Sarah Chapple defends organ and tissue donation after cardiac death for patients who are critically ill and dependent on mechanical ventilation, but who do not meet the requirements for neurological death.
The CBC program “The Fifth Estate” recently aired an episode titled “Dead Enough” that explores issues regarding the declaration of death in critical care units and the state of organ transplant in Canada. As a critical care social worker, I have worked with dozens of families faced with the situation of losing their loved one to a critical illness or sudden traumatic death. Organ donation can be a way of finding something good in a tragic situation, as described by the family of Sarah Beth Therien, the first DCD (donation after cardiac death) donor in Canada.
From my perspective, the portrayal of the consent process for organ donation in this program is highly problematic and left the viewer with an impression of physicians waiting in the wings ready to swoop in and remove organs from patients who still might recover from their injuries if given enough time. The comments from the families of Shane Becker and Brandice Thompson may lead the public to believe that families are being coerced into consenting to organ donation. Although miraculous recoveries can occur, these are extremely infrequent.
It is unethical to approach a family and attempt to coerce consent to organ donation if there is any hope of recovery. In cases of brain (neurologically determined) death, families would not be approached regarding organ donation until a determination of death has already been made by two physicians. The discussion would only occur prior to this, if a family requested such information after being informed that the prognosis was extremely poor. A referral would then be made to the provincial transplant coordinator to check if the patient was a registered donor. It should also be noted that if, at any time, a family requested that the process be stopped, their wishes would always be respected without question.
It is important to distinguish between brain death and cardiac death, as many consider death to have occurred only once respiration ceases and the heart stops beating. Brain death is defined as the irreversible loss of consciousness and all functions of the brain stem including the capacity to breathe. A patient determined to be brain dead is clinically and legally dead, and an evaluation for brain death is often considered in patients who experience a massive head trauma with irreversible brain injury. There is a nation-wide criterion for the testing, determination and diagnosis of brain death in Canada that was published by the Canadian Congress of Neurological Sciences in 1986.
Organ and tissue donation after cardiac death (DCD) is an option for patients who are critically ill and dependent on mechanical ventilation, but who do not meet the requirements for neurological death. These patients have usually experienced a severe and irreversible brain injury with no long term prognosis for recovery, as defined by the Trillium Gift of Life Network in Ontario. Dr. Brian Goldman explains that organ donation after cardiac death means that donation can take place within minutes after the heart stops, precautions are put in place to ensure cardiac death has taken place and that families are not approached in haste. Critics of the DCD process express concern that cardiac death may be reversible after five minutes. However death, although potentially reversible through CPR, is still death once circulation ceases.
A national, multidisciplinary, year-long discussion occurred in Canada in 2005 to address the ethical issues associated with organ donation after cardiac death. Offering organ donation is viewed as an important part of end of life care, and research has shown that organ donation has a beneficial effect on family bereavement. A study from 2008, found that 97 percent of respondents had no regrets about consenting to organ donation and 94.5 percent said they were treated with compassion and respect. There is, however, some room for improvement in these conversations, as half of the respondents also felt confused about brain death and may have felt rushed into making decisions.
Acting as the decision-maker for a loved one with a critical illness is highly stressful, and can result in symptoms of acute stress. Access to clear and consistent information and good interpersonal relationships with the health care staff can help to ease anxiety and stress, especially when the focus of care shifts from life-saving interventions to comfort care and organ donation. Providing families with clear information and encouraging them to write down their questions for the medical team may assist with recall and decrease stress.
Families need to be able to trust the medical team, have their questions answered and be given time to consider options, although the urgency of critical care treatment may not always allow enough time for this t occur The focus in critical care is to save lives, not prolong death, and for some families the potential for organ donation can help them to cope with their grief over a sudden loss.
Sarah Chapple is a Critical Care Social Worker in Vancouver and an Instructor at the University of Victoria in the Faculty of Human and Social Development @sarah_chapple