"Non-Heart-Beating," or "Cardiac Death," Organ Donation: Why We Should Care

Mohamed Y. Rady, MD, PhD, FRCS (Eng.), FRCP (UK), FCCM; Joseph L. Verheijde, PhD, MBA; Joan McGregor, PhD

Disclosures

Journal of Hospital Medicine. 2007;2(5):324-334. 

In This Article

Consent for Organ Donation

Several state laws and federal regulations have been enacted to ensure that organ donation and transplantation practice comply with the ethical and legal standards of society ( Table 1 ). The current regulations require hospitals across the United States to provde regional OPOs with early notification of all patients whose deaths are imminent before life support has been withdrawn so that discussion of organ donation with surrogate decision makers can be initiated independently and consent obtained.[3,5,9] The Organ Donation Breakthrough Collaborative has set a goal of each OPO accomplishing a target organ donation rate of 75% or higher at local hospitals within an assigned donation service area (DSA).[1,2,5] The financial and administrative incentives for the OPO to achieve that target organ donation rate have introduced undisclosed conflict within the donation consent process.[33] Self-serving bias of OPOs can influence whether pertinent information necessary for surrogate decision makers to provide informed consent is disclosed.[34] As an example of this bias, alternative options for care and palliation may be discussed with surrogate decision makers with less enthusiasm than are the benefits and "altruistic" notion of organ donation. In obtaining donation consent, OPOs often avoid disclosing details of perimortem interventions performed on donors that are required for successful procurement of transplantable organs.[10,34,35] After receiving consent for organ donation, OPO staffs also assume the responsibility of planning donor medical care and treatment pathways essential for maintaining organ viability and of preparing for subsequent procurement.[5,36] In essence, the care of the dying patient is guided by a team whose primary interest is the preservation of organs until procurement has been accomplished.

The Uniform Anatomical Gift Act (UAGA) assigns explicit priority to the donor's expressed intent so that consent for organ donation becomes irrevocable and does not require the consent or concurrence of any person after the donor's death ( Table 1 ).[9,37] The donor's authorization to donate, recorded on an organ donor card, the individual's driver's license, or a donor registry, becomes a legally binding advance directive. The UAGA amendment enables OPOs to procure organs without family consent and in certain instances after family refusal to donate.[37]

Other consent options for organ donation from deceased donors have been proposed to maximize OPO recovery of transplantable organs in the United States ( Table 2 ).[8] The IOM has considered presumed consent for organ donation as a favorable option.[8] Presumed consent means the default option is consent to donation, that if an individual has not expressly rejected donation, that individual is considered to have consented to organ donation. Legislative enactment of presumed consent enables OPOs to avoid the potential for surrogates to deny consent for donation, thus increasing the pool of future organ donors. The revised UAGA replaces "nondonation" with the "intent to donate organs" as the default option. In the default option, all measures necessary to ensure the medical suitability of an organ for transplantation can not be withheld or withdrawn until the OPO has determined medical suitability of the individual as a prospective donor ( Table 1 ). The default option overrides the expression of intent in a declaration or advance health-care directives not to have life prolonged by withholding or withdrawing life support system unless the individual has expressed refusal of donation ( Table 1 and Table 2 ). The revised UAGA presumes that for prospective donors the desire to save lives by making an anatomical gift trumps the desire to have life support systems withheld or withdrawn. Mandated consent (or conscription) has also been proposed for recovery of cadaveric organs ( Table 2 ).[38] Under mandated consent, consent for organ donation is automatic from all deceased individuals; therefore, OPOs would not require or request consent because removal of all needed transplantable cadaveric organs would be compulsory. OPO staffs would no longer have to discuss organ procurement from potential donors with family members or other surrogates. An alternative form of donation consent is mandated choice, which requires each individual to decide in advance either to agree to organ donation or to refuse it. Mandated choice is the IOM's least favorite option because it would require extensive public informational programs on organ donation to facilitate individual choices and decision making ( Table 2 ).[8]

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