Article

Controlled Donation After Circulatory Determination of Death: Ethical Issues in Withdrawing Life-Sustaining Therapy

Journal of Intensive Care Medicine 1-8 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066615625628 jic.sagepub.com

Anne L. Dalle Ave, MD, MS1,2 and David M. Shaw, PhD3

Abstract Controlled donation after circulatory determination of death (cDCDD) concerns donation after withdrawal of life-sustaining therapy (W-LST). We examine the ethical issues raised by W-LST in the cDCDD context in the light of a review of cDCDD protocols and the ethical literature. Our analysis confirms that W-LST procedures vary considerably among cDCDD centers and that despite existing recommendations, the conflict of interest in the W-LST decision and process might be difficult to avoid, the process of W-LST might interfere with usual end-of-life care, and there is a risk of hastening death. In order to ensure that the practice of W-LST meets already well-established ethical recommendations, we suggest that W-LST should be managed in the ICU by an ICU physician who has been part of the W-LST decision. Recommending extubation for W-LST, when this is not necessarily the preferred procedure, is inconsistent with the recommendation to follow usual W-LST protocol. As the risk of conflicts of interest in the decision of W-LST and in the process of W-LST exists, this should be acknowledged and disclosed. Finally, when cDCDD programs interfere with W-LST and end-of-life care, this should be transparently disclosed to the family, and specific informed consent is necessary. Keywords transplantation, ethics, controlled donation after circulatory determination of death, withdrawal of life-sustaining therapy

Introduction Many patients die in the intensive care unit (ICU) secondary to withdrawal of life-sustaining therapy (W-LST), after family and health professionals agree that there is no more benefit in continuing life-sustaining therapy (LST) for a patient. Although the practice of W-LST is common in many countries,1 its social and ethical acceptance is not universal. The Ethicus study, published in 2003, showed a variability in WLST among 17 studied European countries (including Israel and Turkey): In the southern countries, withdrawing (17.9%) and shortening of the dying process (0%) were used less frequently than those in the central (33.8%, 6.5%) or northern (47.4%, 0.9%) countries.2 The active shortening of the dying process was defined as the lethal administration of a drug with the specific intent to cause death, that is, euthanasia.2 Controlled donation after circulatory determination of death (cDCDD), also known as Maastricht Category III,3 refers to organ donation after W-LST, usually in the ICU setting. The cDCDD programs have been developed mostly in countries where W-LST is a common accepted procedure, such as the United States,1 Canada,4 United Kingdom,5 Belgium,6 and the Netherlands,7 among others. cDCDD raises several ethical issues, some of which have been widely discussed in the literature, such as the concern that

cDCDD organ donors might not be yet dead when organs are recovered.8-10 The process of W-LST is an essential step in all cDCDD programs. However, it raises specific ethical issues that have been less discussed in the literature. Having conducted a review of diverse cDCDD recommendations and protocols, and of the ethical literature on cDCDD, we examine in detail different components of the W-LST process that might raise ethical issues: (1) conflicts of interest in the W-LST decision; (2) the W-LST procedure (where, how, and by whom) and how it might differ/interfere with end-oflife care; (3) the risk of hastening death; and (4) whether there is a need for specific informed consent. We give particular

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Ethics Unit, University hospital of Lausanne, Lausanne, Switzerland Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland 3 Institute for Biomedical Ethics, University of Basel, Bernoullistrasse, Basel, Switzerland 2

Received August 5, 2015. Received revised November 9, 2015. Accepted for publication December 15, 2015. Corresponding Author: Anne L. Dalle Ave, Ethics Unit, University hospital of Lausanne, Rue du Bugnon 21, 1011 Lausanne, Switzerland. Email: [email protected]

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Journal of Intensive Care Medicine

attention to how ethical recommendations regarding W-LST differ among centers and are followed or realizable in practice. We conclude by making several recommendations.

Conflict of Interest in W-LST Decisions A W-LST decision is generally preceded by the evaluation and establishment that benefits of continued LST do not justify burdens.11 The evaluation that continued LST is inconsistent with the patient’s best interests is a difficult process, and studies have shown that doctors may be ‘‘inaccurate in their prognoses for terminally ill patients.’’12(p469) A large study published in 2009 showed that ‘‘the proportion of hospital survivors with withdrawal decisions ranged from 2.4% to 30.4%.’’13(p626) A Canadian study showed that of 341 patients (over a total of 851 mechanically ventilated patients) ‘‘assessed by a physician on at least one occasion to have a probability of ICU survival

Controlled Donation After Circulatory Determination of Death.

Controlled donation after circulatory determination of death (cDCDD) concerns donation after withdrawal of life-sustaining therapy (W-LST). We examine...
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