Emergency physicians (EPs) are at the forefront of efforts to save patients or preserve options for organ donation for those who cannot be saved. On average, 18 Americans die every day while waiting for transplantable organs. Studies suggest that identifying potential organs for donation early from the ED may help increase organ procurement. However, there is little data that takes into account ethical viewpoints when it comes to organ procurement in the ED, according to Arvind Venkat, MD.
Current organ donor protocols mandate that patients be referred to the local organ procurement organization (OPO) even when the resuscitative process is just beginning, and the prognosis may still be in doubt. “If death is likely, EPs are expected to continue existing measures or implement new measures to preserve the option of organ donation until OPO representatives arrive,” explains Dr. Venkat. “Under current referral policies, EPs may feel precluded from communicating directly with patients’ families about the rationale for aggressive treatments to preserve the option of organ donation when the opportunity for curing the patient has passed.” This can be especially burdensome at times of high ED and ICU volume and when delays occur.
Seeking Practical Solutions
“EPs should be allowed to have honest and forthright communication with families about the status of patients who are viewed as potential organ donors and when OPO referrals have taken place,” Dr. Venkat says. Regardless of whether or not OPO representatives are present, open communication should include:
♦ An explanation of the resuscitative efforts.
♦ The patient’s likely prognosis.
♦ An honest description of options in the dying process.
With open communication, family members can take into account any previously documented patient wishes on organ donation and recognize that the possibility of saving their family member has passed. This gives families the opportunity to outwardly express what the patient would want. “Involving EPs would help families better understand that their real decisions surround the dying process and whether it would permit organ donation,” Dr. Venkat says. With true informed consent, EPs can meet their ethical obligations to patients as potential organ donors by first attempting to save them. If these efforts fail, they can then explain to family members that an OPO referral and certain interventions are required to preserve the option of organ donation.
Dr. Venkat says separating communication about organ donation from the treatment team while simultaneously calling for early OPO referral gives only the appearance of preserving ethical integrity. “Going forward, efforts should be made to benchmark the time it takes for OPO representatives to get to the ED and speak to patients’ family so that delays can be addressed,” he says. “To maximize the value of organ donation, the involvement of both EPs and OPO personnel should be viewed as a means to meet the ethical obligations of all parties involved.”
Venkat A, Baker EF, Schears RM. Ethical controversies surrounding the management of potential organ donors in the emergency department. J Emerg Med. 2014;47:232-236. Available at: http://www.jem-journal.com/article/S0736-4679(14)00369-2/abstract or http://www.medscape.com/viewarticle/829229_print.
Center for Medicare Services. Condition of participation: organ, tissue and eye procurement. Available at: http://pntb.org/wordpress/wp-content/uploads/CMS-Interpretive-Guidelines_8c.pdf.
DuBois JM, Anderson EE. Attitudes toward death criteria and organ donation among healthcare personnel and the general public. Prog Transplant. 2006;16:65-73.
DuBose J, Salim A. Aggressive organ donor management protocol. J Intensive Care Med. 2008;23:367-375.