Organ donation immediately following the withdrawal of life-sustaining therapy and circulatory determination of death (DCDD) is a growing practice, allowing transplantation surgical staff to rapidly recover organs prior to ischemic organ injury. A case study published in the AMA Journal of Ethics examined the ethical considerations of DCDD in the case of a 21-year-old woman with a traumatic brain injury as a result of a life-threatening automobile crash.
Although the patient had a very poor prognosis, the investigators presenting the case study suggested that the age of this patient may have contributed to substantial functional recovery over time. Prior to withdrawing this patient from life-sustaining therapy and announcing DCDD for organ procurement, the investigators suggested that clinicians must be certain of a poor prognosis as evidenced by absence of brain stem functioning. In this patient’s case, the family members supported organ donation and withdrawal of life-sustaining therapy, primarily due to the beliefs that the patient held in everyday life regarding these issues. In addition, declaration of death had to be made a full 5 minutes following cardiac and respiratory arrest in order to proceed with organ procurement.
While withdrawal of life-sustaining therapy is necessary for controlled DCDD, medical ethics suggests that “the decision to be an organ donor should be uncoupled from and never drive the decision to withdraw LST,” and that decisions should be made based on the patient’s own values as best as can be known by surrogates. If these values are not known, the substituted judgement standard can be used to determine the best course. It is generally accepted that DCDD donors should then receive the palliative care that is commonly received by non-donors after life-sustaining therapy has been withdrawn.
The case study researchers concluded that valid informed consent for organ donation should be provided by either patients or their surrogates, with consent “based on an understanding of the exact plan and procedure for terminal palliative care, donor organ support intervention, death determination, and organ donation.”
Bernat JL, Robbins NM. How should physicians manage organ donation after the circulatory determination of death in patients with extremely poor neurological prognosis? AMA J Ethics. 2018;20(8):E708-E716.