Objective:

To systematically evaluate and describe the ethical issues identified in patients who are being evaluated for possible organ donation after circulatory death (DCD).

Background:

DCD refers to the procurement of organs for transplantation from patients whose death is diagnosed using cardio-respiratory criteria. Patients who are potential donors through a DCD pathway often have primary neurologic diagnoses and may lack decision-making capacity, and thus this is relevant for neurologists. Our local DCD policy requires a clinical ethics consultation (CEC) for all patients being evaluated for DCD.

Design/Methods:

Retrospective analysis of all adult patients who had a CEC and were evaluated for DCD. The cohort was identified using three databases (a neurocritical care clinical database, a bioethics consultation database, and the organ procurement organization’s database). Demographics, details of the CEC, and details about organ donation outcomes were extracted from the electronic medical record and databases.

Results:

103 patients had a CEC about DCD. Average age was 46.9 years (range 18-65) and 45% were women. Diagnoses at time of death were stroke (44.3%; including 17.5% subarachnoid hemorrhage,14.6% ischemic stroke, 12.6% hemorrhagic stroke), post-cardiac arrest hypoxic-ischemic brain injury (18.4%), traumatic brain injury (17.5%), and cardiopulmonary disease (17.5%). Of 159 ethical issues identified, the most common included: treatment planning/end of life decision making (n=13); possible medically ineffective care/futility (n=12); and issues surround surrogate decision making or lack of surrogates (n=12). Additional ethical concerns included possible organ donation after brain death and conflict mediation within a patient’s family or between the team and the surrogate(s).

Conclusions:

In this cohort of patients being evaluated for DCD, >80% of the patients had primary neurologic diagnoses. Ethical challenges were common and three main categories were identified: making decisions about treatment and end-of-life care for critically ill patients; determining surrogate decision maker; and conflict among family members or between family members and medical teams.