Speaking as an intensivist and OPO medical director, I do not view the inclusion of organ donation in the guidelines as controversial. With a 10% survival of out of hospital cardiac arrest, end of life discussion is inevitable for most families. Organ donation is part of the end of life discussion and planning for many families. With over 50% of the population registered to be organ donors, the Uniform Anatomical Gift Act (UAGA) is explicitly clear on the obligation of physicians and hospitals to honor the decision (first person authorization) of the patient to be considered a candidate for organ donation. There is no conflict of interest for the treating physician to preserve the option of organ donation for a patient who has made that gift decision as part of their end of life planning. In fact, it is patient centered care. The discussion with the family about donation does not ensue until the decision has been made to withdraw life sustaining therapy or brain death has been declared. The CMS conditions of participation require hospitals to notify the organ procurement organization of patients who may be eligible for organ donation.
Thank you for sharing these insights--which are especially valuable given your OPO expertise. I agree that preserving the option of organ donation (i.e., continuing to provide high-quality life supportive therapies when neurologic recovery seems impossible) does not itself create a conflict of interest and in fact is a healthy way for a treating intensivist to find some hope and optimism in an otherwise tragic situation.
Our controversies, I think, come from the less clear situations. Few will argue with the moral and legal imperative to get a brain dead post arrest patient who is first person designated to donation.
But what about the non-designated comatose but not brain dead patient with marginal organ function the OPO wants to pursue donation after cardiac death on based on the decision of a central administrator, when a complex family is pushing to withdraw care?
At least in my neck of the woods this isn't a hypothetical. And while there is still of course a role for the OPO I do think it's important to recognize the ethical ambiguities and reemphasize the treating doc's obligation to patient first and families second.
Agree there needs to be a clear wall between icu physicians and the organ allocation team - it should really not be mentioned. You can declare prognosis, or declare brain death (why did they change it!), and move on and let them come in after.
Speaking as an intensivist and OPO medical director, I do not view the inclusion of organ donation in the guidelines as controversial. With a 10% survival of out of hospital cardiac arrest, end of life discussion is inevitable for most families. Organ donation is part of the end of life discussion and planning for many families. With over 50% of the population registered to be organ donors, the Uniform Anatomical Gift Act (UAGA) is explicitly clear on the obligation of physicians and hospitals to honor the decision (first person authorization) of the patient to be considered a candidate for organ donation. There is no conflict of interest for the treating physician to preserve the option of organ donation for a patient who has made that gift decision as part of their end of life planning. In fact, it is patient centered care. The discussion with the family about donation does not ensue until the decision has been made to withdraw life sustaining therapy or brain death has been declared. The CMS conditions of participation require hospitals to notify the organ procurement organization of patients who may be eligible for organ donation.
Thank you for sharing these insights--which are especially valuable given your OPO expertise. I agree that preserving the option of organ donation (i.e., continuing to provide high-quality life supportive therapies when neurologic recovery seems impossible) does not itself create a conflict of interest and in fact is a healthy way for a treating intensivist to find some hope and optimism in an otherwise tragic situation.
Our controversies, I think, come from the less clear situations. Few will argue with the moral and legal imperative to get a brain dead post arrest patient who is first person designated to donation.
But what about the non-designated comatose but not brain dead patient with marginal organ function the OPO wants to pursue donation after cardiac death on based on the decision of a central administrator, when a complex family is pushing to withdraw care?
At least in my neck of the woods this isn't a hypothetical. And while there is still of course a role for the OPO I do think it's important to recognize the ethical ambiguities and reemphasize the treating doc's obligation to patient first and families second.
Agree there needs to be a clear wall between icu physicians and the organ allocation team - it should really not be mentioned. You can declare prognosis, or declare brain death (why did they change it!), and move on and let them come in after.