Hospitals grapple with ethics of donation after cardiocirculatory death

In recent years, there has been a push for hospitals to receive organs from donors who are not technically brain dead. The issue of donation after cardiocirculatory death (DCD) is the focus of a recent study that appears in the journal Philosophy, Ethics and Humanities in Medicine, which points out the ethical problems of DCD.1 The researchers argue that DCD donors might not be dead yet, and therefore, DCD might violate the generally accepted dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation.

An individual can be declared dead if he or she has sustained irreversible cessation of circulatory and respiratory function, or irreversible cessation of all functions of the entire brain, including the brain stem. "The first definition refers to circulatory death, if irreversible is understood as 'will not resume spontaneously' after a given period of time and will not be restarted on morally justified grounds," says Melissa Kurtz, MSN, MA, RN, bioethics consultant at The Montefiore-Einstein Center for Bioethics, Bronx, NY. "[For that reason] I do not think donation after circulatory death violates the dead donor rule."

This question of when a patient is dead hinges on two points, but both are simply one's own philosophy. First, it is relevant if one believes a patient who is dependent on life support is, in fact, alive. Some believe the criteria for death is brain death, which is not necessarily the case in patients who are ventilator/life support-dependent. Others have a different idea of what "life" is. Brianna Soper, MA, hospital ethics consultant in Boston, says, "personally, I believe life requires consciousness and the possibility, if not likelihood, that a patient will be able maintain cardiac function independent of life support. This is not true in cases of potential DCD since, by definition, the action of donation is to take place after cardiac death."

Second, under the dead donor rule, a surrogate must make the decision to discontinue life support independent of a decision to donate organs. If the surrogate does make this decision, he or she would believe the patient is no longer experiencing life as the patient would have wanted. "My analysis is based on my own ideals and philosophy, and my preferences are not held by everyone. I do not believe that the dead donor rule is violated, provided the surrogate makes the decision to discontinue life support independently of the decision to donate organs," says Soper.

Carol Bayley, PhD, vice president of Ethics and Justice Education at Dignity Health, San Francisco, says, "I think it's possible that DCD violates the dead donor rule, mostly because we don't have a really stable notion of what we mean by 'dead.'"

Trust also can be an issue. "There is a subset of the American population who already believes that such things as the withdrawing or withholding of treatment or even encouragement to create an advance directive are based more on their (low) socio-economic status than anything else," says Bayley. She is concerned that the great strides that have been made in organ donation of the usual type could be undermined by DCD, especially in this population. "Additionally, I'm not sure it's cost effective," Bayley says. "One gets fewer organs from DCD than from a traditionally dead donor, and the staff time it takes is great."

Soper's only concern is a surrogate being misinformed of the prognosis of the patient. "If there is a chance that the patient's condition could improve and he or she could come off life support and regain cardiac function, it is imperative that the surrogate be informed of this," she says.

One of the primary concerns with DCD is that there is a clear separation between the decision to withdraw life support and the decision to donate organs. Kurtz says, "the option of organ donation should be posed after the decision to withdraw life support, so that there is not an inappropriate hastening to withdraw treatment. Once the decision to withdraw treatment is made, the hospital will contact the appropriate organ procurement organization [OPO], and representatives from the organization will assess whether donation after cardiac death is possible." (For a related story about the role of an ethics committee,below.)

The researchers believe these points have not been fully disclosed to the public and incorporated fully into informed consent. While this step is a huge undertaking, the writers of the paper believe this issue requires a public debate.

"We have no evidence of a consensus, or even public awareness of DCD, much less a public conviction about it," says Bayley.2

References

  1. Joffe A, Carcillo J, Anton N, et al. Donation after cardiocirculatory death: A call for a moratorium pending full public disclosure and fully informed consent. PEHM 2011; 6:17.
  2. Bayley C. Back to basics: Examining the assumptions of donation after cardiac death. HealthCare Ethics USA 2007; 15:2-4.

The ethics committee plays role in DCD

An ethics committee plays several key roles when it comes to organ donation after cardiocirculatory death (DCD).

"One role of a hospital ethics committee is to help develop or revise policies pertaining to clinical ethics. Therefore, one role that ethics committees can play in the issue of DCD is to be involved in developing or revising policies pertaining to organ procurement, especially when donation after cardiac death is involved," says Melissa Kurtz, MSN, MA, RN, bioethics consultant at The Montefiore-Einstein Center for Bioethics, Bronx, NY. Such policies ideally would promote the rights of patients, as well as maximize the likelihood of achieving good patient outcomes, Kurtz says.

The primary role of members of the ethics committee should be to examine the proposed policy rather than just accept an organ procurement organization's (OPO) suggestion that "everyone else is doing it," says Carol Bayley, PhD, vice president of ethics and justice education at Dignity Health, San Francisco.

The understanding of the general public (in hospitals) about such a radical change in organ donation criteria should be part of their concern. "The effect of a DCD policy on the hospital's efforts in palliative care and the pursuit of a peaceful death for their dying patients should be another concern," Bayley says. "They should also ask whether their hospital has sufficient resources to spend on DCD and how they will be sure any policy is carefully followed in each case."

The ethics committee is helpful in determining whether it is ethically justifiable to disconnect life support. Brianna Soper, MA, hospital ethics consultant, Boston, says, "The ethics committee must make their recommendations based solely on the patient and not on the resource of organs." It is the committee's duty to honor what the patient would have wanted and determine whether discontinuation of life support respects the patient's and surrogate's wishes.

"The ethics committee ought not to make this decision based on the benefit of the patient's organs to other patients," Soper says. "While organs are a scarce resource, it is ethically problematic to discontinue life support if it is against the patient's wishes or the patient's best interest."

The ethics committee does have a responsibility to look at other benefits and harms that might occur including financial costs when the medical team believes there is no possibility of the patient regaining consciousness, according to Soper.

DCD case study

An incident regarding DCD occurred recently and involved a hospital's ethics committee.

"A young man tried to commit suicide by hanging himself. He was brought to the hospital, and the OPO [Organ Procurement Organization] suggested DCD, in spite of the fact that the hospital had not adopted a policy. The OPO helpfully supplied one," explains Bayley.

The policy required that all medications be stopped, which in this case, because the man had sustained a terrible brain injury, included anti-seizure medication. "It was stopped, and the man seized all the way to asystole for the requisite number of minutes. The distress of the caregivers was horrible, and they all wondered what in the world they had done," says Bayley.

Staff at the hospital involved in the case were so traumatized that they put a moratorium on DCD until the ethics committee could thoroughly study it and make a recommendation to the medical staff about policy, says Bayley. "The committee, who started out evenly split pro and con for DCD, studied the issues for a year and finally recommended that a policy allowing DCD not be developed for the time being. It was a horrible case, but that ethics committee subsequently really did its homework," says Bayley.

Sources

  • Carol Bayley, PhD, Vice President of Ethics and Justice Education at Dignity Health (formerly Catholic Healthcare West), San Francisco. Email: CBayley@DignityHealth.org.
  • Melissa Kurtz, MSN, MA, RN, Bioethics Consultant, The Montefiore-Einstein Center for Bioethics, Bronx, NY. Email: melissajkurtz@gmail.com.
  • Brianna Soper, MA, Hospital Ethics Consultant, Boston. Email: bss318@nyu.edu.