"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

End-of-Life Care

Quality of end-of-life (EOL) care for an organ donor, as for any individual whose treatment is being withdrawn, is considered the highest priority of care and must not be compromised by the donation process. Yet no studies have investigated the impact of organ donation on the quality of EOL care in NHBOD.[35] Previous reports have criticized the quality of EOL care offered to dying patients in intensive care units (ICUs).[39,40] Many of these patients are undergoing withdrawal of life support in anticipation of death and are considered candidates for NHBOD. The Robert Wood Johnson Foundation (RWJF) Critical Care End-Of-Life Peer Workgroup developed 53 EOL quality indicators to standardize and measure the quality of EOL care.[41] These quality indicators, organized in 7 domains, focus on delivering patient-and family-centered care and facilitating a "good death" experience in the ICU ( Table 3 ).

In a subsequent U.S. survey, the Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project reported that more than 75% of ICUs were still not monitoring the quality of EOL care.[42] The survey also identified multiple barriers to optimal EOL care found in most ICUs. The study group proposed several strategies to overcome these barriers and improve the quality of EOL care ( Table 3 ).[42,43] It can also be inferred from the survey findings that most ICUs are unprepared and lack the necessary tools to appropriately inform patients and families of the trade-off in EOL care for NHBOD. The President's Council for Bioethics has also warned that NHBOD can transform EOL care from a "peaceful dignified death" into a profanely "high-tech death" experience for donors' families.[10]

Several aspects of medical care that are neither palliative nor beneficial are performed for donor management for NHBOD and can explain the feared transformation of the death experience. The revised UAGA reaffirms that all measures necessary to ensure the medical suitability of an organ for transplantation cannot be withheld or withdrawn from the prospective donor and overrides the expression of intent by a prospective donor in either a declaration or advance health-care directive not to have life prolonged by use of life support systems ( Table 1 ).[9] The 2007 amendment to revised UAGA section 21 recognizes the conflict between all measures necessary to ensure organs viability for transplantation and appropriate EOL care and requires the attending physician and OPO to resolve the conflict with the prospective donor or surrogate decision-maker.[9]

OPOs apply donor management critical pathways to potential organ donors in order to maintain organ viability for successful execution of organ procurement.[36] The University of Wisconsin developed a protocol and an evaluation tool to determine the eligibility of potential candidates for NHBOD.[44] The protocol entails temporary discontinuation of mechanical ventilation for a trial of spontaneous respiration lasting up to 10 minutes to determine the likelihood of cardiorespiratory death within 60-90 minutes of the withdrawal of life support. Those patients predicted by the University of Wisconsin evaluation tool to survive a longer time are not candidates for NHBOD and are transferred to palliative care. Those patients who meet the necessary criteria of the University of Wisconsin evaluation tool become candidates for NHBOD and undergo additional antemortem testing, invasive vascular instrumentation, and infusion of medications essential for organ preservation.[36] The instrumentation and medications used for organ preservation can also expedite death on withdrawal of life support.[45] Other interventions (such as circulatory support with invasive and noninvasive devices, extracorporeal perfusion and oxygenation, endotracheal reintubation, mechanical ventilation, and bronchoscopy) are performed when cardiorespiratory death is pronounced in order to maintain organ viability and can inadvertently reanimate the donor during the procurement process.[26]

The process of obtaining donation consent and subsequent donor management protocols for NHBOD deviate from more than 60% of the RWJF quality indicators recommended for optimal EOL care.[35,36,41] Therefore, NHBOD can have a profound impact on the quality of EOL care. There has been a recent proposal to abbreviate the original RWJF quality indicators to include 14 of the 53 (26%) original quality indicators described for optimal EOL care in the ICU ( Table 3 ).[46] Many of the quality indicators expected to be negatively affected by NHBOD are not included in the proposal for an abbreviated list. There has been a concern that the application of an abbreviated rather than a comprehensive metrics for EOL care can portray an incomplete assessment and perhaps misinform donors and their families about the potential trade-off in EOL care. The President's Council on Bioethics has emphasized that comprehensive evaluation of the quality of EOL care is an ethical imperative so that families can decide if the trade-off is acceptable for organ donation.[10] Deciding to donate organs at the end of life can be stressful for many families, and therefore they must be fully informed of the possible consequences. Posttraumatic stress disorders, anxiety, depression, and decreased quality of life have been reported in the deceased's family members who shared in stressful EOL decisions.[47] Posttraumatic stress disorders have been reported in family members of deceased organ donors.[48] Organ-focused behavior by professionals requesting consent for organ donation and ambivalent decision making by family members appeared to increase the risk of relatives of deceased donors subsequently developing traumatic memories and stress disorders. The processes required for successful accomplishment of donation consent and subsequent organ recovery can interfere with many of the interventions that lessen the burden of bereavement of relatives of ICU decedents.[49]

The variability in decision making by health care providers about medical futility and EOL care has been given as a reason for concern about the implementation of NHBOD.[50] The variability of EOL practice raises the possibility of conflicted decision making on medical futility within institutions that have transplant programs.[50] Ethical conflicts and moral distress have been reported among health care providers who were directly involved in organ procurement in NHBOD.[51] The pressure to recover transplantable organs from NHBOD candidates has been associated with health care professionals' perception of euthanasia and premature determination of medical futility and withdrawal of life support. The long-term psychological impact of NHBOD practice on caregivers, health care providers, and professionals remains unknown.

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