Public opinion on different approaches to teaching intubation techniques

Teaching Without Harm: The Ethics of Performing Posthumous Procedures on the Newly Deceased

Physicians must be proficient in and efficient at various lifesaving and life-sustaining procedures. Multiple methods exist to teach these skills to inexperienced medical professionals, ranging from lectures to practical models to live patients. Proficiency and prior knowledge are especially important when novice medical trainees first perform these procedures because of the increased risk of harm in these high-stakes scenarios. To mitigate inherent risks, many medical centers controversially advocate and allow the use of newly deceased patients to practice, teach, and perfect these procedures. As a result, this type of experience facilitates medical training and competency while simultaneously avoiding physical harm to living patients. Nonetheless, it raises numerous ethical and legal considerations, including concerns of damage to the doctor-patient relationship.

This manuscript aims to comprehensively review the ethicality of practicing postmortem procedures and its current debate regarding the role and type of consent. This is followed by examining scenarios where the prior patient or postmortem surrogate consent is required for procedures that do not benefit the patient, including organ donation, cadaver donation, and brain tissue donation. Using these scenarios as a framework, best practices for gaining permission to use the newly deceased for medical training purposes are offered.

Procedures on deceased patients should always be done under competent supervision in a structured manner, with comprehensive explanations to encourage accountability and professionalism and prevent misuse. Informed consent for all educational procedures must be obtained by individuals separate from the treatment team. However, exceptions to this standard could be made in pediatrics (especially in the neonatal intensive care unit) given the intimate relationship between providers and parents. Depending on the situation, consent should be obtained from the patient and/or their family, with separate documentation provided to create awareness. All relative parties should be consented after receiving appropriate time to process to prevent further emotional compromise. If there are concerns about jeopardizing the family and creating further burdens, they should not be approached.

A survey of graduating emergency medicine residents' experience with cricothyrotomy

Introduction:

The Emergency Medicine (EM) Residency Review Committee stipulates that residents perform 3 cricothyrotomies in training but does not distinguish between those done on patients or via other training methods. This study was designed to determine how many cricothyrotomies residents have performed on living patients, the breadth and prevalence of alternative methods of instruction, and residents’ degree of comfort with performing the procedure unassisted.

Methods:

We utilized a web-based tool to survey EM residents nearing graduation and gathered data regarding the number of cricothyrotomies performed on living and deceased patients, animals, and models/simulators. Residents indicating experience with the procedure were asked additional questions as to the indication, supervision, and outcome of their most recent cricothyrotomy. We also collected data regarding experience with rescue airway devices, observation of cricothyrotomy, and comfort (“0–10” scale with “10” representing complete confidence) regarding the procedure.

Results:

Of 296 residents surveyed, 22.0% performed a cricothyrotomy on a living patient, and 51.6% had witnessed at least one performed. Those who completed a single cricothyrotomy reported a significantly greater level of confidence, 6.3 (95% confidence interval [CI] 5.7–7.0), than those who did none, 4.4 (95% CI 4.1–4.7), p<<0.001. Most respondents, 68.1%, had used the recently deceased to practice the technique, and those who had done so more than once reported higher confidence, 5.5 (95% 5.1–5.9), than those who had never done so, 4.1 (95% CI 3.7–4.5), p<<0.001. Residents who practiced cricothyrotomy on both simulators and the recently deceased expressed more confidence, 5.4 (95% CI 5.0–5.8), than those who used only simulators, 4.0 (95% CI 3.6–4.5), p<<0.001. Neither utilization of models, simulators, or animals, nor observance of others’ performance of the procedure independently affected reported confidence among residents.

Conclusion:

While prevalence of cricothyrotomy and reported comfort with the procedure remain low, performing the procedure on living or deceased patients increased residents’ confidence in undertaking an unassisted cricothyrotomy upon graduation in the population surveyed. There is evidence to show that multiple methods of instruction may yield the highest benefit, but further study is needed.

[Fibreoptic clinical training in anaesthesia. Course design and results based on a self-assessment survey]

BACKGROUND AND OBJECTIVE

Fibreoptic intubation is the technique of choice for resolving complications related to a difficult airway. Our aim was to determine whether a clinical-practice-based, individualized course provides sufficient training and confidence to allow anaesthetists to routinely practice fibreoptic intubation.

METHODS

Our hospital developed a clinical-practice-based, individualized course on fibreoptic intubation in general anaesthesia that provided practice in sedated spontaneously breathing patients and insertion through supraglottic devices. From 2005 to 2009, we e-mailed participants for response to an anonymous online self-assessment survey. We asked participants about the training outcomes and their overall degree of satisfaction.

RESULTS

Seventy-seven participants were sent the questionnaire six months after the course and 61% responded. All respondents considered themselves skilled in handling the bronchoscope at the end of the course and 97% used it in their routine practice in patients with difficult airways.

CONCLUSIONS

These results suggest a high success rate can be expected from individually tailored fibreoptic intubation courses that supplement theory and mannequin experience with clinical practice.

Ethics seminars: the ethical debate on practicing procedures on the newly dead

Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.

Practicing procedures on the recently dead

We sought to measure the prevalence of practicing procedures on the recently dead in emergency departments. Surveys were mailed to all medical students, interns, residents in Emergency Medicine, emergency physicians, and trauma team leaders working in the teaching hospitals of a city with a population of 600,000. Of 447 distributed surveys, 222 (49%) were returned. Participants were divided into learners and teachers. Of the learners (n = 162), 6 (4%) had practiced intubation and 4 (3%) had practiced pericardiocentesis on a recently dead patient. Of the teachers (n = 30), 8 (27%) had had learners practice intubation and 4 (13%) had had learners practice pericardiocentesis on a recently dead patient. Of the students and teachers who practiced procedures on recently dead patients, none had obtained consent. The prevalence of practicing procedures on recently dead patients appears to be less than has been reported previously. Intubation is the most commonly practiced procedure on recently dead patients. None of the participants obtained consent before practicing a procedure.

Should doctors practise resuscitation skills on newly deceased patients? A survey of public opinion

Trainee doctors must acquire skills in resuscitation, but opportunities for learning on real patients are limited. One option is to practise these skills in newly deceased patients. We sought opinions from 400 multiethnic guests at an open-access dinner dance for members of a local community. The questionnaire could elicit the responses strongly agree, agree, unsure, disagree or strongly disagree. 332 (83%) guests responded. For non-invasive techniques, 32% of responders supported practice without consent, 74% with consent. Support diminished with increasing invasiveness of procedure. 91% of the sample were uncomfortable about the procedures, the commonest reason being 'respect for the body' (264/302). 86% of responders felt that practice should last for no more than 5 minutes. The most popular solutions were for people to carry a personal card giving consent (89%) and establishment of a central register of individuals consenting to be practised upon after death (79%).

May we practise endotracheal intubation on the newly dead?

Endotracheal intubation (ETI) is a valuable procedure which must be learnt and practised, and performing ETI on cadavers is probably the best way to do this, although lesser alternatives do exist. Performing ETI on a cadaver is viewed with a real and reasonable repugnance and if it is done without proper authorisation it might be illegal. Some form of consent is required. Presumed consent would preferably be governed by statute and should only occur if the community is well informed and therefore in a position of being able to decline. Currently neither statute nor adequate informing exists. Endotracheal intubation on the newly dead may be justifiable according to a Guttman scale if the patient has already consented to organ donation and if further research supports the relevance of the Guttman scale to this question. A "mandated choice" with prior individual consent as a matter of public policy is the best of these solutions, however until such a solution is in place we may not practise endotracheal intubation on the newly dead.