Elsevier

Journal of Critical Care

Volume 59, October 2020, Pages 166-171
Journal of Critical Care

Conflicts of interest in the context of end of life care for potential organ donors in Australia

https://doi.org/10.1016/j.jcrc.2020.06.016Get rights and content

Highlights

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    Discomfort in intensive care patients during end-of-life is common and should be actively anticipated, monitored and treated using individualised palliative sedation and analgesia.

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    There is evidence in the literature that the routine use of sedation and analgesia for end-of-life care in patients who are close to dying does not hasten or precipitate death.

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    The doctrine of double effect is not an essential tenet for the provision of good symptom control during end-of-life care in ICU, but it may conceptually provide reassurance and protection for health practitioners.

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    Donation physicians could be considered to encounter ethical challenges when managing the dual obligation of caring for dying patients and their families while ensuring consideration of organ and tissue donation is performed according to best practice.

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    Perceived and potential conflicts of interest need to be carefully understood and managed and institutions should have policies on withdrawal of life support and end-of-life care in ICUs, which clearly outline the role of the donation physician.

Abstract

End-of-life (EOL) care has become an integral part of intensive care medicine and includes the exploration of possibilities for deceased organ and tissue donation. Donation physicians are specialist doctors with expertise in EOL processes encompassing organ and tissue donation, who contribute significantly to improvements in organ and tissue donation services in many countries around the world. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring organ and tissue donation is considered according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by clinicians, institutions and health care networks. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU.

In this paper we review current controversies around EOL care in the ICU, including the use of palliative analgesia and sedation specifically with regards to withdrawal of cardiorespiratory support, the usefulness of the so-called doctrine of double effect to guide ethical decision-making, and the management of potential or perceived conflicts of interest in the context of dual professional roles.

Introduction

The donation of organs and tissues is considered an act of altruism and human solidarity that benefits those in need and society as a whole. To facilitate organ and tissue donation for transplantation, specialised health care systems and processes have been developed and implemented across the world, and specialist staff have been trained and employed. Donation physicians are specialist doctors with a focus and enhanced expertise in organ and tissue donation who contribute significantly to improvements in organ and tissue donation services [1] in many countries, including Australia. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring consideration of organ and tissue donation is performed according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by health care networks and institutions.

This paper explores the current role of donation physicians in Australia, and discusses concerns that have been raised regarding the practice of donation physicians, in particular with regards to the perceived conflict of interest that may arise when ICU doctors have dual roles in providing end-of-life (EOL) care and donation services. In reviewing current evidence and controversies concerning EOL care in the ICU in general, including the use of the so-called doctrine of double effect to guide ethical decision-making, this paper provides guidance with regards to withdrawal of cardiorespiratory support (WCRS) during EOL care and management of potential or perceived conflicts of interest in the context of dual professional roles.

Section snippets

Donation physicians in Australia and concerns regarding potential or perceived conflicts of interest

In Australia, organ and tissue donation is supported by a network of hospitals and health care providers, known as the DonateLife Network. The DonateLife Network includes 8 DonateLife Agencies, 89 hospitals and 275 DonateLife staff [2]. Most of the 86 donation physicians are also employed by acute care hospitals as intensive care specialists. A small proportion are employed as specialists in other acute hospital areas (e.g. emergency medicine, nephrology).

There have been anecdotal reports of

End-of-life care in the ICU and the importance of palliative sedation for WCRS

The primary goal of intensive care medicine is to help patients survive critical illness whilst preserving and restoring quality of life. However, in most Western countries, approximately one in five people admitted to ICU with a critical illness will die in the ICU and palliative care has become an increasingly important element of ICU practice [4]. In critical illness, when the severity of organ dysfunction defies treatment, when the goals of care can no longer be met, or when life support is

Relief of suffering in EOL care and the doctrine of double effect

Patients are more likely to receive higher doses of both opioids and sedatives as they get closer to death. Palliative care at EOL has historically raised ethical and legal concerns that physicians may provide excessive analgesia or sedation for the purpose of hastening death, rather than relieving the suffering of dying patients, thus violating norms relating to the obligation of nonmaleficence (avoiding harm), specifically to avoid causing the death of a patient. These are not typically

EOL care for potential organ donors and the doctrine of double effect

In the context of EOL care for potential DCD donors, reliance on the doctrine of double effect may become particularly problematic. Accepting the application of double effect within the context of organ donation creates a potential interest on the part of the physician (and family members), that may conflict with their primary duty of care for the welfare of the patient. The dying patient herself may have a strong interest in becoming an organ donor. When such an interest is known, this may

Managing conflicts of interest in EOL care for potential organ donors

Donation physicians may encounter several unique ethical challenges [34], including how to manage potential or perceived conflicts of interests in the performance of their dual roles. Concerns regarding potential conflicts of interests may undermine public trust in deceased donation, discourage health professionals from assisting with exploring deceased donation, or, as discussed earlier, may deter provision of best practice care for patients at EOL [35]. Concerns are particularly prevalent in

Conclusions

Donation physicians in Australia, as in many other countries, have dual obligations as both intensive care physician and donation specialist. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU.

The primary duty of a donation physician is always to provide high-quality EOL care in accordance with the patient's values and preferences when known, or in their best interests when they are unknown. This duty prevails irrespective

Disclosures

Dr. van Haren is State Medical Director (SMD) of DonateLife (Australian Capital Territory); Dr. Nunnink is SMD and Dr. Carter is Deputy-SMD of DonateLife (Queensland); Dr. Cavazzoni and Dr. O'Leary are co-SMDs of the New South Wales Organ and Tissue Donation Service; Dr. D'Costa is SMD and Dr. Radford Deputy-SMD of DonateLife (Victoria); Dr. Jones is SMD of DonateLife (Northern Territory); Dr. Moodie is SMD of DonateLife (South Australia); Dr. Opdam is National Medical Director of DonateLife

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