pol=policyfiles/CEJA/E-8.01.HTM&. Accessed 12/19/02.
11. McNamara RM, Monti S, Kelly JJ: Requesting consent for an invasive procedure in newly deceased adults. JAMA 1995; 273:310-2.
12. Benfield DG, Flaksman RJ, Lin TH, Kantak AD, Kokomoor FW, Vollman JH: Teaching intubation skills using newly deceased infants. JAMA 1991; 265:2360-3.
13. 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; 25:660-5.
14. Iserson KV: Law versus life: the ethical imperative to practice and teach using the newly dead emergency department patient. Ann Emerg Med 1995; 25:91-4.
15. Orlowski JP, Kanoti GA, Mehlman MJ: The ethics of using newly dead patients for teaching and practicing intubation techniques. N Engl J Med 1988; 319:439-441.

Developed by the American College of Emergency Physicians
Ethics Committee
January 2003

Catherine A. Marco, MD, FACEP, Chair
John A. Brennan, MD, FACEP, Board Liaison
Clark D. Chipman, MD, FACEP
Arthur R. Derse, MD, JD, FACEP
Mila L. Felder, MD
Joel M. Geiderman, MD, FACEP
William E. Gotthold, MD, FACEP
Marc M. Grossman, MD
Kathryn L. Hall-Boyer, MD, FACEP
Robin R. Hemphill, MD
Kenneth V. Iserson, MD, MBA, FACEP
Gregory L. Larkin, MD, MS, MSPH, FACEP
Sharon M. Leipzig, MD
David L. Morgan, MD, FACEP
John C. Moskop, PhD
Raquel M. Schears, MD, FACEP
Robert C. Solomon, MD, FACEP