Organ Donation

There is an increasingly demanding need for organs and tissues. Physicians should be involved in community efforts to make potential donors aware of their option to make a gift that would enhance life, health or sight by organ or tissue donation. Physicians should obtain consent from the patient for the disposal and use of tissue, organs or other body parts removed during diagnostic or operative procedures. All potential donors should communicate their preference to their families and have it listed on such documents as driver’s licenses or organ donor cards.

Physicians caring for dying or brain–dead patients who are potential donors should inquire about whether the patient had expressed preferences about donation. Federal and state law and health care accreditation bodies require that hospitals have procedures to ensure that families of hospitalized potential donors are made aware of the option to consent to organ donation. The issue of organ donation often arises in very difficult circumstances and may carry significant symbolic import for the family. Physicians should approach families with sensitivity and compassion.

Furthermore, organ procurement raises ethical concerns about the determination of death that have been partly addressed by legislation that defines brain death. It can also create conflict or the appearance of conflict between the care of a potential donor and the needs of a potential recipient. The care of the potential donor must be kept separate from the care of a recipient. The potential donor’s physician should not be responsible for the care of the recipient nor be involved in retrieving the organs or tissue. However, the potential donor’s physician may alert an organ–tissue procurement team of the existence of a potential donor. Once brain death has occurred and organ donation is authorized, the donor’s physician should know how to maintain the viability of organs and tissues in coordination with the procurement team. Before declaration of brain death, treatments proposed to maintain the function of transplantable organs may be used only if they are not expected to harm the potential donor, whether by causing symptoms or by compromising the chance of survival.

Irreversible Loss of Consciousness

Persons who are in a persistent vegetative state are unconscious but not brain dead. Since their condition is not progressive, patients in a persistent vegetative state are not terminally ill. They lack awareness of their surroundings and the ability to respond purposefully to them. The prognosis for these patients varies with cause. Some physicians and medical societies believe that there are no medical indications for life–prolonging treatment or access to intensive care or respirators when patients are confirmed to be in a persistent vegetative state.

They conclude that these patients cannot experience any benefits or suffer any discomfort and that all interventions should therefore be withdrawn. However, many patients or families value life in and of itself regardless of the neurologic state. For these reasons, goals of care should guide decisions about life–prolonging treatment for patients in a persistent vegetative state in the same manner as for other patients without decision–making capacity.

Intravenous Fluids and Artificial Feedings

Artificial administration of nutrition and fluids is a life–prolonging treatment. As such, it is subject to the same principles for decisions as other treatments. Some stages of illness/diseases require high levels of proof before previous statements or advance directives can be accepted as firm evidence that a patient would not want these treatments in the setting of terminal illness, permanent unconsciousness, or advanced dementia. For this reason, physicians should counsel patients to establish advance care directives and complete these carefully. Clinically, there is unfounded concern that discontinuing the use of feeding tubes will cause suffering from hunger or thirst despite research findings to the contrary. Physicians should carefully address this issue with family and caregivers.