Organ donation

Decision to discuss organ donation

At what stage is this option introduced into the conversation? Some might say, the best time is years before death, with loved ones, around a dinner table. Practically speaking, the best practice is to raise organ donation only after the discussion of dying and palliative therapy has taken place. It is absolutely essential that the decision to withdraw treatment must be made independently of the decision to discuss organ donation.

Antemortem interventions for the potential DCD patient

The question of what one should reasonably do to support the vital functions of a person expected to die, destined to become an organ donor, is a patch of treacherous terrain along the contested borders between medicine, law and ethics. There is a lot of material written about it. For example, this 2016 discussion paper is mainly for the locals (New South Wales), but is relevant broadly because it discusses some of the most important issues. The topic is probably too complex for a written exam answer, and it appears CICM examiners have no appetite for it, but - in the unlikely event that it ever appears - it would seem better suited for a "critically evaluate" discussion question, rather than some sort of stupid black-or-white decision answer. Thus:

• Definition:
  • Antemortem interventions for the organ donor are medications and procedures performed on the patient who is reasonably expected to become a DCD organ donor.
  • To be absolutely clear, these are interventions which are not expected to benefit the patient, who is dying.
  • These interventions are intended to benefit the organ recipient, which is often contrary to the goals of care for the donor ( usually directed to maximise comfort and dignity).
• Rationale
  • Antemortem interventions increase the likelihood of organ donation which has benefits to society more broadly, and which may benefit the patient indirectly insofar as it facilitates their wishes
  • The added time for the grieving family to come to terms with the events is extended, which can be beneficial
  • The evidence suggests that non-therapeutic interventions for the prospective donor significantly improve the viability of the organs
• Advantages and supporting arguments
  • Interventions are often not especially onerous, as the patient often already has had invasive lines and airway devices placed, and to continue using them is not a significant imposition on the patient'd dignity.
  • Heparin, inotropes, steroids and antibiotics are often viewed as acceptable by various professional and government bodies, as these interventions have a very low risk of harm.
  • Though care of the patient is always a priority, clinicians do have a responsibility to society in a broader sense, and often clinicians do make decisions about patient care which are aimed to benefit society as a whole, eg. where one enrols a patient into a clinical trial, or "schedules" and restrains a violent psychotic patient.
  • The patient and their surrogates, in supporting organ donation and agreeing to it, are therefore also expected to support antemortem interventions which maximise the benefit from that decision, eg. therapies and investigations specifically designed to maximise the viability of donated organs.
• Disadvantages and counter-arguments
  • Consent is difficult to negotiate, as the patient is unable to give consent. 
  • Delaying the withdrawal of treatment is not uniformly psychologically beneficial for the family
  • No intervention is entirely harmless, and there is a risk of harm
  • The care of the patient must always outweigh any concerns for the organ recipients, who are not your patients
  • The intrusive use of donation-centered interventions may erode the community support for organ donation

The most important concept to internalise is that under normal circumstances (i.e. outside of the context of organ donation), the decision to withdraw life-sustaining treatment does not usually occur simultaneously with the actual withdrawal of that treatment. There is often a rather long period of time which is permitted between the decision and the act, to facilitate various social cultural or logistic needs by the family. During this time, even though everybody is clear that ongoing blood tests Xrays and inotropes are basically non-beneficial, they are tolerated because they delay the patient's deterioration and buy time for the grieving survivors, something which is broadly viewed as psychologically beneficial. This practice is widespread, and from an ethical point of view these non-therapeutic interventions are equivalent to the antemortem interventions for the patient expected to donate organs.

Postmortem interventions for the braindead patient

Postmortem interventions in a patient who is diagnosed with brain death are fluids, inotropes and vasopressors, hydrocortisone, triiodothyronine and mechanical ventilation, not to mention all the elements of nursing care. As above, these are clearly not intended to benefit the patient, as nothing further will benefit them. There are two ways of viewing this. On one hand, the handling of the deceased should be respectful for them and for their family, and in that sense the ongoing delivery of various forms of medical and nursing care can be framed in the same way as the respectful treatment of the body by the embalming mortician - it is a part of our ritual, what we do with our dead. On the other hand, the scenario where this plays out is usually so traumatic and destructive for the family, that the immediate disconnection from all supports as soon as brain death is confirmed or suspected would be callous, and would not afford the family a sufficient time to grieve normally. In that sense, this is still management which is not expected to benefit the patient directly, and we justify it on the grounds that we as intensivists are expected to manage the family as well as the patient, and that entire unit requires more time, which we can buy with noradrenaline and positive pressure.

Consent is tricky: a dead person cannot give consent, and one can no longer perform emergency interventions upon them as a part of one's duty of care (i.e. one cannot reasonably claim that urgently inserting a central line is justified because it is necessary to save the patient's life and is therefore being done in their best interest). Even before a formal diagnosis of brain death is established, these sorts of invasive procedures are difficult to justify- though technically they are being performed on a living person who could theoretically benefit from them, a forum of peers will immediately identify them as nonbeneficial treatment, cynically imposed on the dying patient purely for the purpose of procuring their organs. 

This means that interventions should really only be performed while the patient still has some chance of survival (i.e. before the full extent of their injury is known, or before the decision to withdraw treatment is made). That sound pretty sensible, and probably represents what the intensivist would do in any other circumstances (i.e. stop offering treatment when it becomes obvious that it is not beneficial). From a practical perspective, that means one is usually limited to using whatever intravascular devices and support therapies are left over from the active treatment period, without escalating any level of care.  

Interventions for the braindead or DCD organ donor

This, from an ethical perspective, is much more straightforward. The rights of the patient, even the deceased patient, must be upheld, and this factors into the decision to perform tests or interventions. Where the patient or their family have already discussed organ donation and have agreed to it, postmortem interventions are more easily justified. In this scenario, the interventions - though they are not beneficial to the patient, and occasionally rather invasive (eg. bronchoscopy), are reasonable because they are intended to facilitate the wishes of the deceased, which were to become an organ donor.