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)
7 Responses to “Terminal patients in the ICU and organ donation”
March 20, 2006
CS
my initial reaction is that there is and should be a distinct wall surrounding those involved with organ procurement (docs, nurses, program managers, etc.)--separating them from those involved in the clinical care of patients. this is for obvious reasons--organ donation and procurement is for the most part a great social good but one that often has at least the appearance of conflict with an individual patient's best interests. even when there isn't any *real* conflict (as in neurologically devastated patients who are dying for whom NBHD is being considered) it is still important to keep this distinction separate. our message in the icu in these cases is we are there to help care for a dying patient in the best way possible, and advocacy for organ donation cannot be a part of that. that being said, for those families that pursue this, it can offer some solace, and that is a good thing. our institution has a (extremely rarely used) NBHD policy and we are usually involved--if the patient's heart keeps beating and organ harvesting is aborted the patients usually come to our palliative floor for ongoing care until they die. but throughout this, while acknowledging that this can be of solace to families, our stance is we are there to help make sure the patient is comfortable whatever decision is made, whether or not the NBHD process happens, etc. Like it or not we are pegged as the death doctors in palliative care, being pegged as the kidney-grabbin' docs is probably a little too much though.
CS I'm glad you put the disclaimer there because up until now I was under the impression you were running an atheistic euthanasia service, so thanks for the clarification (ha ha).
Drew
March 21, 2006
We recently completed a 3 mth prospective quality improvement project on our inpatient palliative care unit, essentially comprising an educational component for team members, info for pts/families and implementation of routine screening/approach for pts eligible for cornea donation. Our hypothesis was that offering eligible donors the opportunity to donate corneas would enhance meaning in terminal illness. We found that 1/3 of admissions were eligible, about 1/2 of eligible pts/families consented and 3/4 of the recovered corneas were transplanted. In 90 days, 9 corneas were transplanted vs 0 transplants in the same 90 day period the yr before. We are inviting donors relatives to a ceremony of appreciation next month. Feedback has been positive. Research could test our hypotheses about dignity and meaning, or influence of donation on bereavment. We have submitted an abstract for an educational workshop on organ donation in palliative care to an upcoming meeting. Axiomatic in approaching donors is support for their decision either way. It is possible that our own attitudes to donation create obstacles and/or are based on myths. Our experience is that one's practice can change - this is an understudied area in palliative care, in my opinion. Here are a couple of refs: "Corneal donation within palliative care: a review of the literature", Philip Edwards, International Journal of Palliative Nursing, Vol. 11, Iss. 9, 23 Sep 2005, pp 481-6 and "The experiences of donor families in the hospice.", Carey I, Forbes, Palliat Med. 2003 Apr;17(3):241-7. Cheers, Paul McIntyre
March 22, 2006
Thanks for the comments.
At Kansas City Hospice we have a few social workers that do a really good job of talking to families about tissue doantion for research. They have gotten a pretty good response. I would imagine a corneal transplant program as you described would be pretty well recieved. It does seem to be a bigger leap when you start to think about larger organ donation (lung, heart, kidney, etc.) I am not sure why....
March 22, 2006
In our program, 80% of patients have metastatic cancer - not eligible for organ donation. The other 20% of patients, including primary brain cancer patients, may be eligible. I think it is a conceptual block in which are hesitations are based on factors which are not as real as we think, a little like opioid myths in some caregivers. With experience, we can learn to do it well, and may even find it adds to patient/family quality. I expect we all have things to learn about when & how to broach these issues with patients/families. Paul McIntyre
March 22, 2006
Paul--always appreciate your comments.
Thanks for the comments--you've introduced me, and I imagine many others, to the literature on corneal transplants in hospice/pall care. I hope you publish your group's experience, and your thoughts on this measurably affecting dignity, bereavement really seem worth investigating.
I do think though that corneal transplants are different from solid organ harvesting, not least because solid organ harvesting/NBHD requires an active (and in some ways dramatic) change in how patients are cared for as they die (they're hauled off to the OR where people stand around hoping their heart stops beating). This, I think, allows room for legitimate questioning, and the real appearance of docs not acting in a patient's best interests. For corneal transplants patients can receive usual terminal care.
Regards,
Drew
March 24, 2006
Good points Drew on the difference between the two.
Transplant medicine gets a quite short shrift in medical school, much like palliative medicine/EOL care has in the past. I wonder if there is a sea change for transplant education?
August 02, 2006
Hello. I am doing a story on non-heart beating organ donation and I would like to talk to you. I am a science reporter at Newsday in NY and my number is 631-843-3026. Thanks. Jamie
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