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Dear Boss,
We recently started a teaching program at our facility and have run into a sticky scenario. One of our attendings took a resident and, after clearing the case with the coroner, allowed her to do an intubation on an 80 year old who had just died. All was well until a member of our nursing staff wrote the attending up for “unprofessional behavior”. When I was a resident this was fairly standard practice but we’re practicing in a new world. How are other teaching facilities handling this?
Sincerely,
Old School Educator
 
Dear Old School,
This issue is even more complex than it may seem on the surface. The good news is that there is a substantial amount of data available. The bad news is that few concrete conclusions have been drawn. This issue intersects ethics and legality and when you consider all of the potential issues it raises, it is actually pretty fascinating.

I am not at all surprised by the nurse’s actions. I have heard the same response from nursing when I worked at academic institutions and from colleagues since that time. I believe most that oppose post-mortem procedures do so due to the “indignity” caused to the recently expired patient. 

Technically, once pronounced, your patient no longer has rights. He can’t vote and he can’t be drafted. In terms of your responsibility to treat the patient, your duty to act ceases when the patient dies.

That said, ownership of the remains transfers to the next of kin, and they certainly have rights. In the most strict sense, you don’t have authority to perform any post-mortem procedures without their permission. Such permission can be obtained as part of the general consent to treatment that all patients sign at the hospital or you could seek it later. Personally, I think it would be very appropriate to seek permission verbally once the patient has been pronounced. This verbal consent does not have to be a formal process, and in fact, making it a big deal with official forms will likely make the family think it is a big deal, resulting in their refusal of consent. But no matter how it is obtained, consent needs to be documented somewhere.

Families typically understand that this is their loved one’s last opportunity to help us educate new health care providers. Depending on your presentation, they will probably not mind your performing a post-mortem intubation. A post-mortem thoracotomy or surgical airway, on the other hand, could be an entirely different situation.

Your approach to this should be well-defined in policy. Without a policy you’ll inevitably have controversy, particularly with such an emotionally-charged topic. Your policy should include the following: intent, scope of procedures to be performed, the number to be performed on one cadaver and how consent will be obtained.

I liken this to organ procurement. There is no doubt that this helps others, but that doesn’t give us the right to harvest organs without permission. This might seem like an extreme comparison, but legally they are fairly similar discussions. 

Another approach, although this will likely trigger follow-up ethics questions, is the timing of pronouncement. I learned many procedures performing them on patients that had no chance of survival. However, the patients had not yet been pronounced. While I’m not necessarily advocating that you get your teaching done before you call the code, many do take this approach to short circuit the whole argument about post-mortem procedures.

In summary, I feel that post-mortem training is appropriate and necessary. Ethically, we must handle it with respect, and legally, it must be handled with clear policy and full documentation.

Kevin M. Klauer, DO, is the Director of Quality and Clinical Education for Emergency Medicine Physicians, Ltd.
 

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