Increasing rates of organ donation: Exploring the institute of medicine's boldest recommendation

Journal of Clinical Ethics

Volumn 20, Issue 1, 2009, Pages 13-22

  Dubois, James M ^a  

^a SAINT LOUIS UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADVISORY COMMITTEE; ARTICLE; BRAIN DEATH; CONFLICT OF INTEREST; ETHICS; EUROPE; HEART ARREST; HUMAN; INFORMED CONSENT; LEGAL ASPECT; METHODOLOGY; ORGAN PRESERVATION; ORGANIZATION; RESUSCITATION; STANDARD; STATISTICS; TIME; TRANSPLANTATION; UNITED STATES;

ADVISORY COMMITTEES; BRAIN DEATH; CARDIOPULMONARY RESUSCITATION; CONFLICT OF INTEREST; DISTRICT OF COLUMBIA; EUROPE; HEART ARREST; HUMANS; INFORMED CONSENT; INSTITUTE OF MEDICINE (U.S.); ORGAN PRESERVATION; PRESUMED CONSENT; THIRD-PARTY CONSENT; TIME FACTORS; TISSUE AND ORGAN HARVESTING; TISSUE AND ORGAN PROCUREMENT; UNITED STATES;

EID: 67649126554     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (55)

1. In 2006, of potential donors or donor families, 66 percent consented to organ donation. See the United Network for Organ Sharing (UNOS) 2006 annual report, http://www.unos.org/Shared Content Documents/Annual-Report-2006.pdf, accessed 28 June 2008. When best practices are followed, actual "conversion" or organ recovery rates (which are always lower than consent rates) exceeded 75 percent. In 2006, at least 16 OPOs had conversion rates above 75 percent.
2. See chapter 2 of the 2007 Organ Procurement and Transplantation Network (OPTN) annual report for a list of specific best practices, http://www.optn.org/ AR2007/chapter-ii-forprint.pdf accessed 28 June 2008.
3. At least three recent surveys indicate low levels of knowledge of donation procedures and concerns about them. See L.A. Siminoff, C.J. Burant, and S.A. Ibrahim, "Racial Disparities in Preferences and Perceptions Regarding Organ Donation," Journal of General Internal Medicine 21, no.9 (2006): 995-1000;
4. L.A. Siminoff, C. Burant, and S.J. Youngner, "Death and Organ Procurement: Public Beliefs and Attitudes," Kennedy Institute of Ethics Journal 14, no.3 (2004): 217-34;
5. J.M. DuBois and T. Schmidt, "Does the Public Support Organ Donation Using Higher Brain-Death Criteria?" The Journal of Clinical Ethics 14, no. 1/2 (Spring/Summer 2003): 26-36.
6. See S.M. Mandeli et al., "National Evaluationof Healthcare Provider Attitudes toward Organ Donation after Cardiac Death," Critical Care Medicine 34, no.12 (2006): 2952-8;
7. C.J. Doig, "Is the Canadian Health Care System Ready for Donation after Cardiac Death? A Note of Caution," Canadian Medical Association Journal175, no.8 (2006): 905-6;
8. G. A. Van Norman, "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 98, no.3 (2003): 763-773 A common theme running through these articles is the conflict between the care for an individual as a dying patient and care for a potential donor. Whether any compromise in care quality occurs, healthcare workers may feel uncomfortable when these lines blur -for example, when OPO staff appear at the bedside early in the dying process, when medications are given to a patient solely for the purpose of enabling successful organ donation, or when donation affects where and when withdrawal of artificial ventilation occurs.
9. See IOM, Organ Donation: Opportunities for Action (Washington, D.C.: National Academies Press, 2006), 34. Kidney transplants are sometimes cost-saving, but only given the government's relatively unique commitment to providing universal access to kidney dialysis.
10. See the Agency for Healthcare Research and Quality report, "National Healthcare Disparities Report, 2003," http://www.ahrq.gov/quai/nhdr03/ nhdr03.htm, accessed 28 June 2008. See also Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003).
11. R. Stein, "New Zeal in Organ Procurement Raises Fears. Donation Groups Say They Walk a Fine Line, but Critics See Potential for Abuses," Washington Post, 13 September 2007.
12. Although HRSA and Greenwall cosponsored the study, the 2006 IOM Committee's official statement of task stated that the purpose of the study was "to provide advice to the Secretary of Health and Human Services in support of legislative requirements of the Organ Donation and Recovery Improvement Act." See http://www.iom.edu/CMS/3740/24738/24370.aspx, accessed 29 June 2008.
13. IOM, Organ Donation: Opportunities for Action, see note 4 above, p. 168.
14. Throughout this article, I will refer to UDCD; however, the 2006 IOM Committee abbreviated this as "uncontrolled DCDD," Washington Hospital Center referred to it as "Rapid Organ Recovery," and past IOM reports and some current European literature refer to it as "uncontrolled non-heart-beating organdonation." All refer to the same kinds of procedures.
15. See S. Satel, "Death's Waiting List," New York Times, 15 May 2006;
16. R. Epstein, "Kidney Beancounters," Wall Street Journal, 15 May 2006;
17. R.J. Howard, "Missed Opportunities. The Institute of Medicine Report: Organ Donation: Opportunities for Action," American Journal of Transplantation 7, no.1 (2007): 14-6;
18. K.K. Das and B.H. Lerner, "Opportunities Not Taken: Successes and Shortcomings in the Institute of Medicine's Report on Organ Donation," Kidney International 71, no.8 (2007): 726-729
19. Data on the categories of deceased donors are available: www.unos.org, accessed 28 June 2008.
20. The so-called Maastricht categories of DCD or non-heart-beating donors include two other "uncontrolled" donors -dead on arrival (Category I), which is rare, and donation from a DND (brain dead) patient who arrests unexpectedly while on the ventilator. The 2006 IOM report focused on Category II, DCD following unsuccessful resuscitation from circulatory arrest. See G. Kootstra, J.H. Daemen, and A.P. Oomen, "Categories of Non-Heart-Beating Donors," Transplantation Proceedings 27, no.5 (1995): 2893-2894
21. See chapter 2, page 8 of the 2007 OPTN annual report, http://www.optn.org/AR2007/chapter-ii-forprint.pdf, accessed 28 June 2008.
22. The procedure is described in detail in appendix F of IOM, Organ Donation: Opportunities for Action, see note 4 above, 310-311 Other possible organ preservation methods would include continuing CPR (discussed briefly below) and the use of extracorporeal circulation, which was not recommended by the IOM and is not discussed here.
23. Ibid., 130.
24. See Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement (Washington, D.C.: National Academies Press, 1997); Institute of Medicine, Non-Heart-Beating Organ Transplantation: Practice and Protocols (Washington, D.C.: National Academies Press, 2000);
25. J.L. Bernat et al., "Report of a National Conference on Donation after Cardiac Death," American Journal of Transplantation 6, no.2 (2006): 281-291 (Pubitemid 43382163)
26. See table 1.3 on page 4 of chapter 1 of the 2007 OPTN Annual Report, http://www.optn.org/AR2007/chapter-i-forprint.pdf, accessed 28 June 2008.
27. E. Sheehy et al., "Estimating the Number of Potential Organ Donors in the United States," New England Journal of Medicine 349, no.7 (2003): 667-74;
28. E. Guadagnoli, C.L. Christiansen, and C.L. Beasley, "Potential Organ-Donor Supply and Efficiency of Organ Procurement Organizations," Health Care Financing Review 24, no.4 (2003): 101-110
29. J. Alvarez et al., "Five Years of Experience with Non-Heart-Beating Donors Coming from the Streets," Transplantation Proceedings 34, no.7 (2002): 2589-2590
30. 20. G. Lombardi, E.J. Gallagher, and P. Gennis, "Outcome of out-of-Hospital Cardiac Arrest in New York City: The Pre-Hospital Arrest Survival Evaluation (Phase) Study," Journal of the American Medical Association 271, no.9 (1994): 678-683 (Pubitemid 24987301)
31. IOM, Moving Forward in Increasing Organ Donation: Opportunities and Barriers to Uncontrolled DCDD in Major Metropolitan Cities. Meeting Summary, December 20,2006 (Washington, D.C.: Institute of Medicine, 2007), 4.
32. S. Gagandeep et al., "Expanding the Donor Kidney Pool: Utility of Renal Allografts Procured in a Setting of Uncontrolled Cardiac Death," American Journal of Transplantation 6, no.7 (2006): 1682-8;
33. J.T Cooper et al., "Donation after Cardiac Death: The University of Wisconsin Experience with Renal Transplantation," American Journal of Transplantation 4 (2004): 1490-4;
34. S. Droupy et al., "LongTerm Results of Renal Transplantation Using Kidneys Harvested from Non-Heartbeating Donors: A 15-Year Experience," Journal of Urology 169, no.1 (2003): 28-31. (Pubitemid 35461541)
35. A. Sanchez-Fructuoso, M. Giorgi, and A. Barrientos, "Kidney Transplantation from NonHeart-Beating Donors: A Spanish View," Transplantation Reviews 21 (2007): 249-54;
36. G. Kootstra, J. Kievit, and A. Nederstigt, "Organ Donors: Heartbeating and Non-Heartbeating," World Journal of Surgery 26, no.2 (2002): 181-184
37. A.E. Kowalski et al., "A New Approach for Increasing the Organ Supply," Clinical Transplantation 10, no.6, part 2 (1996): 653-7;
38. IOM, Organ Donation: Opportunities for Action, see note 4 above. The actual Rapid Organ Recovery protocol used by Washington Hospital Center is published in the 2006 IOM report as Appendix F., p. 305f.
39. IOM, Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement, see note 16 above, p. 80.
40. See American Medical Association, Code of Medical Ethics, opinion E-2.157, http://www.ama-assn.org/apps/pf-new/pf-online accessed 28 June 2008. However, note that opinion E2.155 advocates for pilot testing of presumed consent for organ donation (a much more invasive procedure than organ preservation), suggesting that the AMA should be open to forms of permission short of expressed consent.
41. IOM, Organ Donation: Opportunities for Action, see note 4 above, p. 154
42. Ibid., 16.
43. Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement, see note 16 above, p. 55.
44. Ibid., 60.
45. IOM, Organ Donation: Opportunities for Action, see note 4 above, pp. 152-153
46. Ibid., 157.
47. See chapter 2, page 13 of the 2007 OPTN annual report, http://www.optn.org/AR2007/chapter-ii-forprint.pdf, accessed 30 June 2008.
48. IOM, Organ Donation: Opportunities for Action, see note 4 above, p. 200.
49. Mandell et al., "National Evaluation of Healthcare Provider Attitudes toward Organ Donation after Cardiac Death," see note 3 above.
50. DuBois and Schmidt, "Does the Public Support Organ Donation Using Higher Brain-Death Criteria?" see note 2 above;
51. Siminoff, Burant, and Youngner, "Death and Organ Procurement: Public Beliefs and Attitudes," see note 2 above.
52. IOM, Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement, see note 16 above.
53. Doig, "Is the Canadian Health Care System Ready for Donation after Cardiac Death? A Note of Caution," see note 3 above.
54. D.A. Moore and G. Loewenstein, "Self-Interest, Automaticity, and the Psychology of Conflict of Interest," Social Justice Research 17, no.2 (2004): 189-202.
55. See the Australian Organ Donor Register at: http://www.medicareaustralia. gov.au/provider/pa-tients/aodr/stats.jsp#N10413 accessed 26 June 2008.