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Procedures on dying patients are wrong, study concludes

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7228.137 (Published 15 January 2000) Cite this as: BMJ 2000;320:137
  1. James Ciment
  1. New York

    The practice of allowing trainee doctors to acquire skills by carrying out procedures on dying patients has been challenged by doctors in the United States, who claim that it is an unacceptable departure from the normal system of requiring informed consent. Moreover, many trainee doctors themselves are opposed to carrying out certain of the procedures, the doctors say.

    The authors of the study, whose results were published in the New England Journal of Medicine (1999;341:2088-91), asked 234 trainee doctors in Conncticut to consider the following scenario: an elderly inpatient is receiving cardiopulmonary resuscitation; after 20 minutes there is no response from the patient, who seems to be dying. The doctors were asked whether they felt it was ever appropriate in such a situation for a trainee doctor to gain experience by inserting a femoral vein catheter.

    The researchers found that two thirds of the doctors were opposed to conducting the procedure in such a situation and a third approved. Most of those who opposed the procedure did so on the grounds of patient autonomy.

    Significant minorities also opposed the practice because it “represented a violation of human dignity” (29%) and because of lack of informed consent (18%). Of those who approved of the procedure, the vast majority cited the “need to improve clinical skills so that future patients would benefit.”

    Insertion of a femoral vein catheter was chosen, said the authors, because it is a common procedure that entails little interference with the ongoing performance of cardiopulmonary resuscitation.

    The study also found that the procedure is relatively widespread, with 42%of the respondents saying that they had either conducted it themselves (16%) or seen it performed by others (26%).

    The authors of the study, however, concluded that such procedures are an “unacceptable departure from a system of medical ethics that emphasises the centrality of the patient's well-being and the need for informed consent.”

    They also express concern that “clinical education may unintentionally reinforce attitudes that can reduce patients to mere objects of use in education.”

    “I have had physicians express anger at me for this study,” said Thomas Duffy, one of the five authors of the study and a physician at Yale University School of Medicine.

    “In the current climate—in which people are very suspicious of what happens to them in hospital—it is critical that we address this subject. I feel it is best that physicians write about this, rather than non-physicians exposing it first in an unflattering and inaccurate light.”

    A spokeswoman for the BMA said that the process of intubating a patient who was dying but still alive could not be justified because doctors were not allowed to do anything that was not in their patients' best interests. But the ethics of teaching a junior doctor how to intubate someone, using a patient who was newly deceased, were different.

    “Even when the patient is clearly dead, however, the practice is likely to be distressing for relatives, and this has given rise to dilemmas for health professionals,” she said. Staff would feel very uncomfortable carrying out such procedures in the absence of consent, but they also realise that the end of an episode of failed resuscitation is not the time to ask relatives' permission.

    The practice of intubating newly deceased patients was common in accident and emergency departments and some obstetric units in the United Kingdom in the early 1990s, she added. Some staff had expressed concern that the procedure was performed without consent and without ethical guidelines.

    This combination of staff anxiety and lack of any form of authorisation is thought to have made the practice less common in the United Kingdom, though no accurate figures exist.


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    (Credit: WELLCOME TRUST PHOTO LIBRARY)

    Central venous catheterisation—should doctors be allowed to learn the technique on dying patients?

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