Monday, March 20, 2006

Terminal patients in the ICU and organ donation

In my job as a palliative medicine doctor, I am frequently talking with patients and families about the potential of withdrawal of ventilators/pressors/dialysis in the ICU. Obviously this is not the only thing I talk about, but it often comes up in discussing dignity and futility and all the things that demonstrate our limits with modern medicine.

One of the things I have not seen implemented well (in person or in literature) is a way to make organ donation and palliative medicine work a little closer together. An article in the current Intensive Care Medicine describes a pilot project to develop a program for non-beating heart donors (NBHD) after withdrawal of life support. This Swiss study was prospective and identified 73 of 516 deaths that might be appropriate for NBHD of kidney, liver or lung. While they found that there was too much variability in how patients died in the ICU after withdrawal to implement their program, they did come up with some interesting data and discussions.

Part of the dilemma in implementing a NBHD organ procurement program was the variability of time after withdrawal of intubation or pressors. They note it would be hard to have a surgical team on standby for a variably prognostic cardiac death versus a brain death where the organs are procured in the OR after the aorta is clamped (from my ancient 1998 knowledge during my organ transplant rotation on surgery).

But this does give some helpful prognostic information for professionals dealing with near-death prognostication and how to communicate to family members.

------------------------------------------Survival time (h)
Traumatic brain injury (n = 21) ----------> 6.1 (2.4 -– 12.5)
Stroke (n = 25) --------------------------> 3.9 (1.3 -– 11.5)
Anoxic brain injury (n = 27) --------------> 3.6 (1.0 -– 9.8)
All patients (n = 73) ----------------------> 4.8 (1.4 - 11.5)

But it really gets interesting as they discuss the ethics of purposely hastening death with opioids and sedatives for the purpose of improved procurement times for NHBD. They cite a JAMA article about the European ETHICUS study that states this happened in 6.5% of ICU deaths. (I will comment on that older article after I get a chance to read it more closely.)

Although they clearly state that the ethics of utility/distributive justice may demonstrate this approach to be ok, they note it does violate beneficence and the principle of double-effect. All of this gets me to my point in reading this article which was....should there be more integration between palliative medicine and organ transplantation?

On one hand palliative medicine professionals are good communicators as are organ transplant procurement professionals. We could minimize the trauma of discussing these issues with family members if we worked together more closely...BUT could we also portray that we are working 'in cahoots' to grab as many organs as we can, thus tainting the noble goals of palliative medicine with the mis-perception of becoming a vulture? I am not sure where to sit on this fence, but it is an idea that I have not come across much in the palliative medicine literature.

It reminds me of how a colleague of mine sees the euthanasia/physician-assisted suicide (PAS) issue and its relevance to hospice. If hospice/palliative medicine professionals (THE experts at suffering at the end of life) are also the same people who assist with PAS or euthanasia, it would risk people not coming to us for help because they would fear we would push euthanasia or PAS voluntarily or involuntarily, and therefore we would do less healing and comforting.

(My Standard Disclaimer: Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)

(PS: I have used this disclaimer ever since I gave Resident Grand Rounds on the controversy of euthanasia and PAS, because so many people got the wrong idea because I wanted to discuss the ethical dilemmas inherent within.)

Free article of the text available by registering for Springer Link (pretty quick and simple)

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