Ethics case study
Talking about organ procurement when one of your patients dies
- Previously published ethics case studies are available online.
- For additional ethics resources, visit the College's Center for Ethics and Professionalism
This is the 23rd in a series of case studies with commentaries by the ACP–ASIM Ethics and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical cases to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.
As a third-year medical student, Jane excelled. She thoughtfully researched each of her patients' diseases and was always prepared for rounds. Jane's resident and attending noticed how well she related to each of her patients, particularly a transplant patient, Sam, who had recently received a new kidney.
When the opportunity arose, Jane eagerly attended a special lecture on the ethics of organ transplantation. She was surprised to learn that federal regulations did not allow doctors who were not specifically trained in requesting organ donations to approach patients' families about donation. According to the regulations, only an organ procurement representative or a trained, designated requestor should talk to patients' families about organ donation. Jane suspected that she was not the only person at her medical center unaware of this rule.
Jane's suspicions were later confirmed when she witnessed her resident notify the family of a 42-year-old patient that the man had died from a heart attack. During the course of the conversation, the resident mentioned that the family should think about organ donation. Jane remembered the resident's exact words to the patient's wife: "I'm sorry to bother you about this, but I'm supposed to ask you about donating your husband's organs."
Jane sensed that the wife felt offended and perhaps even frightened that the resident would bring up the topic of organ donation. At the same time, Jane could not help but think about Sam, her kidney-transplant patient, and how grateful he was to have received a donated organ.
Jane now realized that neither her classmates nor most of the residents at her medical center ever received instruction on how to request organ donations from patients or their families. Her resident had recognized the importance of procuring organs, but he wrongly assumed that it was his responsibility to raise the issue with the patient's family. At the end of her rotation, Jane decided to give an oral presentation on the issue of organ procurement, focusing on the new federal regulations.
The federal regulations, which went into effect in 1998, were introduced to increase the overall number of organ donations. A study cited in the regulation's preamble found that organ donation consent rates were markedly higher when an organ procurement organization (OPO) approached the family about potential donation (67%) than when hospital staff approached the family (9%).1
Because of this "overwhelming" statistical evidence,2 the federal government now requires that the person who approaches the family about organ donation be an organ procurement representative or a designated requestor. Designated requestors are individuals who have completed a course approved by an OPO on how to approach potential donor families to request organ or tissue donation.3
Physicians are not excluded from becoming "designated requestors." In fact, the government specifically recognizes that physicians may choose to receive training for this role.4
Before the federal regulations went into effect, most physicians believed that it was their responsibility to broach the topic of organ donation with the families of recently deceased patients.5 The ACP "Ethics Manual" (Fourth Edition), which was written prior to the federal regulations, reflected the traditional view that the potential organ donor's physician "should inquire about whether the patient had expressed preferences about donation."6 As late as 1998, published articles continued to state that "primary physicians are a vital link to encourage patients and families to discuss organ and tissue donation . . . ."7
This viewpoint rightly acknowledged the benefits of the long term relationship established between primary care physicians and their patients and families. Ideally, physicians would discuss organ donation with their established patients in the context of advance directives.
Physicians who lack specific training in organ procurement, however, may be unable to provide patients or their families with enough information for them to give informed consent for an organ donation.5 Some physicians may also be uncomfortable acting as organ requestors, even if they have a long term relationship with the patient and family. In addition, as this case study illustrates, some physicians may not be naturally attuned to the subtleties of timing and communication needed in making organ donation requests.8
The ethical problem with physician-initiated requests—even by trained physicians—lies in a real or perceived conflict of allegiances.9 On one hand, physicians act as the principal advocate for patients, caring for their medical needs, maintaining vital functions as much as possible and providing palliative care as life comes to an end. As a designated organ donation requestor, on the other hand, a physician seemingly acts on behalf of potential organ recipients. This conflict may undermine physicians' ethical obligation of beneficence to their patients.
The ACP "Ethics Manual" gives specific directions in certain aspects of the issue: "The potential donor's physician should not be responsible for the care of the recipient nor be involved in retrieving the organs or tissue."6 Wearing two hats raises suspicion that a physician's attention to the needs of the organ recipient will compromise the care of the donor. Families might even worry that the patient has been declared brain dead prematurely in order to harvest his organs.
Because of the apparent conflict of roles, some have suggested that formal requests for organ donations be made by personnel not directly responsible for the clinical care of the potential donor.9 Others contend that there is in fact no conflict because the physician is merely offering the option of organ donation rather than making a literal request for donation.7 When a patient is in the final stages of dying or has recently died, however, the family may be too emotionally charged to register the subtle distinction between suggesting and requesting an organ donation.
While physician-initiated requests for organ donation raise ethical concerns, completely removing physicians from the procurement process may be counterproductive. Organ procurement representatives lack the benefit of a previous relationship with the deceased patient's family. Physicians can thus serve as the bridge between the family and the designated requestor, emotionally preparing the family for a discussion about organ donation, while at the same time clearly defining their role as an advocate for both the patient and the family.
Such a delineation of roles also ensures that the notification of death is separated from donation requests. Allowing the family time to accept the news of the patient's death is vital. The patient's family must clearly understand that death has occurred, especially in instances where brain death has been established but the patient's body is being technologically supported. Otherwise, disconnecting life support and harvesting organs may be seen as killing the patient.
In one surveyed population, 21% of respondents believed that a patient could recover after brain death.<<sup>10 The physician has the lead role in helping families understand and accept either a grave prognosis, imminent brain death or confirmed brain death. An established protocol for communicating about these issues is necessary.11
Ultimately, if the physician has prepared the way, the job of the organ procurement officer or designated requestor will not only be easier, but likely more successful.
Acknowledgements: The Ethics and Human Rights Committee would like to thank Vincent Herrin, ACP–ASIM Associate, and Peter Poon, JD, authors of the case history and commentary, and Shirley Schlessinger, FACP, medical director, Mississippi Organ Recovery Agency, for her contributions.
1. 63 Fed. Reg. 33,856, 33,860 (1998), citing Klieger J, Nelson K, Davis R, et al. Analysis of factors influencing organ donation consent rates. J Transplant Coord. 1994;4:132-4.
2. See also von Pohle WR. Obtaining organ donation: who should ask? Heart Lung. 1996;25:304-9 (reporting successful donation consent achieved by an OPO in 32 of 36 cases compared with 1 success out of 29 cases by physicians).
3. 42 C.F.R. § 482.45(1)(3) (1998).
4. HCFA Quality of Care Information; Hospital Conditions of Participation for Organ Donation; Questions and Answers, A26. See www.hcfa.gov/quality/4a1.htm.
5. McGough EA, Chopek MW. The physician's role as asker in obtaining organ donations. Transplant Proc. 1990; 22:267-71.
6. American College of Physicians, Ethics Manual, Fourth Edition. 1998.
7. Coolican MB, Swanson MA. Primary health-care physicians: vital roles in organ and tissue donation. Conn Med. 1998;62:149-53.
8. Riker RR, White BW. The effect of physician education on the rates of donation request and tissue donation. Transplantation. 1995;59:880-4.
9. Tolle SW, Bennett WM, Hickam DH, Benson, JA. Responsibilities of primary physicians in organ donation. Ann Intern Med. 1987;106:740-4.
10. The Gallup Organization Inc., "The American Public's Attitudes Toward Organ Donation and Transplantation," conducted for The Partnership for Organ Donation, Boston, Feb. 1993.
11. DeJong W, Franz HG, Wolfe SM, Nathan H, et al. Requesting organ donation: An interview study of donor and nondonor families. Am J Crit Care. 1998;7:13-23.
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