I just talked to a regular reader of this humble blog, a good friend doing his residency in another institution. He brought up the code I mentioned here, and was appalled by the fact that procedures were still being done on a patient long after he'd died because the practitioners needed practice. "I've got some ethical issues with that," he said. "People donate their bodies to science so we can practice procedures on them. That's not what happened here."
I've got news, people. When you make yourself a full code in a hospital--namely, when you elect to have full cardiopulmonary resuscitation done in the event that your heart or lungs stop working--you're donating your body to science. You're allowing your physiology to be manipulated in a wholly unnatural way, and if you are not healthy at baseline, you have an excellent chance of dying long before you're left for dead. When such a high proportion of inpatient CPR efforts are futile to begin with, it's very easy to blur the line between potentially resuscitative and futile procedures within the larger framework of CPR. In a teaching hospital, if something can be learned by doing it to your body during a code, it will be done.
A few people present at this particular code had the same reaction as my friend did, and were quite dismayed by the length and procedural density of the code. I was not. The man knew what he was signing up for when he made himself a full code. Any dignity lost by being "coded" had already been lost early in the resuscitative effort. And the learning that took place will benefit the next person who needs the procedures that were practiced.
Plus, the man was dead. Do you think he cared?
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Aha, another answer to a question that I, as a pathologist, get asked occasionally. My usual answer is "make sure your next of kin requests an autopsy." Why? There is a good chance that significant new information about the subject's health and illness will be discovered. This in turn educates the attending physicians and his or her trainees. It may form part of a scientific study or become a case report. It will improve the accuracy of the recorded cause of death, important in epidemiologic studies. Tissues and organs can be retained (with permission) to allow research or education. Finally, the autopsy may be done by a pathology resident, offering practical training experience. And, of course, the body can be turned over to the funeral home the same day the autopsy is done.
Obviously, a generous person can offer both...
Ii have no claim on my dead body - although my heirs and successors might - simply because dead people have no claims or rights. So long as they don't stew me up or use my head as a football, I'm perfectly happy for them to practice techniques on me that might save other people's lives (and hey, I might come back as a result of their ministrations, you never know). So I can't see that anyone's rights are being violated in this case.
As the "friend at another institution" in question in this blog, I have to clarify. Procedures during a code are fair game, necessary, and arguably - until the code is reasonably called - you could put a line in every vein and artery in the body if the patient needs access. My gripe with the code you described is that it read like it went way beyond a "reasonable" length of time with the (paraphrased) quote "I did chest compression for days after he was dead so the cardiologist could practice pericardial windows". Was there any hope whatsoever...at all...that the pericardial windows would bring the dude back? If so, then go for it. But if a procedure is obviously just for the sake of practice...eh...kinda shady.
Second point, no one... NO ONE outside of medicine in the States has any idea what happens when we code someone. I told you in the same conversation that I had to pre-code a 91 year old woman for 4.5 hours last week because the family said "do everything." We knew it was futile. We knew she'd die within 24 hours. And we couldn't sedate her because her vitals wouldn't stand it. She was awake and semi-alert through some of the most painful procedures I can imagine. We probably poked her more than 25 times. We called her family 3 times and explained the situation and they still said "do everything". When families say "do everything", they don't know the horrors we put their loved ones through when we know it's futile. We are the physicians. We have the education and experience to "do everything" without doing unnecessary procedures that have no hope of saving the patient at all...just for our learning. At the end of that whole code, I wished we had videotaped it so we could put it on 20/20 so people could see the reality of a code and get them to consider DNR/DNI status before it's too late. America is not educated about either the torture or futility of CPR and codes in general. We are. I friggin' love codes and I'm a procedure whore. They are literally the only part of my job I like. And I put a big line in a newly dead patient in the ER in med school because it was my chance to learn. And Lord knows that I get a little excited about the thought of practicing a pericardial window, but a very small amount of experience has taught me that we are the ones who have the responsibility to end futile codes after the requisite 4-5 rounds of epi and atropine and adhere to what the family and patient would have wanted when they said "do everything"...not what we want because we need to practice one more fem line so we can be good at them for that next patient who may have a chance of being saved. There are very specific programs for people to donate their bodies to science so we can practice on them. "Do everything" does not automatically enroll a patient in those programs. My feeling is that codes in the acute setting, even futile ones, have the specifc goal of bringing a patient's vitals back. There is a time, a place, and a slew of more than willing donated cadavres for practice.
I find this post very disturbing. It seems to me that you see a person being coded as a subject, not a patient; clinical material, not somebody's mom or dad or grandpa or grandma, who, in the interest of furthering "education" can serve as a handy guinea pig if a resuscitation attempt is unsuccessful.
"The man knew what he was signing up for when he made himself a full code." Oh, he did? Did he sign a statement that said that after he was no longer viable permission was granted to practice line insertions on his body?
"When you make yourself a full code in a hospital--namely, when you elect to have full cardiopulmonary resuscitation done in the event that your heart or lungs stop working--you're donating your body to science." I thought BLS and ACLS were based on evidence--and like any other evidence-based intervention there is not 100% "success" but that doesn't give medical people permission to tinker around with stuff that is outside the the usual and customary application of an intervention, does it?
"When such a high proportion of inpatient CPR efforts are futile to begin with, it's very easy to blur the line between potentially resuscitative and futile procedures within the larger framework of CPR. In a teaching hospital, if something can be learned by doing it to your body during a code, it will be done." Ok, then...let's just dispense with scientific review committees and with IRB (Institutional Review Boards) that guard patient rights...let's just go back to the mindset of the Tuskegee Syphilis Study which is an example of the most outrageous examples of disregard of basic ethical principles of conduct (not to mention violation of standards for ethical research).
Please, let me NEVER be your patient.
Doc Signout...I would still be your patient any day of the week...except maybe Thursday since "Gray's Anatomy" is on.
I've heard a lot through my training that if you don't want to be used by interns and residents to learn, then you shouldn't go to a teaching hospital. And although not all of our patients get that choice (the only Level I Trauma hospitals in the state are teaching hospitals), it's something i agree with.
When a code is futile, you're not dealing with a patient anymore--you're dealing with a body. Is that the time to crack open the chest and have the students all gather round? No. But if you've already cracked the chest, it doesn't hurt anything to grab the new intern and show her or him around while you're in there.
Yes, we should respect our patients. But learning how to start a line right on a body that can't feel anything is going to make it easier to start lines on the patients who can.
Signout, i'd be your patient.
Ursa, there are parts of the world where every single solitary hospital - every one - is a teaching hospital. Luckily, in most of those parts of the world the doctors make sure that patients and their families know what a code means, and the vast majority choose to go DNR/DNI.
Yes, Ursa--in some parts of the world, diamonds are free, and everyone eats chocolate cake for breakfast!
Where is this magical place?
Charlene, you might be right. But as slander noted, when doctors in America try to make a patient DNR/DNI, they have to overcome the meme that medicine can do anything. And although many of us make great efforts to have patients and families understand what a code really is, it's hard to change a person's deep-seated, culturally reinforced beliefs in one conversation. No one in this country expects to die--that's pretty different from many parts of the world.
Slander, I'm not talking about doing an amputation during a code just because you can--I'm talking about repeating a procedure for educational purposes. I believe there's greater good than harm in the situation I've described, and I'm not the first person to come up with the rationale for this: Thomas Aquinas beat me to it. (The good intention here is to educate future doctors; the harmful side effect is "disrespect" of the patient's wishes.)
Von, you're confusing research, patient care, and education--something that's not hard to do in the setting of a teaching hospital. It seems that the main thing that bothers you is that I don't identify a coding patient as a person. I've copped to that already. Although every patient is a person, that personhood does not prevent me from doing terrible, painful things to their bodies to keep them alive, if that's what they want. It also does not prevent me from feeling it's OK to prolong those efforts past the point of utility if it means educating a cardiologist. What it should do is force me to aggressively lobby for DNR/DNI status in patients who would be served poorly by a code.
And Von, you might already be my patient. And you probably like me a lot.
Yes, Ursa--in some parts of the world, diamonds are free, and everyone eats chocolate cake for breakfast!
Where is this magical place?
Charlene, you might be right. But as slander noted, when doctors in America try to make a patient DNR/DNI, they have to overcome the meme that medicine can do anything. And although many of us make great efforts to have patients and families understand what a code really is, it's hard to change a person's deep-seated, culturally reinforced beliefs in one conversation. No one in this country expects to die--that's pretty different from many parts of the world.
Slander, I'm not talking about doing an amputation during a code just because you can--I'm talking about repeating a procedure for educational purposes. I believe there's greater good than harm in the situation I've described, and I'm not the first person to come up with the rationale for this: Thomas Aquinas beat me to it. (The good intention here is to educate future doctors; the harmful side effect is "disrespect" of the patient's wishes.)
Von, you're confusing research, patient care, and education--something that's not hard to do in the setting of a teaching hospital. It seems that the main thing that bothers you is that I don't identify a coding patient as a person. I've copped to that already. Although every patient is a person, that personhood does not prevent me from doing terrible, painful things to their bodies to keep them alive, if that's what they want. It also does not prevent me from feeling it's OK to prolong those efforts past the point of utility if it means educating a cardiologist. What it should do is force me to aggressively lobby for DNR/DNI status in patients who would be served poorly by a code.
And Von, you might already be my patient. And you probably like me a lot.
I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.
He brought up the code I mentioned here, and was appalled by the fact that procedures were still being done on a patient long after he'd died because the practitioners needed practice.
thanks for information