Organ donation after medical assistance in dying offers possibilities

Each year, more than 2,000 Canadians receive organ transplants from posthumous donors. The growing popularity of medical assistance in dying (MAID) means that more donor organs might become available. A new guideline published Monday in the Canadian Medical Association Journal (CMAJ) helps navigate the legal and ethical challenges.

The guideline was written by a blue-ribbon panel of health professionals representing Canadian Blood Services, the Canadian Critical Care Society, the Canadian Society of Transplantation and the Canadian Association of Critical Care Nurses. The panel was led by Dr. James Downar, an expert in critical care and palliative care and a supporter of MAID.

Deceased organ donation accounts for more than three in four transplanted organs, they said.

Under current legislation, patients must give consent to MAID immediately prior to receiving an assisted death. They must also consent to organ donation after their death. That opens up the possibility of getting consent both for MAID and organ donation after death at the same time.

What the panel has created is a guideline that navigates some tough medical, legal and ethical issues.

There are several key recommendations for health professionals and for patients. To protect patients from choosing MAID as a means to becoming organ donors, consenting to MAID must be done prior to any discussion of organ donation. The guideline also emphasizes choice. Patients should be asked if they want to donate organs so that they have the option should they desire it.

To reduce the risk that consent was obtained by coercion, patients must be deemed competent to personally give consent and withdraw that consent at any time. Since blood testing prior to organ donation can be onerous, steps should also be taken to minimize the disruption on patients, especially in those minutes immediately prior to MAID taking place. 

Death declared

Health professionals have raised concerns that the provision of MAID might affect the timing of organ donation. The guideline states that the so-called "dead donor" rule must always be respected. That means vital organs can be harvested only from a donor who is deceased as the result of MAID. No attempt can be made to harvest organs before the patient is declared dead.

In other words, the act of harvesting organs cannot in any way contribute to or be the cause of the patient's death.

The guideline states that death resulting from medical assistance should be confirmed by a second physician after a 5-minute "no touch" period of continuous observation. During the 5-minute interval, no attempt can be made to harvest donor organs.

Observing the "dead donor" rule that includes a 5-minute "no touch" period all but assures that the heart would not be viable for organ donation. In an email, Downar said that the lungs are retrievable, although this does not happen in every instance of organ donation following MAID. 

Concerns have been raised that MAID might adversely affect the quality of donor organs such as the liver, kidneys and pancreas. However, in 50 cases of organ donation after MAID in the Netherlands, no significant organ damage has been detected.

Protection for patients paramount

Like Canada, the Netherlands permits medical assistance in dying. To be eligible for MAID in that country, patients must have a grievous and irremediable medical condition. In a commentary in CMAJ, Dr. Johannes Mulder with the Dutch Family Doctors Association states that the idea of organ donation offers people a possibility to do good as the final act in their lives. This, Mulder argues, makes the patient vulnerable to pressure to choose MAID to increase the availability of donor organs.

To address that concern, the guidelines permitting organ donation after MAID in the Netherlands stipulate that surgical recovery and transplant teams should not be involved in the patient's end-of-life care or MAID. In addition, it should not be disclosed to a potential organ recipient that the donor received MAID. As well, physicians directly involved in the provision of MAID should not discuss organ donation with patients.

The decision to donate organs after MAID means the patient must undergo additional testing and be admitted to hospital where they die in unfamiliar surroundings. As a consequence, the next of kin have only a limited time to grieve over the body before organs must be harvested surgically.

A new approach discussed in the commentary makes possible organ donation after MAID at home. The death occurs at home after which anesthesia drugs and life support are used to maintain the body during transport to hospital for organ donation.

Some experts have proposed that patients be permitted to consent to what's called organ donation euthanasia. This involves putting the patient under anesthesia followed by getting the organs ready for removal. The doctors would then use potassium chloride to stop the heart, following which the organs would be removed.

This controversial approach could potentially make all organs including the lungs and the heart available to would-be recipients.

It's unlikely this proposal will gain widespread approval in the near future in Canada. The guideline in CMAJ is a reasonable first step.