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'We all must act with the patient’s best interests as our primary goal'

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Donation after circulatory death (DCD) often presents ethical and legal challenges to clinicians involved in this patient group – but why?

sam north

With extensive clinical experience, clear guidelines and documents to support clinicians in practice, it would seem we as the multidisciplinary team have the tools to be able to make these important best interest decisions when the end of life comes for our patients

However, it is acknowledged universally that concerns about the lawfulness and ethics surrounding DCD persist. 

The concern about a perceived conflict of interest between the clinicians caring for the patient and the subsequent request for organ donation from the relatives, and the lawfulness of the extent of intervention that can take place pre-mortem to facilitate the donation, have all been reported to affect decisions about DCD.

The concerns above were certainly present within Jersey ICU pre-2012-2013. Having joined the organisation after leaving a specialist nurse in organ donation (SNOD) role in London, it was clear that there were many missed opportunities to fulfil the end-of-life wishes for patients and their relatives.

With more patients requiring transplantation, the concept of DCD is not new and allows a group of patients who are not brain stem dead to go on and become donors – increasing the availability of organs.

Patients suitable for DCD donation in the UK are generally those with a catastrophic brain injury but who do not reach the criteria for brain stem testing. However, their neurological injuries are often so severe that a decision to withdraw treatment is made upon the grounds of patients best interests.

The clinical pathway of DCD is very clear in that the decision to withdraw treatment comes before any consideration of DCD.

“The most poignant and often difficult decisions come after the consent for DCD has been granted”

DCD guidelines also recommend that the end-of-life conversation and the request for organ donation should be separated.

But the most poignant and often difficult decisions come after the consent for DCD has been gained. How far can and should clinicians go to ensure that organ donation goes ahead and that it has the best possible outcome for patient, relative and recipient?

Intervention to sustain life and ensure a favorable outcome for the patient and the family once again work towards the notion of patients’ best interests.

If a patient is on the organ donor register and had expressed in their life their wish to donate, it is then deemed acceptable to intervene as long as the intervention aims to improve the transplantation outcome and causes the least possible distress and harm for the patient. Often these decisions are made in conjunction with the family.

Locally the approach to DCD in the local hospital has dramatically changed with a 70% increase in DCD referral rate since 2012.

This has come about through education and collaboration between the NHS Blood and Transplant team based in the UK. However, the aim is not to gain consent for organ donation but to ensure that all end-of-life care options are considered and that organ donation is seen as a normal part of end-of-life conversations.

The law is clear: if we as clinicians and healthcare professional continue to treat patients with their best interests as our primary goal, then we can be reassured that our professional, moral and ethical objectives are upheld.

Sam North is acting critical care manager, Jersey ICU

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