Since the beginning of organ transplantation, there has been an increasing disparity between the supply and demand for organs. The waiting list for kidneys has almost tripled, and the waiting list for livers has increased tenfold since 1990, while donations have less than doubled.¹ To meet increasing demands, some centers have begun transplanting organs from patients who have died circulatory deaths after withdrawal of life support. Such donors are termed “non-heart-beating cadaver donors” (NHBCDs). Kidneys and livers from NHBCDs have similar viability to those from brain-dead donors, and even lungs and hearts have been successfully transplanted from NHBCDs.²

Because NHBCDs suffer a circulatory death, blood supply to vital organs is interrupted between the time of death and the removal, cooling and preservation of organs. One strategy to reduce this “warm ischemic time” and to promote organ viability is to withdraw life-support in an operating room (O.R.), where organ harvest can commence immediately after death.

Anesthesiologists often learn about NHBCDs when they discover that they have been designated to withdraw medical treatment from such a patient and monitor and manage their symptoms until death ensues. Many have questioned the legality and ethics of using NHBCDs. Another important question is whether it is professionally appropriate for anesthesiologists to participate even if the use of NHBCDs is both legal and ethical.

Clear legal precedents, such as those of Karen Ann Quinlan, Nancy Cruzan and Claire Conroy, have established the rights of patients to forgo or terminate life-sustaining treatments. Patients also have the right to donate their organs for transplantation, irrespective of the cause of death.³ Ethical questions, however, are more complex.

A primary principle in medical ethics requires respect for patient autonomy, including patient desires to terminate life-sustaining therapy and donate organs. Another is the principle of beneficence, or “doing good.” Terminating life-sustaining treatment may be beneficent by ending unbearable burdens such as physical, emotional and psychological suffering, loss of dignity and independence and financial impoverishment.

Other ethical principles require physicians to avoid harm (nonmaleficence) and to promote justice, or fair treatment of patients. Some experts worry that the use of NHBCDs could potentially violate the principle of nonmaleficence, erode important values such as trust, respect for human dignity and professionalism^2,4 and present serious “slippery slopes” and conflicts of interest for physicians.

The decision to forgo life support may be unduly biased by physician prejudices. Physical suffering can result from the placement of perfusion cannulae or monitoring devices or during transfer of the patient from the intensive care unit (ICU) to the O.R. Patients could be denied the comfort of loved ones during death, and families could be denied the opportunity to comfort loved ones as they die.

Care of the dying patient could be manipulated and compromised in the interest of preserving organ viability. Physicians may inappropriately withhold sedatives and/or analgesics to avoid the appearance of euthanasia. Alternatively they may administer sedatives, analgesics and/or muscle relaxants to hasten death, a practice that is both illegal and unethical. Medications administered for organ preservation, such as heparin and phentolamine, could hasten death by aggravating high intracranial pressure or promoting fatal hemorrhage.^3,5

Patient dignity would be compromised if dying patients become “commodified” as a source of transplantable organs. The professional image of doctors is tarnished if they are perceived as being primarily interested in the dying patient for the vital organs they may provide.⁴

Slippery-slope issues arise around the definition of “irreversible” cardiopulmonary death, questions of which patients ought to be used as NHBCDs and the economics of end-of-life care and organ transplantation.

Legal criteria for cardiopulmonary death require “irreversible” loss of cardiopulmonary function. Some NHBCD protocols define this as occurring two minutes after onset of asystole based on limited scientific data suggesting that spontaneous resumption of circulatory function will not occur. Successful resuscitation, however, has been reported after 15-30 minutes of asystole.² Is cardiopulmonary arrest irreversible when circulation will not be restored or when it cannot be restored?

The literature suggests that we are psychologically predisposed to use certain vulnerable or marginalized patients as organ donors. Physicians generally apply much poorer quality-of-life ratings to severely handicapped patients than do the patients themselves, and surveys indicate that physicians and nurses would act on their prejudices and deny life support to patients with severely handicapping injuries, even if patient wishes were unknown.^2,6 Some physicians have proposed actively euthanizing comatose patients for their transplantable organs, a suggestion that is particularly disturbing in light of a British study that indicated that up to 41 percent of “permanently comatose” patients had been misdiagnosed and that some were actually awake and aware.²

The economics of end-of-life care promotes conflicts of interest in using NHBCDs. Twenty-seven percent of all Medicare expenditures are for end-of-life care, with hospice care offering only modest savings.⁷ In contrast organ transplantation appears to be highly profitable. Studies report that charges for certain types of transplants exceed actual costs by up to 240 percent.² NHBCD programs could theoretically cut costs of end-of-life care while promoting profitable enterprise. One result could be that important ethical distinctions will be set aside and morally questionable actions might be endorsed because of this favorable economic profile.

Potentially most, if not all, of the ethical concerns regarding NHBCDs can be managed by meticulous attention to protocols designed to prevent unethical treatment of dying patients. It is worrisome, however, that many centers instituted the use of NHBCDs without protocols and/or policies that address key issues discussed here.² After a 1997 episode of the television program “60 Minutes” suggested that vital organs were being removed from patients before they were actually dead, the Department of Human and Health Services requested a review of NHBCD practices in the United States by the Institute of Medicine (IOM), which serves as an advisory body to the government on matters of public health. IOM reviews in 1997 and 2000 supported the use of NHBCDs but were critical of organ procurement agencies for incomplete and inconsistent protocols and were concerned about issues such as the irreversibility of cardiopulmonary arrest and which medications could ethically be administered prior to death to improve organ viability.⁸ IOM urged construction of comprehensive protocols, further research and continued review to avoid conflicts in care of the NHBCD.

Even if ethical concerns are resolved, is it professionally appropriate for anesthesiologists to be involved with NHBCDs? The answer, in most cases, is probably “no.” The presence of an anesthesiologist for an NHBCD is both unnecessary and potentially harmful. NHBCDs do not require anesthesia; organ harvest does not take place until after death. The presence of an anesthesiologist could give the mistaken impression that the donor is not dead and therefore might suffer during organ harvest. There may be legitimate reasons for withdrawing life-support in an O.R. setting, but last-minute transfer of end-of-life care from the primary medical team to strangers in the O.R. is inappropriate and potentially harmful.

Withdrawal of life-sustaining medical treatment requires special physician training and knowledge, including the ability to support and counsel patients and families, respect for patient autonomy and religious and cultural beliefs, knowledge about pharmacology and physiology during end of life, ability to detect and meet nonphysical needs of patients, ability to communicate and empathy.^2,9 Inadequately trained physicians may undertreat patient suffering and mishandle important social, psychological, ethical and legal issues concerning the dying patient. The specialties of internal medicine, family medicine and intensive care medicine consider this so critical that they require specific training in end-of-life care in their core curricula.² The Joint Commission on Accreditation of Healthcare Organizations has published standards for the palliative care of dying patients.² In 2001 the Ethics Committee of the Society of Critical Care Medicine published recommendations for end-of-life care in the ICU, including protocols for treatment withdrawal and appropriate use of sedatives and narcotics.¹⁰

As of yet, anesthesiology residency and anesthesiology critical care medicine do not have formal training requirements in end-of-life issues or withdrawal of life support. Some anesthesiologists practicing intensive care or palliative care medicine may indeed have adequate experience and/or training to withdraw life support, but it cannot and must not be assumed that most anesthesiologists have adequate knowledge or experience to undertake care of the dying patient. Only physicians with appropriate training and experience should be involved in withdrawal of life-sustaining treatments in patients who will become NHBCDs, and hospital protocols that automatically transfer care of a potential NHBCD to the O.R. anesthesiologists should be revised.

References:

1. United Network of Sharing. UNOS Transplant Patient Data source. August 9, 2002. <www.unos.org>.

2. Van Norman G. Another matter of life and death: What every anesthesiologist should know about the ethical, legal and policy implications of the non-heart-beating cadaver organ donor. Anesthesiology. 2003; 98(3):763-773.

3. Luce J, Alpers A. End-of-life-care: What do the American courts say? Crit Care Med. 2001; 29(2)(suppl):N40-45.

4. Dubois JM. Non-heart-beating organ donation: A defense of the required determination of death. J Med Law Ethics. 1999; 27(2):126-136.

5. Cist A, Truog R, Brackett S, Hurford W. Practical guidelines on the withdrawal of life-sustaining therapies. International Anesthesiol Clin. 2001; 39(3):87-102.

6. Madorsky J. Is the slippery slope steeper for people with disabilities? West J Med. 1997; 166(6):410-411.

7. Emanuel E. Cost savings at the end of life: What do the data show? JAMA. 1996; 275(24):1907-1914.

8. Cassel C, Allee M, Beasley C, et al. Non-Heart-Beating Organ Transplantation: Practice and Protocols. A Report of the Committee on Non-Heart-Beating Transplantation II, Institute of Medicine, National Academy Press, Washington, DC; 2000.

9. vonGunten C, Ferris F, Emmanuel L. The physician-patient relationship. Ensuring competency in end-of life care: Communication and relational skills. JAMA. 2000; 284(233):3051-3057.

10. Truog R, Cist A, Bracket S, et al. Recommendations for end-of-life care in the intensive care unit: Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001; 29(12):2332-2348.

Gail A. Van Norman, M.D., is Clinical Associate Professor of Anesthesiology and Affiliate Associate Professor of Medical History and Ethics, University of Washington, Tacoma, Washington.