Faculty Bibliography

It is not uncommon for oncologists and other clinicians to encounter families who wish that grave medical information be withheld from their loved ones. Despite families' typically benevolent motives in making these requests, often, nondisclosure is not in the patients' best interests. Furthermore, nondisclosure may challenge physicians' professional obligations to their patients. However, there are particular situations in which nondisclosure is ethically appropriate, if not ethically obligatory. This article discusses potential benefits and harms associated with therapeutic nondisclosure in adult patients and offers strategies to effect more appropriate disclosure when therapeutic nondisclosure is contemplated.

Do-not-resuscitate (DNR) orders are commonly found in treatment plans for patients near the end of life. Orders for partial resuscitation (eg, "do not intubate") have evolved from DNR orders. Although the ethics of DNR orders have been widely examined in the medical literature, little has been written about the ethics of partial resuscitation. This article explores the ethical implications of partial DNR orders and identifies the need to develop care plans addressing life-threatening conditions for patients with DNR orders.

OBJECTIVE: To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients. DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices. RESULTS: Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement. CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.