Balancing respect for dying with the need to hone skills

Many ethicists find practicing medical techniques on dying patients indefensible, but, according to a recent study, some residents believe it's sometimes OK.

By Vida Foubister, amednews staff. Jan. 24, 2000.

Should housestaff perform procedures that aren't medically indicated on dying patients to improve their skills and thus benefit future patients?

The authors of a New England Journal of Medicine study -- in which 34% of the residents surveyed at five Connecticut hospitals said it is sometimes appropriate to do so -- say no.

Training on the near-dead

"Practicing physicians at the bedside have a first and primary responsibility to the patient in front of them," said Lauris C. Kaldjian, MD, assistant clinical professor of medicine at Yale University School of Medicine. "If they give up that primary responsibility, then patients have a right to be concerned when they go to their doctor, to wonder, 'Is this doctor really acting in my interest or in someone else's interest?' "

Dr. Kaldjian and his colleagues undertook the study after a student in an ethics tutorial brought up an incident similar to the example used in the study; the example was the insertion of a femoral-vein catheter for practice during the cardiopulmonary resuscitation of an elderly patient who is not expected to survive.

Though many involved in training programs admit it's a tempting option, they were surprised by the level of its acceptance.

"It may reflect the fact that we're talking with students who are still in the process of being acculturated in the profession and have not yet adopted all the norms and standards we have as physicians," said Robert Orr, MD, director of clinical ethics at Loma Linda University in California.

Like house officers in the study who said they believe inserting a femoral-vein catheter for practice is sometimes permissible, Charles Rainey, MD, a forensics fellow in psychiatry at the Medical College of Wisconsin, Milwaukee, views it as an opportunity to improve clinical skills and benefit future patients.

"We're making an assumption that [the patients] would be altruistic," he said. "If the family consents, it's both ethically and legally permissible."

One option, said Arthur Caplan, PhD, director of the University of Pennsylvania Center for Bioethics, Philadelphia, is asking patients for their "blanket" permission upon their entering a teaching hospital as opposed to asking the family during an emergency resuscitation.

"That's very tough to get under the circumstances, so I like the blanket approach better," he said.

But Dr. Kaldjian and others, including Herbert Rakatansky, MD, chair of the AMA's Council on Ethical and Judicial Affairs, said that even with informed consent, it is unacceptable for physicians in training to practice catheter insertions on dying patients. In fact, it violates the Code of Medical Ethics.

"If it's not necessary for the patient's welfare, it's not appropriate to do it," Dr. Rakatansky said.

Asking the family of a dying patient for consent also raises questions.

"I'd have a hard time seeing a family give informed consent for an invasive procedure to be done on someone when it was not required," said Lawrence Shuer, MD, chief of staff at Stanford Hospital and Clinics and associate dean for graduate medical affairs at Stanford University in California. "I just can't see the logic in it."

For Dr. Shuer, that reluctance extends to the newly dead, a practice that was discussed at a recent CEJA open forum.

"Today, with what we have in terms of models, I don't think that sort of practice is necessary," he said.

That's not an opinion shared by all doctors.

Kenneth V. Iserson, MD, director of the bioethics program at the University of Arizona Health Sciences Center in Tucson, has long advocated for continued use of the newly dead for training purposes.

"It's been done for generations of physicians without consent and with a tacit understanding," he said. "We have to learn somewhere."

CEJA plans to present a report on the use of the newly dead for training purposes to the AMA House of Delegates this year.

Even if this option is found to be acceptable in some circumstances, it's not useful for all procedures, including the catheter insertion that was studied. Still, Dr. Kaldjian maintained there are alternatives to practicing on dying patients.

"There are other ways of learning skills, but they take more effort," he said. "What is at stake here is so important that we ought to be putting that effort forward."

ADDITIONAL INFORMATION:

Training on the near-dead

Of 234 house officers asked about the insertion of femoral-vein catheters for practice during cardiopulmonary resuscitation of patients not expected to survive:

34% said the insertion is sometimes appropriate.
26% said they've observed someone else do the insertion.
16% said they've attempted the insertion themselves.
13% said they've been asked to do the insertion.
6% said they've asked someone else to do the insertion.

Source: Lauris C. Kaldjian, MD, et al., "Insertion of femoral-vein catheters for practice by medical house officers during cardiopulmonary resuscitation," New England Journal of Medicine, Dec. 30, 1999