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Opinion: Challenges with OPOs

By Currents Editor posted 03-02-2020 10:21

  
By Wade Smith, MD, PhD, FNCC

I have practiced neurocritical care since 1994. As a fellow in 1993, I engaged in the first case of donation after cardiac death (DCD) in California. This experience, coupled with prior ethics consultation experience as a resident, initiated a career-long interest in organ donation. However, I have had several struggles with the organ procurement process throughout my career, and I am writing this article to ask if others have had similar or dissimilar experiences.

A few years ago, I was taking call for ethics when I was made aware of a young man on ECMO transferred from an outside hospital. Unfortunately, he died by brain death criteria and as a person who signed an organ donor card, the family was approached to explain that they would procure his organs. 

His young wife was aware of her husband’s desire to donate but had the following argument: “If his organs are taken, it might impair an autopsy determining why he arrested in the first place. Since he was found at work, I want to know if he was exposed to something.  I want a full autopsy. I have two young children to raise without a father. If his employer caused his death, there could be financial compensation that will allow me to raise my family.” 

She was sleep deprived, and we suggested that she go home and that we address it the next day, but she refused to leave his bedside. The team was confronted by the visual of having her escorted from the ICU while he was taken to organ procurement. As an ethicist and a human being, I was supportive of the wife’s request and the patient did not donate. CMS was alerted by the Organ Procurement Organization (OPO) of my interference with the legal requirement to not interfere with this man’s donation. 

Designating yourself as an organ donor is done by signing a living will and is codified in the Anatomical Gift Act. Since it is considered a will, no person or entity can interfere with the process. Thinking about this, I am certain that the patient did not anticipate this scenario when he checked the box on his driver’s license at the DMV. This is not informed consent in my opinion.

More commonly, I have experienced friction having OPO coordinators asking to be involved in DCD discussions with families. An experienced coordinator is essential to provide the details of donation in this circumstance and is an essential part of the consent process. But I have occasionally experienced coordinators completely alienating families and having that jeopardize the doctor-family relationship. At our institution, we require the OPO to first contact the ethics consultant on call to help initiate the process and help judge timing. I think this is an essential firewall to help advocate for patients and the organ donation system as whole.

Have you had difficulties with this process? Have you been asked to do something that makes you uncomfortable? Do you have examples that you can share with me? If you do, and/or if you have any comment about this, please email me at Wade.Smith@ucsf.edu. In particular, I am interested if your decision to be a registered organ donor has been influenced (positively or negatively) by your engagement locally in your organ donation process.

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