In a Problem-Based Learning Discussion Sunday, members of a roundtable discussion group were asked to think about whether they would participate in a procedure harvesting organs from a living organ donor who was close to death.

Discussion leader Richard L. Wolman, M.D., an anesthesiologist at the University of Wisconsin School of Medicine and Public Health in Madison and a member of ASA’s Committee on Ethics, presented a hypothetical case of a 48-year-old male physician with amyotrophic lateral sclerosis (ALS) living in hospice who refused long-term intubation and ventilator support.

The patient acknowledged his death was inevitable and expressed an interest in donating any or all of his perfused organs before he died under general anesthesia or after extubation of a short-term endotracheal tube.

As of April 9, 2016, more than 121,000 transplant candidates were on waiting lists for organs in short supply. In 2015, only about 15,000 donors ­— 9,000 deceased, 6,000 living — provided organs for waiting candidates. On average, 22 people die every day waiting for an organ transplant, Dr. Wolman said.

“To protect and maintain public trust in the transplantation program in the United States, the Dead Donor Rule was established in the 1960s as an ethical axiom of organ donation. The DDR states that it is unethical for organ procurement to cause death or injury and, except in the case of living donation, it is unethical for organ procurement to precede death,” he said.

In the early years of the U.S. transplantation program, death was defined as cardiopulmonary death, and all organ donors were required to be non-heartbeating donors.

However, with the advent of mechanical ventilation and aggressive life-support techniques, a growing number of unconscious patients were kept alive in intensive care units, representing a potential source of needed organs, such as kidneys.

In 1980, the Uniform Determination of Death Act defined death as either cardiopulmonary death, that is, irreversible cessation of circulatory and respiratory function, or brain death, that is, irreversible cessation of all functions of the brain and brain stem. Nonetheless, the organ shortage continued.

In 1992, the Pittsburgh Protocol from the University of Pittsburgh Medical Center transplant program defined a process called donation after cardiac death, raising a number of ethical and practical issues related to organ donation, including informed consent, the difference between the terms “cannot resuscitate” and “will not resuscitate,” and who should withdraw life-sustaining therapies, Dr. Wolman said.

Controversy regarding participation by anesthesiologists in donation after cardiac procedures led the ASA House of Delegates to create ASA’s Sample Policy for Organ Donation After Cardiac Death, which recommends that anesthesiologists who are not also critical care physicians should not withdraw life support.

After presenting extensive background information on the patient’s capacity to make an informed decision about the donation, the medical criteria for brain death, the Institute of Medicine’s criteria for donation after cardiac death, legal and other salient issues, Dr. Wolman then asked members of the discussion group if they would participate in end-of-life organ donation procedures. And if so, whether they would establish any conditions.

Kent Pearson, M.D., an attending physician at the University of Iowa in Iowa City, said, “I would participate if an external psychiatrist evaluated the patient and an attorney or attorneys were involved in approving the procedure.”

Christos Koutentis, M.D., an anesthesiologist in private practice in New York, commented, “When I was last doing liver transplant procedures, anesthesiology was never involved in any decision-making regarding organ retrieval either as a group or by the liver transplant anesthesiologist.

“In our group of 16 anesthesiologists, some people refused to participate in retrieval procedures, but it was never discussed openly. It was something I really struggled with. I think the decision to withdraw life support needs to be made by critical care physicians as a group ahead of the time of the procedure.”

 

Return to Archive Index

• 
• 
• 
•