Organ donation: organ harvesting or end of life care
Deepak Bhonagiri
Liverpool Hospital, NSW, Australia
Intensivists manage end of life care issues regularly and
discussions regarding organ donation are considered to be an extension
of end of life care. Intensive care is based upon the ethical
principles of Autonomy, beneficence and non-maleficence (1). Discussing
and consenting a patient already in ICU for organ donation may fulfil
some of those ethical principles especially in an environment where 75%
of the community are said to support organ donation and a majority of
license holders in NSW consent to organ donation on their license.
Admitting a patient to ICU purely for the purposes of organ donation
does not fulfil any of the above ethical principles. However, 61% of
intensivists who responded to a survey (2) on attitudes towards organ
donation agreed that admitting severely brain injured patients to ICU
for the sole purpose of organ donation was acceptable.
The increasing gap between the number of patients on the transplant
list and the number of available organs receives regular media
publicity. Governments therefore respond to this and measures such as
"opt out", the Organ Donation Collaborative and increasing registration
of intent to donate are trialled. Measures to increase consent to organ
donation in potential organ donors in ICU may change the focus of
intensivists from end of life care to facilitation of organ
"harvesting". The word "harvesting" is closely associated with organ
donation and is indeed one of the MESH terms in Medline (3).
"Harvesting" is synonymous with "reaping", "gathering" or " collection"
of crops.
In the USA the "Organ Donation Breakthrough Collaborative"(4) has been
in place for the last 5 years and has been associated with an increase
in the number of organ donors there. Adoption of that methodology in
Australia (5) has delivered less significant increase in organ donor
numbers. The performance indicators and targets for hospitals
participating in the collaborative include a 100% request rate and a
75% consent rate of all potential organ donors. This utilitarian
performance managed, outcome driven strategy promotes organ
"harvesting" and not end of life care.
The UK recently adopted a presumed consent/ opt out approach to organ
donation which led to fierce debate in the community (6). The National
Clinical Taskforce on Organ and Tissue donation 2008 (7) in Australia
recommends against a similar approach in Australia. The report states
that such a move may not be associated with any significant increase in
organ donor numbers. The concurrent use of the driver's license
registration and the Australian Organ Donor Registry in NSW has
resulted in the registration of intention to donate or refusal to
donate of > 2 million NSW drivers' license holders. Other Australian
States and territories have stopped registering intention to donate via
the driver's license and have fewer registrations. Of note, the actual
consent rate to organ donation in NSW is very close to the intent/
consent registration rate on the drivers' license and much less than
the >75% support expressed in community survey on organ donation.
The perceived conflict of interest faced by intensivists as they change
roles from managing a patient in the expectation of recovery, to end of
life care and consent and medical management of a potential organ donor
may be minimised by designated requestors. These may be in the form of
Organ Procurement organisation staff like in the USA or Designated
Medical specialist like in Spain (8). The Spanish model is worth
reviewing due to its success in increasing organ donor rates from 19
per million population to 34 per million population. The Spanish organ
donor rate remains higher than other countries' even when other
denominators such as donors per 1000 hospital deaths or donors per 1000
deaths due to CVA are considered. Some components of the Spanish model
such as repeated requests in case of non- consent and advocating organ
donation to families are not commonly practiced in Australia.
There are no surveys studying the attitude of Australian intensivists
towards designated requestors. The Joint faculty of Intensive care
Medicine has a mandatory requirement that the Australian (Organ) Donor
Awareness Program (9) is completed by all trainees before conferring
the Fellowship of the JFICM.
In coming years Intensivists in Australia and New Zealand are likely to
come under increasing pressure and scrutiny over low organ donor
numbers. Maintenance of regular audits demonstrating the number of
potential and actual organ donors, continuing medical education on
organ donation and active engagement with the public and government on
issues related to organ donation will be required to continue ethical
and dignified end of life care including organ donation and not organ
"harvesting"
Australasian outcomes of organ transplantation are among the best in
the world as demonstrated by the improved quality of life and cost
saving associated with renal transplantation as compared to dialysis
for end stage renal failure (10). Organ retrieval surgery and
allocation of organs for transplantation allow for the optimal
management of donor organs. The number of organs retrieved and
transplanted per donor in Australia is better than or equivalent to
other countries in the world. These outcomes are achieved not only due
to organ retrieval, transplantation and post transplantation management
but also because of good resuscitation, identification and ethical
management of potential organ donors. Lowering the medical thresholds
and exclusions to increase organ donor rates may increase the number of
organ donors but will not necessarily be associated with comparable
recipient outcomes.
The total number of organ donors in Australia has remained around 200
for the past 10 years (11). This may represent the "pool" of organ
donors in Australia. Any future reviews into organ donation should have
a greater recognition of the unique role of intensivists in cadaveric
organ donation and the ethical conflicts inherent to organ donation.
Resources to support health care professionals involved in the care of
potential organ donors need to increase and community awareness and
education
- ABC of intensive care Winter B,Cohen S, BMJ1999; 319:306-308
- ANZICS Survey on Brain Death and Organ Donation 2006 (from the final report-2008 of the National Clinical Taskforce on Organ and Tissue Donation)
- Medical Subject Headings [MeSH]. US National Library of Medicine, National Institutes of Health http://www.nlm.nih.gov/mesh/meshhome.html
- Organ Donation and Transplantation Breakthrough Collaborative, Health Resources and Services Administration, US Department of Health and Human Services, 2007)
- National Organ Donation Collaborative - Australians Donate
- On the state of public health: Annual report of the Chief Medical Officer 2006 http://www.dh.gov.uk/cmo
- National Clinical Taskforce on Organ and Tissue Donation - final report 2008
- The Spanish Model http://www.ont.es/contenido.jsp?id_nodo=5&&&keyword=&auditoria=F
- ADAPT - Australasian Donor Awareness Programme www.adapt.asn.au/
- Cass A, Chadban S, Craig J, et al. Economic impact of end stage kidney disease in Australia. Melbourne: Kidney Health Australia, 2006. http://www.kidney.org.au (accessed May 2006)
- ANZOD - Australia New Zealand Organ Donation Registry http://www.anzdata.org.au/ANZOD
