When a patient dies, some people might assume that the duty of the doctor has ended. However, the doctor may have to consider the needs of any family, friends or carers in terms of understanding the death and bereavement process. The doctor may also have to complete a death certificate. As part of the funeral services, a cremation might be planned. At this point, the doctor may need to consider if the body can be cremated in its current state.
1. Gain an awareness of the risks of cremating medical implants
2. Understand what could be considered hazardous implant
3. Reflect on the wider use and impact of medical implants
It may feel insensitive to investigate the nature of residual implants in the body of a deceased loved one. However, there is no doubt that it must be done because eventually every patient dies. Training in this area therefore seems particularly neglected since it is an issue every doctor must face at one time or another. Do you recall the cremation lecture at medical school? Me neither.
An understanding of what happens to implants during a cremation is a practical necessity. If anything, the importance is growing; cremation accounts for approximately 75% of all funerals in Great Britain and as individuals become older they are more likely to prefer to be cremated. As technology advances, implants of varying type are becoming increasingly common and as life expectancy increases, individuals are more likely to have an implant fitted at some point in their life. However, this is not a new issue as the following letter to the BMJ in 1977 highlights:
“Little notice was taken of the presence of surgical hardware post mortem until September 1976, when the mercury zinc batteries in a pacemaker left in a body exploded during cremation with force sufficient to damage the brickwork lining of the cremation chamber. The strength of the explosion had possibly been increased by the presence of hydrogen produced in near-exhausted batteries. In the course of their duties those working at the crematorium periodically observe the process of cremation, and an explosion on this scale could cause injuries or even death. A further risk is that such an explosion could release toxic gases or even infectious material from the corpse.”
The letter goes on to also highlight the potential risk of radioactive isotopes in medical implants to staff in the crematorium as well as the dispersion of radioactive material to the surrounding area in the smoke generated from the cremation. It is suggested that doctors be asked about the nature of implants on cremation forms and whether implants have been removed prior to a body being released to an undertaker. Indeed, two supplementary questions were eventually added to form B of the Cremation Act certificate:
(a) Has a pacemaker or any radioactive material been inserted in the deceased (yes or no)?
(b) If so, has it been removed (yes or no)?
In 1991 another author decided to investigate some local crematoriums to find out more information:
“I sent a standard letter about the disposal of implants to 20 crematoriums in Greater London; I subsequently visited six of these. The staff of five of the crematoriums had collected all implants found after cremation for a short period before my visit; the other crematorium had collected a few unexpected metal implants or ingested objects found over the years… Only one crematorium disposed of implants in the general rubbish, a practice that is contrary to the recommendations of the Federation of British Cremation Authorities. The most common metal residues were hip and knee replacements. Other implanted items collected included intramedullary nails, sliding hip screws, and components from hemiarthroplasties. Less commonly retrieved were McLoughlin nail plates, Jewett nail plates, and Enders nails; one Souttar’s tube and one triangular fixation device for hip fractures were also retrieved. At one crematorium a substantial number of coins were found: their presence is probably related to social customs in some ethnic groups. The unexpected items found included a variety of forceps (Spencer-Wells, Jean’s, and artery), a pacemaker, a ring cutter, a micrometer, and a pair of Mayo scissors.
The current England and Wales cremation medical certificate contains the following question:
(a) Was any hazardous implant placed in the body (e.g. a pacemaker, radioactive device or ‘Fixion’ intramedullary nailing system) (yes or no)?
(b) If Yes, has it been removed (yes or no)?
How often do you complete a cremation medical certificate?
What implants would you consider hazardous?
Although the question on the current form includes some examples of hazardous implants, The Cremation (England and Wales) Regulations 2008 (annex A) contains a more detailed list of implants that could cause problems during cremation:
- Implantable Cardioverter Defibrillators (ICDs)
- Cardiac resynchronization therapy devices (CRTDs)
- Implantable loop recorders
- Ventricular assist devices (VADs): Left ventricular assist devices (LVADs), Right ventricular assist devices (RVADs), or Biventricular assist devices BiVADs)
- Implantable drug pumps including intrathecal pumps
- Neurostimulators (including for pain & Functional Electrical Stimulation)
- Bone growth stimulators
- Hydrocephalus programmable shunts
- Fixion nails
- Any other battery powered or pressurised implant
- Radioactive implants
- Radiopharmaceutical treatment (via injection)
Cardiovascular Implantable Electronic Devices (CIEDs)
CIEDs as an umbrella term that includes the pacemaker, implantable cardioverter-defibrillator (ICD), cardiac resynchronisation device (CRT), implantable loop recorder (ILR) and implantable cardiovascular monitor (ICM). Of these, the pacemaker is probably the best known but all of them are becoming more common and all necessitate a battery as a power source. With regards to the pacemaker, the explosive component is the battery: as they are heated they may produce a gas which rapidly expands causing the pacemaker casing to burst as well as causing an explosive chemical reaction. Pacemaker technology is evolving; they are designed to last longer, the power source may therefore be stronger and subsequent explosive potential more powerful. Simultaneously, pacemakers are becoming smaller and more difficult to detect. Add in the fact that pacemakers can also migrate subcutaneously (get your metal detector ready to try and find it – no joke), you might be able to understand why many crematoria staff have had personal experience of explosions at some point in their career. That being said, there are also case reports that some modern pacemakers don’t appear to explode when cremated, but do you know who manufactured the pacemaker you’re about to send for cremation and is it worth the risk? As for some of the other CIEDs, active ICD devices must be deactivated (usually by a cardiac physiologist) before they can be removed.
The Reveal LINQ™ Insertable Cardiac Monitoring System
Ventricular assist devices (VADs)
VADs are mechanical circulatory assist devices used to assist a failing heart. They may be used as bridge devices while patients are awaiting heart transplantation, as a means of temporary respite while heart function is restored or as destination devices in themselves. Again, as medical technology develops, more devices are being implanted but still only about 100 individuals are living with an LVAD in the UK . These pumps can be placed inside or outside the body, the power source and controller being external. Again the battery component of a VAD is potentially explosive. However, since current VADs have an extracorporeal battery, these could be returned to team who implanted the pump. However, this may change in the future as wireless VADs with a battery inside the body is on the horizon. With regards to the pump itself there appear to be differences of opinion regarding removal prior to cremation.
A left ventricular assist device
Implantable drug pumps including intrathecal pumps, neurostimulators, bone growth stimulators
Again, the issue with these devices appear to be issues surrounding battery disposal. For example, this is taken from the manual of one such implantable drug pump:
“The pump will need to be explanted upon your death. If you are terminally ill, please notify your caregiver and primary doctor that the pump may explode during cremation and needs to be removed prior to cremation or burial.”
Another pump manual states:
“The pump should be removed before burial or cremation. In some countries, removal of battery- powered implantable devices is mandatory before burial because of environmental concerns. Also, the pump should be removed before cremation because the cremation process causes the battery to explode. Explanted devices should not be resterilized or reimplanted.”
This is taken from the webpage of a spinal cord stimulator company:
The battery in these devices can explode in fire so do not dispose of the remote control or charger in fire. Dispose of used batteries in accordance with local regulations. The stimulator should be explanted in the case of cremation and returned to Boston Scientific. External devices to be disposed of per local regulatory requirements. Please contact your healthcare professional for information.
A few more interesting issues are touched on here including explantation, reimplantation, safe disposal and environmental concerns.
The Fixion nail is an intramedullary device that can be inserted through small incisions to fractured bones and then expanded to lock hydraulically. Here’s an animation about how it is inserted. There have been case reports of the Fixion exploding during a cremation.
Radioactive implants and radiopharmaceutical treatment
Radiotherapy is usually associated with cancer treatment, which may well be palliative. It therefore seems particularly surprising that there is considerable confusion about the potential danger of radioactive material and cremation. Part of the issue is related to the the time interval between the introduction of radioactive material and death, in addition to the varying half-lives of the isotopes used. It may therefore be a case of when cremation is allowed, not if it is allowed. The Canadian Nuclear Safety Commission have a webpage with advice and the following table is adapted from their guidance:
|Nuclear substance||Typical applications||Autopsy||Embalmment||Cremation|
|Iodine-125||Brachytherapy, to treat prostate cancer||2 years||1 month||2 years|
|Palladium-103||Brachytherapy, to treat prostate or breast cancer||3 months||1 month||3 months|
|Strontium-89||Nuclear medicine, to provide pain relief from bone cancer||2 years||2 weeks||1 year|
|Yttrium-90||Nuclear medicine, to treat a variety of conditions and diseases such as arthritis and various cancers||6 weeks||2 weeks||6 weeks|
|Phosphorus-32||Nuclear medicine, to treat a family of diseases characterised by increased blood cell production||5 months||2 months||5 months|
|Iodine-131||Nuclear medicine, to treat various types of tumours and hyperthyroidism||2 months||2 months||2 months|
But the prospect of delaying a cremation by a few months or years while the isotope decays is undignified. Implants may have to be removed by a specialist, in the case of radioactive injectable solutions they may not be able to be removed and crematorium staff may require specialist training. Remains may not be appropriate for a standard urn. There may even have to be a radiation survey of the crematorium afterwards.
One material that I noted which didn’t make the regulatory list of hazardous implants but perhaps should is the mercury in dental amalgam. As the health of the population improves, increasing numbers of people are dying with their teeth intact (albeit repaired). Cremating dental amalgam releases mercury into the atmosphere causing environmental harm and potentially very serious health problems. The level of mercury in the hair of crematoria staff has been noted to be significantly higher than controls. The cost of reducing mercury emissions is considerable and the cost of installing filters in a crematorium is being passed on to the family of the deceased.
Other implants, recycling and ownership
So now we’ve come the end of the list of implants listed in the England and Wales regulations for cremation (and I’ve added amalgam to this due to targets on mercury emissions), but what about all the other implants? Joint prostheses (e.g. hip, knee), silicone breast implants, metallic heart valves, even IVC filters? Seemingly, many of these items are ok to cremate. Although silicone implants can leave a residual gooey substance, metal implants often withstand the process.
Silicone gel-filled breast implants
These metals can be removed from the ashes with a magnet or manually in the case of bigger implants. Once retrieved, they can be recycled. Orthometals and Implant Recycling are two such organisations which specialise in the recycling of metal after cremation. The metal is recycled and may end up being used in different sectors (e.g. automotive), but what about reusing the implant itself? In what seems like the single use disposable world of medicine the idea of reuse is near extinction. However, there are efforts to reuse some implants. Pace4Life is one such initiative to reuse pacemakers from the UK in developing countries. Here is a news story about them. Similarly in the US, ICD reuse is being trialed. It has been suggested that lack of knowledge and communication with specialists results in the inappropriate disposal of potentially reusable medical implants. Have you ever been asked?
But who’s implant is it anyway? There appears to be some ambiguity over who legally owns a medical implant. In the UK, the Department of Health issued the following guidance in 1983:
“On implantation an implant becomes the property of the person in whom it has been implanted and it remains his or her property even if it is subsequently removed. Following the patient’s death it forms part of his or her estate unless there is any specific provision to the contrary.”
Since 1983 the complexity of medical devices has increased enormously and many of the devices are expensive. Add in the confusion as to whether an implant is part of the body and whether that body can be considered property with all its associated legal rights, you can see that eventually someone might ask for their implant back or indeed stipulate that it forms part of an inheritance.
Right, time for some questions to stimulate reflection.
Who should own an implant?
Who should remove an implant prior to cremation?
Who is responsible for safe disposal of an implant?
Who should pay for this process?
Are there any religious or cultural aspects to consider about implant removal before a cremation?
Should we remove teeth filled with amalgam before a cremation?
Should we be discussing the environmental impact of medical devices with patients before they are implanted?
Should all implants come with a device donation card to be used after death?
Does reusing a a medical implant feel different to organ donation?
Important note: Please do not use this blog post to inform your decision as to whether a particular implant is suitable for cremation or reuse. I am not responsible for any decisions that you may make. If you’re uncertain about a particular device you should consider asking:
- The doctor who originally inserted the implant
- A doctor in the speciality associated with the implant
- The hospital records department who may be able to locate the operative notes and clarify the nature of the implant
- Your local hospital bereavement office
- The funeral director
- The crematorium
Medical and technological advances are leading to more medical implants. These implants are increasingly sophisticated and harder to detect. As people live longer, more time may have passed since the implantation, so less information (if any) might be available about it. People also travel more and may have to move for care issues as they become older resulting in reduced continuity of medical record. This may reduce the confidence of a doctor tasked with completing a cremation medical certificate. Crematorium explosions are more common than you may think, but that shouldn’t make you more relaxed about medical implants. An implant donation card or international registry of implants might be helpful but there are ethical considerations as well as legal ones regarding implant ownership. Finally, if as a medical community we open up about the reuse of medical implants we could make a significant dent in the cost of such devices while simultaneously reducing the environmental impact of unnecessarily disposing of them. Perhaps a metal detector should be added to the itinerary of the doctors bag.
The exploding body
Hidden hazards of cremation
Metal residues after cremation
A migrating pacemaker
Pacemaker explosions in crematoria: problems and possible solutions
Cremation of Leadless Pacemaker
Implanted cardiac devices are reliably detected by commercially available metal detectors
The potential dangers of medical devices with current cremation practices
Discontinuation of a Left Ventricular Assist Device in the Home Hospice Setting
Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care
“No one has ever asked for it back!” A survey assessing the fate of reusable external fixation equipment in mortuaries
Explosion of Fixion humeral nail during cremation: Novel ‘‘complication’’ with a novel implant
Radiation safety issues regarding the cremation of the body of an I‐125 prostate implant patient
Amount of mercury from dental amalgam filling released into the atmosphere by cremation
Amalgam and crematoria