Palliative Care Practitioners Discuss Processes and Ethics of Organ Donation
Panelists Alan Chiu, M.D., from UT Southwestern and Parkland Health (left), and Derek Chui, D.O., from Baylor Scott & White Health.
The January 2023 educational program hosted by the DFW Palliative Medicine Interest Group focused on organ donation, its foundations, procedures, ethical issues, and the role of palliative care practitioners. Panelists Alan Chiu, M.D., from UT Southwestern and Parkland Health, and Derek Chui, D.O., from Baylor Scott & White Health, led the discussion.
Essential organ donation knowledge includes the fact that the U.S. Department of Health and Human Services contracts with an organ procurement and transplantation network (OPTN) to provide organ donation in the United States. The only U.S. OPTN is the United Network of Organ Sharing (UNOS), which works with regional organ procurement organizations. Those organizations, like Southwest Transplant Alliance (STA) headquartered in Dallas, do screening and matching, receive certification, and interface with medical providers and patient families. Other organizations in Texas include Lifegift and Texas Organ Sharing Alliance.
Organ donation can occur after a comatose patient meets brain death criteria (Donation After Brain Death) or when the decision is made to discontinue mechanical ventilation/other life support in a comatose or gravely ill patient who planned to donate organs (Donation After Circulatory Death). According to 2021 organ donor statistics, 47% were donation after brain death, 22% were donation after circulatory death, and 31% were living donations. UT Southwestern had more than twice the number of donors in 2021 compared to Baylor or Medical City.
The discussion covered various medical management procedures done prior to organ recovery, and the strict rules used to determine death:
Cessation of life-sustaining therapies
Asystole must be observed within 60-90 minutes to preserve organ viability
Two- to five-minute waiting period after arrest before pronouncement of death
Death to be determined by a person not associated with an OPO organ recovery team
Organ recovery begins only after death declared (typically in the ICU or operating room)
Organ Donation Process Example
Ethical considerations include recognizing our primary obligation to the patient first, then to the bereaved family, and lastly to internal/external health care organizations. Recognize how organ donation procedures could potentially impact the quality of end-of-life care. Clinicians tend to favor the patient and their family, while OPOs work under the concept of “dual advocacy” to represent both the patient and the prospective organ recipient.
Panelists shared a few case studies showing how various approaches by palliative care team can include compassion for the patient and their family, cooperation with health care providers, and effective communication with OPOs to facilitate the option to donate organs.
Baylor Scott & White Health favors Apnea testing with a checklist approach performed by a physician. When the family does not accept brain death, “the physician may elect to maintain the patient’s body on organ support for a short period of time (usually not to exceed 24 hours after determination of death).”
During this process, Supportive Palliative Care consultation can support the family by communicating end-of-life options and explaining how organ donation impacts the way life-sustaining therapies are withdrawn. Caregivers contact the OPO donor referral line, giving them sufficient time to evaluate donor potential, and facilitate contact with the family if appropriate. Only the OPO will approach the family for donor authorization.
The full PDF of the education presentation is available, along with the video of the virtual session.