THEETHICSOFPRACTICINGPROCEDURESONTHENEARLYDEAD

The report from the field was not promising by any stretch, extensive trauma, and perhaps most importantly unknown “downtime” (referencing the period where the patient received no basic care like CPR). The patient remained pulseless en route, we were all aware of the markedly poor prognosis.

On arrival the patient was swarmed by providers. Trauma surgeons at the foot of the bed cut down at the femoral artery to deploy a device that might mitigate bleeding – still in experimental stages. The patient’s ability to safely breath was certainly compromised, a tube in the trachea will solve that. Where the blood went was the question, tubes inserted into each of his lung cavities could reveal the answer. Replacing some of what was lost was important too, a straw-sized catheter into a major vessel can help there. The surgeons’ device hadn’t had any appreciable impact so a large cut was made across the left side of the chest – might as well examine the heart and hub of potentially bleeding things in the area. The heart was empty, a surefire sign of as yet unidentified bleeding; contractions were rare and spastic. The time of death was declared and the frenzy of activity ceased.

Students and residents crowd around the open chest cavity as the chief resident explains the procedure and exposed anatomy – a student lingers to close the wound. The bedside ultrasound that revealed fluid in the abdomen was repeated and the unique findings were explained to eager learners. People file out slowly, sharing feedback about the resuscitation, it’ll go even smoother next time.

It’s a common scenario. By most measures this patient was both dead and unsalvageable. The futile attempt at resuscitation was recognized by most at the outset, but proceeded because it provided a bounty of critical experiences for trainees at all levels – experiences which in the future could prove life-saving. Ethical concerns surrounding this tacitly recognized activity are plentiful and our unease as providers suggests that we recognize this though are unsure of how to reconcile our feelings. The major difficulties are as follows:

  1. Patients have a right to have critical procedures performed by experienced providers.
  2. Effective training requires live practice and can at best be only supplemented by simulation (cadavers/models).
  3. Obtaining informed consent is challenging. Patients and their families are not adequately educated regarding the nature of medical training and the operation of teaching hospitals. Further, these discussions are often not feasible during a resuscitation, or may appear insensitive after a failed resuscitation.
  4. Providers may be deceptive by extending failed resuscitations in attempts to secure procedures for trainees.

The importance of these experiences for trainees is without question. Patients deserve to have experienced providers performing critical procedures, though that in turn requires a sufficient number of those very procedures to gain competency. Teaching hospitals mitigate this discrepancy by closely supervising trainees until procedural competency is achieved.

To secure the necessary certification, training programs must provide sufficient exposure to allow trainees to become proficient at the performance of these critical procedures. Most are common enough that trainees gain competency relatively early in the training period. Others are more rare, and unfortunately still more critical. These prized procedures are indicated in only the most critically ill patients – they are staggeringly invasive but potentially life-saving. It is conceivable that experience gained through resuscitations extended despite a low probability of favorable outcome could be beneficial to future patients.

The solution to this predicament is challenging. What is evident is that patients are not sufficiently educated regarding the nature of medical education and that this leads to dishonesty by providers (who are merely trying to secure the training of their residents for the betterment of future patient care) and a critical breach in the implicit trust of the patient-physician relationship. Some possible responses would be to increase awareness of medical education and training practices through public service announcements – followed by an opt-out policy similar to organ donation in many countries. I’m mostly curious to hear what others think of this practice and how you would feel if you or a family member was in a similar situation.

References:

  1. Jetley AV, Marco CA. Practicing Medical Procedures on the Newly or Nearly Dead. Chichester, UK: John Wiley & Sons, Ltd; 2012:299–310. doi:10.1002/9781118292150.ch27.

  1. My wife and I were in a similar position in 2004 – 2005. In 2004 we found out that our in-utero daughter had Hypoplastic Left Heart Syndrome as well as Turner’s Syndrome. We met with specialists, both cardiologists and a genetic counselor. We completed stress tests twice weekly, and continued talking to doctors about what our daughter Ella would need for life. Ella was born and immediately admitted to a Children’s Hospital ward, and the next day underwent open-heart surgery. She stayed in that hospital room for the first three weeks of her life.

    Probably late in the second or early in the third week of that stay, we were discussing with the surgeons plans for the next operation in the series (the Norwood, if memory serves). Just before leaving the room they mentioned, off-handly, something about an eventual heart transplant.

    My wife and I were both surprised. The doctors seemed surprised at our surprise. We eventually clarified that the surgeries and other therapies were merely palliative, that, in fact, Ella would need a heart transplant sometime between 12 and 20 to continue living. Up to that point we had only discussed the open-heart surgeries and the eventual genetic treatments necessary. No one had mentioned anything about the inevitability of the heart transplant.

    This doesn’t line up precisely with what you’re after but I feel there are enough similarities to mention. If I felt for a moment that the series of surgeries advised were mostly for instructive purposes, that there really was no long-term positive prognosis for our daughter, I can’t say how I would’ve felt. As it was, the news was pretty tragic for us. I understood, though, that there were mitigating circumstances, that precious as she was my daughter was probably not the object of a conspiracy or malfeasance.

    Ultimately, the issue was about communication. If we had known prior to her being born that Ella would not only have the hard life of which we had been made aware, but an even harder life, I’m not sure we would’ve decided anything differently but we would’ve been able to make decisions with all reasonably available knowledge.

    I guess, for me, if the situation were slightly different and matched more closely yours in the post, I would prefer to have that little bit of time spent educating me and trusting me and helping me make the best decision possible in the situation. I don’t have the working experience of a doctor in that situation but my just-now not-quite-as-cycnical-as-usual self thinks that many people have sufficient reasoning faculties as to be able to take in that information and reason effectively.

    But I guess, slightly more cynically, maybe not, in the wake of the Trump effect.

    Hope you’re well!

    Daniel Black

    Dec 23, 04:42 PM #

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