AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2005, Volume 7, Number 1.

Module 4

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Case 4.2: Practicing a Procedure on the Newly Deceased—Mrs. Milos's Pericardiocentesis

Additional Information

Performing procedures on the newly deceased for training purposes without gaining permission from the family violates the norm of respect for deceased patients and their families. It also threatens to undermine the trust in the medical profession that is so pivotal to its relationship with the community. Because the patient receives no benefit, the traditional concept of presumed consent does not apply here, and there can be no waiver of informed consent.

Opinion 8.181, "Performing Procedures on the Newly Deceased for Training Purposes"

Physicians should work to develop institutional policies that address the practice of performing procedures on the newly deceased for purposes of training...[that] ensure that the interests of all parties involved are respected under established and clear ethical guidelines...The following considerations should be addressed before medical trainees perform procedures on the newly deceased:

(1) The teaching of life-saving skills should be the culmination of a structured training sequence, rather than relying on random opportunities. Training should be performed under close supervision, in a manner and environment that takes into account the wishes and values of all involved parties.

(2) Physicians should inquire whether the deceased individual had expressed preferences regarding handling of the body or procedures performed after death. In the absence of previously expressed preferences, physicians should obtain permission from the family...When reasonable efforts to discover [such] preferences...or to find someone with authority to grant permission...have failed, physicians must not perform procedures for training purposes on the newly deceased patient.

This opinion challenges the claims put forward by both the President's Commission [1] and the American Heart Association [2] regarding intubation—both have argued that this non-invasive procedure can be performed without consent. This will remain a contentious issue, but the primacy of respect for patient and family preferences suggests that even these non-invasive procedures require permission. Similar to the views on organ donation in the United States, there should be a presumption of refusal which can only be overcome by previously expressed preferences or family permission.

Regardless of Dr. Desai's decision about attempting a pericardiocentesis, in Opinion 8.18, "Informing Families of a Patient's Death," the Code is clear that Lydia and Carl should not be asked to inform Mrs. Milos's son of her death. If Dr. Desai has some prior experience informing families of a patient's death as the treating physician in the ER, she may be in the best position to inform the patient's family. Outside of the ER, it is much more likely that the resident on the case would not be primarily responsible. Instead, as Opinion 8.18 explains: "Physicians in residency training may be asked to participate in the communication of information about a patient's death if that request is commensurate with the physician's prior training or experience and previous close personal relationship with the family."


References

  1. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Research Involving the Comatose and Cadavers in Implementing Human Research Regulations. Washington, D.C. Government Printing Office. 1983:39-41.
  2. Emergency Cardiac Care Committee and Subcommittee, American Heart Association. Guidelines for Cardiopulmonary resuscitation and Emergency Cardiac Care, VIII: Ethical Considerations in Resuscitation. JAMA. 1992;268:2282-2288.

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