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Dalle Ave AL, Sulmasy DP. Does Sedation Affect Patients' Spiritual Experience at the End of Life? An Intersection Between Medicine and Spirituality. J Pain Symptom Manage 2023:S0885-3924(23)00762-5. [PMID: 37871840 DOI: 10.1016/j.jpainsymman.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/03/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics (A.L.D.A.), Georgetown University, Washington, DC, USA.
| | - Daniel P Sulmasy
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics (D.P.S.), Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
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Dalle Ave AL, Sulmasy DP. End-of-life Practices: An ethical framework for clinicians. Anaesth Crit Care Pain Med 2023; 42:101216. [PMID: 36933797 DOI: 10.1016/j.accpm.2023.101216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
Most hospitalized patients die following a decision to forgo life-sustaining treatment and/or focus on comfort care. Since "Do not kill" is a general ethical norm, many healthcare professionals (HCPs) are uncertain or troubled by such decisions. We propose an ethical framework to help clinicians to understand better their own ethical perspectives about four end-of-life practices: lethal injections, the withdrawal of life-sustaining therapies, the withholding of life-sustaining therapies, and the injection of sedatives and/or analgesics for comfort care. This framework identifies three broad ethical perspectives that may permit HCPs to examine their own attitudes and intentions. According to moral perspective A (absolutist), it is never morally permissible to be causally involved in the occurrence of death. According to moral perspective B (agential), it may be morally permissible to be causally involved in the occurrence of death, if HCPs do not have the intention to terminate the patient's life and if, among other conditions, they ensure respect for the person. Three of the four end-of-life practices, but not lethal injection, may be morally permitted. According to moral perspective C (consequentialist), all four end-of-life practices may be morally permissible if, among other conditions, respect for persons is ensured, even if one intends to hasten the dying process. This structured ethical framework may help to mitigate moral distress among HCPs by helping them to understand better their own fundamental ethical perspectives, as well as those of their patients and colleagues.
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Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics, The Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy Washington MD
- MS
- DC 424, 20057, United States.
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Depts. of Medicine and Philosophy, and the Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy 419, Washington, DC 20057, United States.
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Dalle Ave AL, Sulmasy DP. Death Lost in Translation. Am J Bioeth 2023; 23:17-19. [PMID: 36681911 DOI: 10.1080/15265161.2022.2159098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics and the Pellegrino Center for Clinical Bioethics, Georgetown University
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics and the Pellegrino Center for Clinical Bioethics, Georgetown University
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Dalle Ave AL. Determination of death: From irreversibility to assumability. Am J Transplant 2022; 22:1727-1728. [PMID: 35278273 DOI: 10.1111/ajt.17030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia, USA
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
- Departments of Medicine and Philosophy, and Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
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Abstract
The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Rue Du Bugnon 21, 1011, Lausanne, Switzerland.
- Institute for Biomedical Ethics, University Medical Center 1, Rue Michel-Servet, 1211, Geneva 14, Switzerland.
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, The Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy 419, Washington, DC, 20057, USA
| | - James L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Abstract
Objective Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation. Analysis When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified. Conclusion The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.
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Affiliation(s)
- Dale Gardiner
- Adult Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Jack K Kilcullen
- Medical Critical Care Services, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
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Dalle Ave AL, Shaw DM. Positive HIV Test Results from Deceased Organ Donors: Should We Disclose to Next of Kin? The Journal of Clinical Ethics 2018. [DOI: 10.1086/jce2018293191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
The whole-brain criterion of death provides that a person who has irreversibly lost all clinical functions of the brain is dead. Bedside brain death (BD) tests permit physicians to determine BD by showing that the whole-brain criterion of death has been fulfilled. In a nonsystematic literature review, we identified and analyzed case reports of a mismatch between the whole-brain criterion of death and bedside BD tests. We found examples of patients diagnosed as BD who showed (1) neurologic signs compatible with retained brain functions, (2) neurologic signs of uncertain origin, and (3) an inconsistency between standard BD tests and ancillary tests for BD. Two actions can resolve the mismatch between the whole-brain criterion of death and BD tests: (1) loosen the whole-brain criterion of death by requiring only the irreversible cessation of relevant brain functions and (2) tighten BD tests by requiring an ancillary test proving the cessation of intracranial blood flow. Because no one knows the precise brain functions whose loss is necessary to fulfill the whole-brain criterion of death, we advocate tightening BD tests by requiring the absence of intracranial blood flow.
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Affiliation(s)
- Anne L. Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
- Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L. Bernat
- Neurology Department, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Dalle Ave AL, Shaw DM. Positive HIV Test Results from Deceased Organ Donors: Should We Disclose to Next of Kin? J Clin Ethics 2018; 29:191-195. [PMID: 30226819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the context of deceased organ donation, donors are routinely tested for HIV, to check for suitability for organ donation. This article examines whether a donor's HIV status should be disclosed to the donor's next of kin. On the one hand, confidentiality requires that sensitive information not be disclosed, and a duty to respect confidentiality may persist after death. On the other hand, breaching confidentiality may benefit third parties at risk of having been infected by the organ donor, as it may permit them to be tested for HIV and seek treatment in case of positive results. We conclude that the duty to warn third parties surpasses the duty to respect confidentiality. However, in order to minimize risks linked to the breach of confidentiality, information should be restrained to only concerned third parties, that is, those susceptible to having been infected by the donor.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Switzerland, and Institute for Biomedical Ethics, University Medical Center of Geneva, Switzerland.
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland, and Care and Public Health Research Institute, Maastricht University, the Netherlands.
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Dalle Ave AL, Shaw DM, Elger B. Practical Considerations in Donation After Circulatory Determination of Death in Switzerland. Prog Transplant 2017; 27:291-294. [PMID: 29187117 DOI: 10.1177/1526924817715458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Faced with similar issues of organ scarcity to its neighbors, Switzerland has developed donation after circulatory determination of death (DCDD) as a way to expand the organ pool since 1985. Here, we analyze the history, practical considerations, and ethical issues relating to the Swiss donation after circulatory death programs. In Switzerland, determination of death for DCDD requires a stand-off period of 10 minutes. This time between cardiac arrest and the declaration of death is mandated in the guidelines of the Swiss Academy of Medical Sciences. As in other DCDD programs, safeguards are put to avoid physicians denying lifesaving treatment to savable patients because of being influenced by receivers' interest. An additional recommendation could be made: Recipients should be transparently informed of the worse graft outcomes with DCDD programs and given the possibility to refuse such organs.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,2 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,3 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - David M Shaw
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Elger
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,4 Centre for Legal Medicine, University of Geneva, Geneva, Switzerland
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Abstract
Background The fundamental determinant of death in donation after circulatory determination of death is the cessation of brain circulation and function. We therefore propose the term donation after brain circulation determination of death [DBCDD]. Results In DBCDD, death is determined when the cessation of circulatory function is permanent but before it is irreversible, consistent with medical standards of death determination outside the context of organ donation. Safeguards to prevent error include that: 1] the possibility of auto-resuscitation has elapsed; 2] no brain circulation may resume after the determination of death; 3] complete circulatory cessation is verified; and 4] the cessation of brain function is permanent and complete. Death should be determined by the confirmation of the cessation of systemic circulation; the use of brain death tests is invalid and unnecessary. Because this concept differs from current standards, consensus should be sought among stakeholders. The patient or surrogate should provide informed consent for organ donation by understanding the basis of the declaration of death. Conclusion In cases of circulatory cessation, such as occurs in DBCDD, death can be defined as the permanent cessation of brain functions, determined by the permanent cessation of brain circulation.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University hospital of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.
| | - James L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Abstract
Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,2 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L Bernat
- 3 Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abstract
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.
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Affiliation(s)
- Anne L. Dalle Ave
- Ethics Unit, University hospital of Lausanne, Lausanne, Switzerland
- Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - David M. Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse, Basel, Switzerland
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Dalle Ave AL, Gardiner D, Shaw DM. The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors. Transpl Int 2016; 29:612-8. [DOI: 10.1111/tri.12772] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/20/2016] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Anne L. Dalle Ave
- Ethics Unit; University Hospital of Lausanne; Lausanne Switzerland
- Institute for Biomedical Ethics; University Medical Center; Geneva Switzerland
| | - Dale Gardiner
- Nottingham University Hospitals NHS Trust; Nottingham UK
| | - David M. Shaw
- Institute for Biomedical Ethics; University of Basel; Basel Switzerland
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Dalle Ave AL, Gardiner D, Shaw DM. Cardio-pulmonary resuscitation of brain-dead organ donors: a literature review and suggestions for practice. Transpl Int 2015; 29:12-9. [PMID: 26073934 DOI: 10.1111/tri.12623] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 05/18/2015] [Accepted: 06/10/2015] [Indexed: 11/28/2022]
Abstract
"Organ preserving cardiopulmonary resuscitation (OP-CPR)" is defined as the use of CPR in cases of cardiac arrest to preserve organs for transplantation, rather than to revive the patient. Is it ethical to provide OP-CPR in a brain-dead organ donor to save organs that would otherwise be lost? To answer this question, we review the literature on brain-dead organ donors, conduct an ethical analysis, and make recommendations. We conclude that OP-CPR can benefit patients and families by fulfilling the wish to donate. However, it is an aggressive procedure that can cause physical damage to patients, and risks psychological harm to families and healthcare professionals. In a brain-dead organ donor, OP-CPR is acceptable without specific informed consent to OP-CPR, although advance discussion with next of kin regarding this possibility is strongly advised. In a patient where brain death is yet to be determined, but there is known wish for organ donation, OP-CPR would only be acceptable with a specific informed consent from the next of kin. When futility of treatment has not been established or it is as yet unknown if the patient wished to be an organ donor then OP-CPR should be prohibited, in order to avoid any conflict of interest.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Dale Gardiner
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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