Palliative Care Consultation in the Process of Organ Donation after Cardiac Death

The bereavement experiences of families of potential organ donors: a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES

To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature.

METHOD

Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death.

FINDINGS

Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient's death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement.

RECOMMENDATIONS

Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs.

CONCLUSION

The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow.

Attitude of the Older Population Toward Controlled Asystole Donation

INTRODUCTION

Studies about the knowledge of and attitude toward new lines of organ donation in a group of older people are important due to the increase in older organ donors.

OBJECTIVES

To analyze the attitude of citizens over 65 years of age in southeastern Spain toward controlled asystole donation (CAD) and to determine the psycho-social profile that influences this attitude.

METHODS

The study population consisted of citizens over 65 years of age. A representative sample was obtained in southeastern Spain (N = 420). A questionnaire about attitudes toward CAD was used, detailing in the questionnaire that this is a type of donation from people who have died of circulatory and respiratory criteria after the limitation of life support treatment. Several psychosocial variables were also taken into account. Statistical analysis included the χ2 test and multivariate analysis.

RESULTS

The completion rate was 84% (n = 351). Favorable attitude toward organ donation and transplantation (ODT) was 98% (n = 344) overall, and CAD was viewed favorably by 45% (n = 158). The psychosocial variables that influenced attitude toward CAD were mainly having received a talk about ODT (odds ratio [OR] 5.6), knowing the opinion of one's partner (OR 7.95), acceptance of cremation (OR 1.09), and acceptance of autopsy (OR 3.002).

CONCLUSIONS

The attitude of older people toward CAD is unfavorable despite a willingness to support ODT in general. This attitude is influenced by variables of social and family dialogue about ODT, attitude to body manipulation, and having received information about ODT.

End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review

Background

Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care.

Purpose

The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients.

Research design and Study Sample

This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation).

Results

Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment.

Conclusions

There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.

The ethics of testing and research of manufactured organs on brain-dead/recently deceased subjects

Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased.

Grief, Stress, Trauma, and Support During the Organ Donation Process

The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family's experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other's positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members' efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other's roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff.

Controlled Donation After Circulatory Determination of Death

Controlled donation after circulatory determination of death (cDCDD) concerns donation after withdrawal of life-sustaining therapy (W-LST). We examine the ethical issues raised by W-LST in the cDCDD context in the light of a review of cDCDD protocols and the ethical literature. Our analysis confirms that W-LST procedures vary considerably among cDCDD centers and that despite existing recommendations, the conflict of interest in the W-LST decision and process might be difficult to avoid, the process of W-LST might interfere with usual end-of-life care, and there is a risk of hastening death. In order to ensure that the practice of W-LST meets already well-established ethical recommendations, we suggest that W-LST should be managed in the ICU by an ICU physician who has been part of the W-LST decision. Recommending extubation for W-LST, when this is not necessarily the preferred procedure, is inconsistent with the recommendation to follow usual W-LST protocol. As the risk of conflicts of interest in the decision of W-LST and in the process of W-LST exists, this should be acknowledged and disclosed. Finally, when cDCDD programs interfere with W-LST and end-of-life care, this should be transparently disclosed to the family, and specific informed consent is necessary.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVES

To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.

DATA SOURCES

A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury."

DATA EXTRACTION AND SYNTHESIS

We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.

CONCLUSIONS

Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

Parental experiences and recommendations in donation after circulatory determination of death*

OBJECTIVE

To describe parents' experience of organ donation decision making in the case of donation after circulatory determination of death.

DESIGN

Qualitative exploratory analysis.

SETTING

Participants were recruited from the ICU of a single children's hospital located in the western United States.

PARTICIPANTS

Thirteen parents, 11 families who consented to donate their child's organs.

INTERVENTIONS

Interviews (average 82 min).

MEASUREMENTS AND MAIN RESULTS

Transcribed interviews were analyzed using the constant comparative method to identify themes that reflected similarities in parents' experiences. The themes we found included 1) factors contributing to parental decision making, 2) under the circumstances of the child dying, and 3) donation decision and its impact on parental grief. Factors that influenced the decision making all related to the child dying, including protecting the child's body and helping the child to die peacefully. Finally, parents made recommendations about the organ donation process, including empathy, attend to end-of-life concerns, and the provision of relevant information for donation decisions.

CONCLUSIONS

Parents' decision making was related directly to end-of-life experience and grief process. Providers need to orient to parents' end-of-life concerns to support parents' decision-making process and improve donation after circulatory determination of death procedures.

An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death

RATIONALE

Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues.

OBJECTIVES

To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders.

METHODS

A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders.

RESULTS

A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD.

CONCLUSIONS

The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

Stakeholder perceptions of thoracic rapid tissue donation: An exploratory study

Rapid autopsy or rapid tissue donation (RTD) is a novel method of tissue procurement in which 'fresh' tissue is collected within 2-6 h following the death of a patient. While the use of RTD offers many opportunities to develop new therapies for lung cancer patients, it raises ethical concerns. The purpose of this study was to examine knowledge, perceptions and ethical concerns about recruiting patients for an RTD program. To achieve research goals, we conducted six focus groups, each containing 5-10 participants (N = 38). Participants were cancer patients (n = 17) their caregivers (n = 6), physicians (n = 6) and clinic staff (n = 9) from the Thoracic Oncology Program at Moffitt Cancer Center, in Tampa, Florida, USA. All focus groups were audio-recorded and conducted using a semi-structured focus group guide. The transcripts were analyzed using hand-coding methods. Data were coded independently by at least two researchers, and an inter-rater reliability rate of ≥90% was achieved. Knowledge about RTD was low among all groups, with physicians having slightly higher knowledge; all groups agreed that RTD offered major benefits to cancer research; physicians and clinic staff were mainly concerned about making a patient feel uncomfortable and reducing hope, while, patients and family members were more concerned about logistics and how the family would be affected during tissue retrieval. All groups agreed the physician was the appropriate person to begin a discussion about RTD and that recruitment should be individualized. All groups reported that physician training is necessary, as well as an awareness campaign for patients and families to be more receptive about RTD. The results of this study suggested more education is needed for all stakeholders to learn about RTD prior to the initiation of a research program. Our approach of querying all stakeholders provides a firm foundation for future training modules regarding RTD programs in lung cancer.

Palliative care after attempted suicide in the absence of premorbid terminal disease: a case series and review of the literature

Palliative care involvement in the management of incomplete suicide in patients without terminal illness is rare. This paper documents two such cases and explores some of the clinical and ethical issues raised.

Donation after cardiac death: ethical dilemmas and implications for advanced practice nurses

Donation after cardiac death has always presented ethical concerns among health care providers. As advanced practice nurses and critical care nurses, it is our responsibility to ensure that health care providers and families are educated about the process and that we remain advocates for the potential donors. This article reviews the donation after cardiac death process, provides a donation after cardiac death hypothetical case report and its outcome, and addresses the ethical concerns associated with donation after cardiac death from both opponents' and proponents' points of view. It will also discuss the benefits of obtaining a palliative care consult and the roles of the advanced practice nurse in the care of the potential donor.

Organ donation after cardiac death from withdrawal of life support in patients with amyotrophic lateral sclerosis

OBJECTIVE

Donation after cardiac death (DCD) or donation of organs after removal of life support is an accepted means of organ retrieval that usually occurs in the setting of sudden illness but has not been described in people with progressive neurologic illness. We report DCD in two people with progressive amyotrophic lateral sclerosis (ALS).

METHODS

Case series at an academic medical center of two men with progressive ALS who underwent withdrawal of artificial life support, rapid cardiac death, and subsequent organ donation. The primary outcome was donation of organs in concordance with patient and family wishes.

RESULTS

Both patients underwent peaceful withdrawal of life support in the presence of family, and multiple organs were donated.

CONCLUSIONS

Patients may legally and ethically refuse life-sustaining care. These patients considered their lives to be more burdensome than beneficial near the end of their lives, both carefully planned the time and circumstance of their deaths, and both fulfilled a long-standing desire to donate their organs. This study describes a potential opportunity for patients with progressive neurologic illness.

Organ donation after circulatory death: vital partnerships

OVERVIEW

The authors present the case of a woman in her mid-50s who sustained extensive brain injury in an accident but wasn't declared brain dead. The case highlights some of the clinical and ethical considerations of organ donation after circulatory death (also known as non-heart-beating donation and donation after cardiac death). It also illustrates the interdisciplinary teamwork necessary for organ donation in such cases, involving nurses and other clinicians in the ICU, palliative care, and the local organ procurement organization, among others.

KEYWORDS

cardiac death, circulatory death, donation after cardiac death, end-of-life care, ethics, non-heart-beating donation, organ donation, organ donation after circulatory death, organ transplantation, palliative care.

A multidisciplinary organ donor council and performance improvement initiative can improve donation outcomes

The shortage of organs available for transplantation has become a national crisis. The Department of Health and Human Services established performance benchmarks for timely notification, donation after cardiac death (DCD), and conversion rates (total donors/eligible deaths) to guide organ procurement organizations and donor hospitals in their attempts to increase the number of transplantable organs. In January 2007, an organ donor council (ODC) with an ongoing performance improvement case review process was created at a Level I trauma center. A critical care devastating brain injury protocol and a DCD policy were instituted. Best performance benchmarks were evaluated before and after establishment of the ODC. At our center, the total number of referrals increased from 96 in 2006 to 139 in 2007 and 143 in 2008. Timely notification rate increased from 64 per cent in 2006 to 83 per cent in 2007 and 2008 (P < 0.01). DCD rate increased from 0 per cent in 2006 to 13 per cent in 2007 (P = 0.06) and 10 per cent in 2008 (P = 0.09). Conversion rate increased from 53 per cent in 2007 to 78 per cent in 2008 (P = 0.05) and 73 per cent in 2009 (P = 0.16). Organs transplanted per eligible death trended upward from 1.80 in 2007 to 2.54 in 2009 (P = 0.20). As a consequence, the establishment of a multidisciplinary ODC and performance improvement initiative demonstrated improved donation outcomes.

Brain death: ethical challenges to palliative care concepts of family care

Brain death is a controversial issue that is often difficult for families to understand or accept. Palliative care interventions can help families to accept the death. However, delaying pronouncement of brain death may be detrimental to the family and lead to financial, ethical, and legal complications, including the potential for insurance fraud. We describe a case of brain death in which the passage of time along with continuation of life support without concomitant testing for brain death led to decreased acceptance of the patient's death by the family. Clinicians should weigh the risks and benefits of harm to the family when deciding how long to keep a brain dead patient on a ventilator. Pronouncement of death, which is good basic medical care regardless of the cause or mechanism of death, should not be delayed for family considerations. Risk management should be involved early in the decision process, if life support is withdrawn without the family's assent.

Organ and Tissue Donation and Transplantation

Since 1968, vital organs, necessary for life, have been removed from patients for transplantation into patients in whom corresponding organs have ceased to function. Since then this has been morally justified by the claim that the donor is “brain dead” or has suffered “cardiac death.” Brain death is defined as complete and irreversible loss of all brain function, and cardiac death is declared two to five minutes after cessation of the heartbeat.

The moral problem is that the criteria used to declare that brain death or cardiac death has occurred are arbitrary, open to serious world-wide debate, variable in definition and application, and, more seriously, do not necessarily provide moral certainty that real death has occurred and that such organ retrieval does not actually cause the death of the donor.

This problem has been debated over the years at the Pontifical Academy of Sciences and remains a subject of legitimate debate to this day. The declaration of brain death or cardiac death also does not appear to be consistent with the teaching of Pope Benedict XVI that the definition of death receive the consensus of the entire scientific community and does not give everyone certainty that the primary criterion is respect for the life of the donor and that the organs are removed from a dead body, a cadaver.

Understanding the antecedents of the acceptance of donation after cardiac death by healthcare professionals

OBJECTIVE

A 3-yr study funded by the U.S. Department of Health and Human Services was conducted to identify potential barriers to and opportunities for increasing the number hospitals with donation after cardiac death (DCD) protocols, the support of DCD by individuals involved in the donation request process, and the number DCD donors recovered. This study reports the qualitative findings.

DESIGN

Methods used included an advisory committee and an extensive array of key informant interviews and focus groups.

SETTING

Hospitals and telephone contact.

SUBJECTS

Discussions with nurses, physicians, social service staff, clergy, administrators, and organ procurement organization staff. A total of 216 people participated.

INTERVENTIONS

Collection and analysis of information regarding perceptions of DCD, potential barriers and opportunities, and strategies for gaining support.

MEASUREMENT AND MAIN RESULTS

Key barriers included a lack of knowledge about DCD, psychological barriers for DCD vs. brain death, concerns about whether death has been reached, saving vs. killing patients, trust in the organ procurement organization, moving from saving patients to being a donation advocate, and concerns with the DCD process. Opportunities included education initiatives, well-trained requesters, a cultural shift, a consistent DCD protocol separating care from recovery, process monitoring, and a strong sense of teamwork.

CONCLUSIONS

Our findings provide a better understanding of healthcare professionals' knowledge, attitudes, and behaviors regarding DCD. Understanding these issues is critical to the implementation of strategic plans for DCD programs. One of the biggest barriers to overcome is a lack of knowledge of DCD, which leads to misperceptions, which in turn contribute to negative attitudes and/or discomfort by healthcare professionals. Communication efforts that are able to educate healthcare professionals and eliminate misperceptions will increase support for DCD. Key to future success requires confident and well-trained DCD requesters.

An empirical examination of the antecedents of the acceptance of donation after cardiac death by health care professionals

Findings are reported from a US Department of Health and Human Services (DHHS) funded study to identify barriers to increasing support for donations after cardiac death by health professionals. A donations after cardiac death (DCD) acceptance model is conceptualized and tested via 806 survey responses from certified requestors, all of whom had their identities protected through Institutional Review Board (IRB) protocol. The overall model was significant and explained 35% of the variation in DCD support. Greater knowledge about DCD, greater trust in the organ procurement organization (OPO) and a belief that futility has been reached were all positively associated with DCD acceptance. Negative perceptions of DCD versus brain death, transitioning from caregiving to donation advocate, concerns about the DCD process and the idea that DCD leads to active participation in the death reduced its support. The three greatest impediments to support of DCD exist when health professionals feel they are playing an active role in killing the patient, that a state of death has not yet been reached, and that DCD has more psychological barriers than does the brain death donation process. Opportunities and strategic initiatives are discussed to overcome these barriers, including the value of communication and education initiatives and the need for well-trained requestors. The implementation of these strategic guidelines helped to increase the number of DCD donors by 225%.