Practice makes perfect, but at what cost?
Study highlights troublesome dilemma
A year and a half ago, Lauris C. Kaldjian, MD, assistant clinical professor of medicine at Yale University, was confronted with a disturbing situation. A medical student came to him with a problem: The student had observed an intern performing a nontherapeutic invasive procedure on a patient undergoing unsuccessful cardiopulmonary resuscitation (CPR).
The procedure was not designed to benefit the patient — who was deemed about to die — but to allow the student to gain more experience performing the difficult procedure.
Allowing interns and medical residents to learn from and perform procedures on recently deceased patients is a well-documented — though controversial — practice, says Kaldjian (see related story, p. 37). But allowing an invasive procedure on a patient not yet declared dead was, to him, a foreign and troubling concept.
"The student was very disturbed by what was witnessed, and that conversation led to an immediate sense that I had an obligation to not only deal with this at a local level, but to make a study of it," he explains. "Not only did I have a local concern, but this is presumably an issue throughout teaching hospitals in North America."
Survey yields surprising results
The encounter led Kaldjian and four others to put together an anonymous survey of medi -cal house officers at three separate institutions. The survey was designed to elicit information about how often house officers were asked to insert femoral-vein catheters for practice during CPR. The study results were published in the Dec. 30, 1999, issue of The New England Journal of Medicine.1
That particular procedure was chosen because it is common, the anatomical location of placement would not interfere with the ongoing performance of CPR, and its performance is unnecessary when adequate intravenous access already exists, says Kaldjian.
The survey asked respondents to consider a hypothetical scenario in which a patient had been undergoing unsuccessful CPR for 20 minutes. Typical resuscitation efforts on nonresponsive patients last at least 30 minutes before the patient is pronounced dead.
The results of the survey were very surprising, says Kaldjian. Of the 234 house officers completing the survey, 34% believed it was "sometimes appropriate" to insert a femoral-vein catheter for practice on a patient undergoing CPR. Another 26% actually had observed the practice, and 16% said they had performed the catheterization themselves.
Interestingly, Kaldjian reports conversations with house officers following the study’s publication that indicate some of them consider patients undergoing CPR to be deceased, and the treating physician’s duty is to "bring them back to life."
"Some house officers indicated that they believed that a patient undergoing CPR is dead and that CPR is an effort to bring them back to life, rather than to sustain life," Kaldjian explains.
"Looking at the patients in that light might allow some physicians to consider using the body in the same way that you would if they were recently deceased," he says. "My response to that is that we need to be more clear about whether or not we believe the patient to be dead."
Allowing interns to perform procedures solely for practice on patients who are still alive dangerously erodes the concept of patient autonomy and informed consent, Kaldjian says. "My judgment is that, legally, we can and must say that until a patient is declared dead, as far as the law as concerned, they are alive. So that should have an impact on how we look at what we are doing," he adds.
"And our ethical and moral tradition dictates that, if we are still treating the patient, we consider [that patient] to be alive and that there is a chance he or she will continue living. Otherwise, we are wasting everyone’s time and should just call the code. In the interim, if we are treating the patient as if he were dead, we have surely done a bad thing," he says.
The conflict at the heart of the matter, however, is the difficulty of performing certain invasive medical procedures and how medical students can learn to do them safely and effectively.
Physicians have voiced their opinions to Kaldjian opposing his conclusion that practicing on patients is unethical, he says. "I always want to make it clear that people who would justify this practice believe they are doing it for the right reasons — that they are better preparing physicians to serve patients."
Practice sometimes is the only choice
Many difficult medical procedures cannot be effectively taught any other way than by practice, advises Arthur R. Derse, MD, JD, FACEP, a practicing emergency physician and the associate director of medical and legal affairs for the Center for the Study of Bioethics at the Medical College of Wisconsin in Milwaukee.
Femoral-vein catheters, intubations, and central line placements, for example, are difficult to learn and, if the physician does not practice on a patient recently deceased or dying, then the physician most likely will end up performing the procedure on a patient who desperately needs it, and needs it to be performed correctly.
"Other people will say that they should just practice on a mannequin, but there is nothing quite like the real situation," he says. "If they do not get experience performing these procedures when the stakes are low, and the patient is deceased or dying, then they are not going to have experience doing it when the stakes are high and you really have to get the tube in place on a patient who can’t breath. They won’t know how to do it," explains Derse.
Derse makes a definite distinction between performing procedures on a patient who is already deceased and a patient who is still alive, and in procedures performed for practice vs. allowing a less-experienced physician to attempt a difficult procedure under supervision.
"There is a fine line, though, between doing things for no benefit and you are practicing on someone, and a line in which procedures are performed that would have some benefit to the patient, but you allow less-experienced people to do it," he notes.
During Derse’s own residency, he recalls how students might be allowed to perform certain procedures when the resuscitation was not progressing well and the patient was believed to be dying, he says.
"That was the time when, typically, you "would allow people with less experience to get involved," he says. "You are still doing procedures that would benefit the patient, but it is someone with less experience doing it because the outcome is not going to be changed that much. The risk of that person making a mistake and causing a bad outcome is much less."
On the other hand, there is no question that the benefit to the patient is actually secondary and the primary benefit tends to become the experience afforded the resident, he adds.
"I don’t think that when someone is dying they should be doing procedures willy-nilly. [I think] they should be doing things that have the possibility of still helping the patient," Derse says. "Doing a central line is getting another line in to give the patient drugs. For the dying patient or the patient in extremis, the possibility of benefit has got to be a part of it."
Practicing procedures on deceased and dying patients is not something Derse recommends, but prohibiting the practice outright may result in greater harm to a greater number of patients, he says. "I’m not a supporter of it and I don’t do it, but if we completely outlaw it, it will be done surreptitiously."
Make a decision and stick to it
The first role of the hospital and the facility’s ethics committee should be to decide whether they support this practice in any form; the second should be to determine when and in what manner it would be appropriate, he says.
"I think if it is standard policy that the patient’s family will be told about it, and it is policy that you minimize the potential harm to patients who are living, only performing procedures that will benefit that patient, and minimize the intrusion to the individual after they have died, it could be permissible."
Teaching hospitals must deal directly with this issue to prevent the development of unwritten policies that encourage questionable behavior, adds Kaldjian. "Institutions do have their own traditions," he states.
"There is a culture in a training program that things get passed on, maybe by mouth, not by written policies. One could imagine with a practice like this, it could be the case that a small number of influential teachers set a tone and set an example, either for good or for bad. These traditions can be passed on within this small group of people who share a similar space and training, and one can see how these practices become self-perpetuating."
Reference
1. Kaldjian LC, Wu BJ, Jekel JF, et al. Insertion of femoral-vein catheters for practice by medical house officers during cardiopulmonary resuscitation. N Engl J Med 1999; 341:2,088-2,091.
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