Page 14

NCS Currents June 2016

NEUROCRITICAL CARE ETHICS Potential Donor Management – Ethical Imperative or Unwarranted Paternalism? By Harry Peled, MD and Michael Rubin, MD Those of us who work in the Neuro ICU frequently encounter patients with devastating brain injury in which progression to brain death seems to be inevitable, but has not yet occurred. In many of these cases, the family wishes to have “everything done” and has not yet accepted the certainty of impending brain death. In these situations, there should be no barrier whatsoever to initiating treatment per the catastrophic brain injury guidelines. What is being done to maintain the patient also supports the organs for potential donation. In addition, since brain death cannot be declared in the presence of hypotension or severe electrolyte abnormality, optimizing bodily functions may in fact bring matters to a more rapid resolution through a proper declaration of brain death. If one does not Harry Peled, MD maintain the patient as a potential organ donor prior to timely approach by the organ procurement organization, autonomy is compromised by precluding the family’s option to donate. Traditionally, physicians tend not to get specific consent for treatment focusing on optimizing the potential for organ donation prior to brain death declaration. There is concern that the family may not be ready to face the pressure of making a decision on organ donation. There is also a concern that a premature approach for organ donation may undermine the family’s trust in the care team and blur the lines between the care team and the potential transplant team. However, there certainly is coordination between the care team and the transplant team. The care team, by law, notifies the organ procurement organization of impending deaths according to defined clinical criteria. Timing of brain death declaration and approach to family is a planned, joint effort. However, one can question whether treating the patient solely for the purpose of benefiting others without express consent is truly ethical after the patient is stabilized. Many of us are finding this problem is becoming more common and intense as physicians and patients have a far better understanding of the inevitability of death in many situations and wish to de-escalate care prior to progression to brain death. We are left with the question, do we discuss organ donation at the same time as de-escalation of care? Do we wait, and if so, for how long? The foundation of the physician-patient-family relationship is beneficence – that all actions are being taken for the benefit of the patient. There will also be significant benefits to others if donation occurs. We all agree that organ donation is beneficial and, if a premature approach will prevent this, then it might be ethical to treat without consent for some interval in order to achieve that end. However, in many ways this seems to contradict one of the basic concepts of medical ethics which is respect for autonomy. If the family wishes to de-escalate care and the patient develops diabetes insipidus, for example, is it okay to administer vasopressin? This may be problematic on several levels. Although, of course, the focus needs to be on the patient and the family, this lack of disclosure may cause problems which we cannot ignore. The need for truthfulness is a value we tend to take as a given in our professional relationships. One of the main goals of effective palliative care is to inform the family of what to expect and the next steps of the journey. The palliative care staff often feels the value of veracity is sacrificed when everyone knows organ donation will and should be discussed. Family may be in the zone where they do not wish to withdraw the ventilator but do not want further escalation of care. Nurses are concerned that families will ask why they are giving a certain medication or why blood is being drawn. These actions may seem inconsistent and are in fact inconsistent if interventions are performed solely for the unrevealed purpose of donation. So what is the best course of action? As in many areas of bioethics, a simple answer risks being oversimplistic. However, we feel that there might be a need to make an adjustment in terms of timing of approaching the family if we wish to institute catastrophic brain injury guidelines at a time when the family is interested in de-escalating treatment. Once patient treatment is being altered based on the possibility of organ donation, it seems mandatory to have an informed discussion with the family with the organ procurement organization present as to whether the family wishes to proceed with those next steps. In terms of trust, making a conscious decision to not inform the family why we are doing or ordering therapies – to unilaterally assume that they are not ready to hear the truth – is not respecting autonomy. When we are in the gray zone, it would not be surprising if families actually sense some of the tension in the staff and the delay in honest discussion reduces the chance of consent for donation rather than enhancing it. There is most certainly an ethical imperative to try to manage every patient with devastating brain injury in a way that preserves options for organ donation. Undue delay in sharing the goals with family when the goals have changed from focusing on the patient to focusing on others appears to be unwarranted paternalism. We feel that further discussion to obtain clarity on this issue and with local ethics committees might be of benefit for all impacted stakeholders. More honesty may well be the best policy. Harry Peled, MD is the Medical Director of the In-Patient Cardiology/ Non-invasive Lab and Medical Director of Critical Care at the St. Jude Medical Center in Fullerton, California. He is a member of the NCS Ethics Committee and an invited guest writer for Currents. Michael Rubin, MD 14


NCS Currents June 2016
To see the actual publication please follow the link above