Ethics/concepts
Treatment of Potential Organ Donors in the Emergency Department: A Review

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The expanding role of emergency medicine in the care of potential organ donors presents unique ethical challenges. This article introduces emergency providers to the ethical challenges of organ donation, including issues of patient autonomy and consent, public perception and trust, goals of care, and the determination of death.

Introduction

The gap between the number of individuals awaiting organ transplantation and the number of organs donated has been increasing steadily during the past decade. There are currently more than 100,000 individuals awaiting organs for transplantation, whereas fewer than 30,000 organs are transplanted each year.1, 2 As a result of this disparity, the medical and organ procurement communities have endeavored to increase the number of organs available for transplantation.

Emergency medicine has recently been recognized to play an important role in the organ donation process.3 Although referral for organ donation was traditionally viewed as the domain of inpatient critical care providers, recent evidence highlights the importance of emergency providers in the organ donation process. Specifically, potential donors referred to organ procurement organizations from the emergency department (ED) are far more likely to undergo successful donation than those referred from inpatient settings. In one recent study of referrals to a large organ procurement organization, although far more referrals were initiated from inpatient settings (89%) compared with the ED (11%), referrals from the ED were nearly 3 times more likely to go on to successful donation compared with those from inpatient settings.3 The increased likelihood of successful donation from the ED persisted even after controlling for potential confounding variables such as mechanism of injury, age, and race. The higher rates of successful donation from the ED may be due to earlier recognition and referral of potential donors, allowing additional time for organ procurement organization involvement, providing more time for family decisionmaking, and identifying potential donors with fewer premorbid conditions, including pneumonia, sepsis, and multiorgan failure.3, 4

Meanwhile, clinical advances in transplantation and resuscitation medicine, coupled with efforts to expand the organ donor pool, have raised the possibility of procuring organs from individuals experiencing circulatory, rather than neurologic, death. The majority of these donations occur in controlled, inpatient settings after the discontinuation of life-sustaining therapies such as mechanical ventilation. However, uncontrolled donation after circulatory death is also possible, such as when a patient experiences an unexpected cardiac arrest, is pronounced dead—potentially even in the ED or out-of-hospital setting—and then has care rapidly transitioned to organ preservation and retrieval efforts. Uncontrolled donation after circulatory death has taken place throughout the United States, as well as in Barcelona, Paris, Tokyo, and elsewhere.5, 6, 7, 8, 9, 10, 11 There is growing interest in the ED as a potential source of organ donors, and studies of uncontrolled donation after circulatory death in the out-of-hospital and ED settings are under way.12, 13, 14

This expanding role of emergency medicine in the care of potential organ donors presents unique ethical challenges. Little attention has been paid in the medical literature to these challenges, and what little attention has been paid lacks practical guidance relevant to emergency physicians.15 This article will introduce emergency providers to the ethical challenges of organ donation, including issues of the determination of death, patient autonomy and consent, public perception and trust, goals of care, and conflict between public health and individual patient care.

Section snippets

Determination of Death

The majority of donated organs are retrieved from live donors or through donation after neurologic determination of death. Determination of neurologic death (also referred to as “brain death”) typically requires time and the involvement of neurology or neurosurgery specialists and, as a result, rarely occurs in the ED setting. Nevertheless, the act of referring a patient for potential organ donation can begin before a formal determination of brain death is made. Indeed, the majority of organ

Conclusion

With growing attention being paid to the ED as a valuable source of potential organ donors, emergency providers need to be cognizant of the ethical challenges and aware of the potential benefit of overseeing the referral of potential organ donors from the ED. Emergency providers should review their organ procurement organization's referral guidelines and, given the increased likelihood of successful donation when patients are referred from the ED, should have a low threshold for referring

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    Supervising editor: Robert K. Knopp, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

    Publication date: Available online June 13, 2012.

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