Organ Procurement After Euthanasia: Belgian Experience

doi:10.1016/j.transproceed.2008.12.025

Transplantation Proceedings

Volume 41, Issue 2, March 2009, Pages 585-586

https://doi.org/10.1016/j.transproceed.2008.12.025 Get rights and content

Abstract

Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.

Section snippets

Methods

Between 2005 and 2007, four patients (3 in Antwerp and 1 in Liège) in two Belgian university hospitals expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years, and all had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. They were totally dependent on third parties for personal care and were without quality of life.

Extensive discussion with local ethical

Results

The euthanasia procedures were carried out on the date requested by the patient, by three physicians independent from procurement or transplant teams, in the operating room. After clinical diagnosis of cardiac death, the procurement team performed organ procurement by femoral vessel cannulation (double-balloon triple-lumen catheter) and quick laparotomy for topical cooling. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in 2 patients,

Discussion

The involved physicians, the transplant team, and the institutional ethics committee had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. The potential in Belgium (and the Netherlands) could be substantial. According to the Federal Control and Evaluation Committee Euthanasia in Belgium, the percentage of patients with debilitating neurologic disease with their request for euthanasia granted was between 5.0% and 9.5% of all euthanasia

References (3)

G. Kootstra
Statement on non–heart-beating donor programs
Transplant Proc
(1995)

There are more references available in the full text version of this article.

Cited by (72)

Neurology ethics at the end of life
2023, Handbook of Clinical Neurology
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences.
Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021
2022, American Journal of Transplantation
The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients.
Outcomes of lung transplantation from organ donation after medical assistance in dying: First North American experience
2022, American Journal of Transplantation
Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49–64] years vs. 48 [32–59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1–3] vs 2 days [1–3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.
Lung transplant outcome following donation after euthanasia
2022, Journal of Heart and Lung Transplantation
Organ transplantation is hampered by shortage of suitable organs. In countries with a legal framework, organ donation following euthanasia is an option labeled “donation after cardio-circulatory death category V” (DCD-V). We describe our experience with lung transplantation (LTx) after euthanasia and evaluate post-transplant outcome using a matched comparison to DCD-III (withdrawal from life-sustaining therapy) and donation after brain death (DBD).
All bilateral LTx between 2007 and 2020 were retrospectively analyzed. Matching was performed for recipient age and gender, indication for LTx, mean pulmonary artery pressure, extracorporeal life support, and donor age, which resulted in 1:2 DCD-III and 1:3 DBD matching. Primary graft dysfunction (PGD), chronic lung allograft dysfunction (CLAD), and patient survival were analyzed.
A total of 769 LTx were performed of which 22 from DCD-V donors (2.9%). Thirteen women and 9 men expressed their wish to become organ donor after euthanasia. Euthanasia request was granted for irremediable neuromuscular (N = 9) or psychiatric (N = 8) disorder or unbearable and unrecoverable pain (N = 5). PGD (grade 3, within 72 hours post-transplant) was 23.8% in the DCD-V cohort, which is comparable to DCD-III (27.9%; p = 1.00) and DBD (32.3%; p = .59). CLAD-free 3- and 5-year survival were 86.4% and 62.8%, respectively, and comparable to DCD-III (74.4% and 60.0%; p = .62) and DBD (72.6% and 55.5%; p = .32). Five-year patient survival was 90.9%, not significantly different from both DCD-III (86.0%; p = 1.00) and DBD (78.1%; p = .36).
We observed that LTx with DCD-V allografts is feasible and safe, yielding no evidence for differences in short- and long-term outcome compared to matched cohorts of DCD-III and DBD.
Euthanasia through living organ donation: Ethical, legal, and medical challenges
2019, Journal of Heart and Lung Transplantation
Euthanasia is categorically prohibited in almost all countries throughout the world. In Belgium and the Netherlands, combining euthanasia and subsequent organ donation in a so-called donation after circulatory-death (DCD) procedure is feasible on legal and medical grounds, and is increasingly gaining social and ethical acceptance. However, heart transplantation after DCD is currently not performed in Belgium and the Netherlands after euthanasia due to concerns surrounding the prolonged warm ischemia time associated with DCD and its effect on subsequent heart function. A number of patients who undergo euthanasia explicitly express their wish to donate their organs in a “living organ donation” procedure, which then causes death. Assuming that euthanasia is permitted, as expressed in Dutch and Belgian legislation, this exploratory article addresses whether it is legally and ethically sound to donate organs, especially the heart, as a living donor and to perform euthanasia in the same procedure in a patient who fulfills the due diligence requirements for euthanasia. Organ donation euthanasia (ODE) would then cause death by the associated surgical procedure, and in addition would improve the quality of the other donated organs, a procedure that would fully respect the patient's autonomy.
Organ donation after medical assistance in dying: a descriptive study from 2018 to 2022 in Quebec
2024, CMAJ. Canadian Medical Association Journal

View all citing articles on Scopus

View full text

DonationOrgan Procurement After Euthanasia: Belgian Experience

Abstract

Section snippets

Methods

Results

Discussion

Statement on non–heart-beating donor programs

Transplant Proc

Donation
Organ Procurement After Euthanasia: Belgian Experience