Author: Hashim Zaidi, MD (EM Resident Physician, PGY-1, NUEM) // Edited by: Carrie Pinchbeck, MD (EM Resident Physician, PGY-3, NUEM) // Expert Commentary: Dave Lu, MD
Citation: [Peer-Reviewed, Web Publication] Zaidi H, Pinchbeck C (2016, June 21). Perimortem Procedures: Yes or No? [NUEM Blog. Expert Commentary by Lu D]. Retrieved from http://www.nuemblog.com/blog/perimortem-procedures/
The Procedure of A Lifetime
After a prolonged battle with cancer Ms. Jeanenne Smith, an 89 year old female, was brought to the emergency department in cardiac arrest. Upon arrival ACLS was initiated, however, all members of the team recognized that efforts would likely be futile. When her husband arrived, resuscitative efforts were ceased at his request based on a discussion of the current situation and the patient's wishes expressed when she was alive. Shortly after the death pronouncement there began a conversation among the care team about obtaining permission from Mr. Smith to perform certain post mortem procedures for purely educational value. Procedures such as surgical airway techniques that could be life saving but had never been performed by most of the residents present. The subject seemed taboo to even discuss and with the adrenaline of the resuscitation still flowing, heated opinions began to emerge concerning the ethics, legality, and repercussions of performing procedures on the recently deceased.
This issue often presents when there is a need for education in a specific procedure that is rarely performed, which in our particular case was a cricothyrotomy. An emergency physician’s familiarity with airway anatomy and proficiency with airway management is an expectation not only of any training program but from society as a whole. While there has been a dramatic decrease in the number of cricothyrotomy published numbers thanks to advances in airway education, equipment, and innovation, the incidence still ranges from 0 to 18.5% of all secured airways varying with the setting, patient, and provider characteristics [1]. Some physicians such as Dr. Kenneth Iserson, an emergency physician and staunch supporter of training on the recently deceased, mention the societal expectation of competence with critical life saving procedures as impetus to practicing and teaching on the newly dead [2].
Opportunities for learning, however, come from a small mixture of sources ranging from actual emergency department airways, to the operating room, to increasingly accurate simulation models. Makowski found in a recent survey of nearly 300 graduating US emergency medicine (EM) residents that less than a quarter (22%) had performed a cricothyrotomy on a living patient prior to completing residency training [3]. In terms of controlled practice, the alternatives to the recently deceased are many but each come with advantages and drawbacks. Simulation models are becoming increasingly inexpensive but still fail to match the real world complexity of multilayered tissue. Cadaver labs match anatomy planes to a degree but preserved cadavers lack tissue elasticity and preservative often distorts realism. Live animal labs present a whole new realm of complications in ethics in addition to expense, availability, and safety concerns. Resident learners having performed the procedure on the recently deceased in conjunction with simulation, however, did report higher levels of comfort in performing the procedure than simulation alone.
Examining post mortem practice of the procedure has led to a spectrum of opinions on the topic over the last several decades. Opponents of the practice cite that the process can be perceived as disrespect for the human body and may compromise the relationship between the providers and family during a critical time irrespective of approach. Cultural, religious, and community practices as well as level of medical insight may all influence a family's perception of a request for an unknown procedure on their recently lost loved one [4]. Many argue that the approach or request no matter how conscientious would leave some family members in horror and that there are few educational endeavors worth such an impact.
Additionally, state laws and hospital policies all have varying levels of medicolegal interpretation on a subject that is often still too infrequently discussed. Legal rights over the body exist currently with ‘quasi-property rights’ for the family and loved ones; these refer to the interests of relatives for cadavers and are allowed possession and control of the body for the purposes of proper burial and disposal in accordance to the decedent’s beliefs and values [5]. This legal semi-state has been used by both proponents and opponents of postmortem procedures as well as organ procurement for and against practices with courts siding with varying sides depending on individual circumstances.
While autopsy is often a question proposed to a decedent's survivors, little in the way of precedent for immediate post mortem procedures currently exists. Which family members are the correct ones to ask? What if the question poses disagreement among members present or family members who hear of it later after the ED encounter? Legal representation from medical insurance companies may also not cover this unique scenario if complications or damages are claimed. Additionally, Tomasini et al. recently explored the difficult question of whether post mortem harm from providers is possible. The answers the authors reveal challenge what medical providers reasonably perceive as harm and what loved ones may endure in their perception of what is occurring to their significant other [6]. Specific examples cited often revolve around issues of failing to obtain the proper consent particularly in pediatric populations leaving understandable widespread grief among survivors and family members.
In contrast, proponents of post mortem procedures for educational purposes detail that when conducted in the proper manner the practice allows for respect to the deceased and upholds the ideals of respect for those who have passed. Given a structured, supervised, bedside teaching environment to perform a novel technique in a way that cannot be fully replicated in a simulation lab or animal lab is a uniquely realistic learning experience. The venue is also inexpensive, readily available and can not cause harm to a deceased individual. While many authors such as Iserson would suggest that explicit consent is not required, the prevailing opinion in the modern medico-legal environment is that consent would be the proper approach from the next of kin or family of the decedents and that to proceed under implied consent would subvert the physician's fiduciary duty to his or her patients. While only “quasi” property rights exist, they are rights of the family and next of kin and to ignore them for education or otherwise would be unethical; in addition, such a practice could open the door to ignore such rights for less noble purposes as well.
What about the notion that even attempting to obtain consent could cause irrevocable harm? Several studies conducted in ICU and emergency department settings have attempted to look at the success of obtaining consent. Most notably, Olsen et al. in 1995 had attending physicians try to obtain post mortem procedural consent via a developed script from families and found 39% consented to cricothyrotomy on their loved one as a teaching tool. Forty five percent in that study refused and 16% were deemed too distraught to approach by the physician [7]. Most interestingly, on a 6 week follow up only one family reported being offended by the request while 12% percent did not recall the request. Each individual physician may have personal preferences as to what an acceptable number is that may be offended by such requests. Regardless, consent seems to be feasible when performed in a thoughtful and empathetic manner. Many advocate that an approach based on values would result in the greatest success. Asking next of kin if their loved one was a generous person and would they have been interested in making one last contribution even in death via education of others is an approach advocated by Goldblatt [8].
Like many aspects of emergency medicine however, the protocol or standard is sometimes overruled by the patient or family in front of you. Each individual family or death is an emotionally trying time with circumstances that emergency providers are often not privy to. Utmost care must be taken when requesting something that is not medically necessary. Aside from hospital ethics and policies, in addition to regional legal stature, if any factors complicate an individual's death then they would be far from the ideal candidate for obtaining consent for post mortem procedures. If post mortem procedures are to be requested of a patient’s next of kin it should be when the relationship between family and physician are in such a condition that the trust and sanctity surrounding death would remain no matter the decision to proceed with a post mortem procedure.
A multitude of legal and ethical issues surround performing procedures on the recently dead. Additionally, consequences to the deceased, their loved ones, the medical care team, and to the public exist with such a practice. The rights of the patient and loved ones as well as the virtues expected to be demonstrated as healthcare providers and institutions come into question. Post mortem procedures are a polarizing issue; however, through discussion and discourse the practice may be reformed from a social taboo to a regulated and appropriately elected process with ethical, legal, and professional groundings given the proper environment and culture.
Expert Commentary
Hi Hashim,
This is a very interesting topic that engenders much debate. No matter what side you are in favor of, it is important to know the guidelines and laws surrounding the issue.
What do professional guidelines say?
- AHA (1992): The practice of resuscitation procedures is ethically justifiable.
- President’s Commission (1993): Specific consent from next of kin should be obtained only when clinicians go beyond the normal scope of teaching.
- AMA (2002): Training procedures should not be undertaken without reasonable efforts to obtain informed consent from families. If these efforts fail “the training supervisors must forgo the training opportunity”.
What does the law say?
- Issue is governed primarily by state law, so know what it is in your state!
- Some examples:
- Illinois: One could be charged with Abuse of a Corpse (Class 2 or Class 4 felony) if one removes or engages in conduct with a corpse without authority. Physicians and students are exempt if performing “acts in accordance with usual and customary standards of medical practice” or acts “in furtherance of his or her education at the accredited medical school.”
- New York: One could be charged with a misdemeanor if one engages in “dissection of a body without legal right or permission of the deceased”.
- Ohio: One could be charged with Abuse of a Corpse (misdemeanor of the 2nd degree) if one “treat[s] a human corpse in a way that he knows would outrage reasonable family sensibilities.” Alternatively, one could be charged with Gross abuse of a Corpse (felony of the 4th degree) if one “treat[s] a corpse in a way that would outrage reasonable community sensibilities”.
What have the courts said?:
- Burney v. Children’s Hospital in Boston (1897): Father of the deceased sued after the hospital performed an autopsy on his son without consent. Court found in favor of the father based on a “right of possession for the purposes of burial and other lawful disposition.”
- Lacy v. Cooper Hospital/University Medical Center (1990): Parents sued after a pericardiocentesis was performed after their son was declared dead. Court held the degree of mental distress suffered by the family was not severe enough to meet the requirements for intentional or negligent infliction of emotional distress.
As one can see, state and case law on the issue can be variable and open to interpretation based on the particulars of each case (it’s always about the details). From an ethical standpoint though, I firmly believe that the physician ought to obtain permission from the family of the newly deceased before practicing any procedure for educational purposes. These conversations require skill and sensitivity, and if the family cannot be reached or is unwilling, the physician should forgo the procedure(s). Altruism on the part of the deceased or the surviving family cannot be assumed or enforced, and physicians cannot jeopardize the trust of the public. However, there is undeniable value in being able to practice otherwise rare, life-saving procedures for the benefit of future patients, so I encourage physicians to engage families on this request in appropriate settings and with the utmost care and compassion.
Dave W. Lu, MD, MS, MBioethics
Assistant Professor; Department of Emergency Medicine; Northwestern University Feinberg School of Medicine
References
- Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy--a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21:43.
- Iserson KV. Postmortem procedures in the emergency department: using the recently dead to practise and teach. J Med Ethics. 1993;19(2):92-8.
- Makowski AL. A survey of graduating emergency medicine residents’ experience with cricothyrotomy. West J Emerg Med. 2013;14:651-661.
- Ardagh M. May we practise endotracheal intubation on the newly dead?. J Med Ethics. 1997;23(5):289-94.
- Moore GP. Ethics seminars: the practice of medical procedures on newly dead patients--is consent warranted?. Acad Emerg Med. 2001;8(4):389-92.
- Tomasini F. Is post-mortem harm possible? Understanding death harm and grief. Bioethics. 2009;23(8):441-9.
- 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.
- Goldblatt AD. Don't ask, don't tell: practicing minimally invasive resuscitation techniques on the newly dead. Ann Emerg Med. 1995;25(1):86-90.