By Ariane Lewis, MD
Patients admitted to neurointensive care units frequently suffer sudden, unexpected and severe brain injuries that render them unable to participate in goals-of-care discussions. Facilitating decision making for this population can be very ethically challenging, particularly when patients are candidates for organ donation. Although organs are desperately needed by over 118,000 people in the U.S. alone, organ donation should not be addressed with families until after end-of-life decisions have been made. In this issue of Ethics Corner, we discuss three recent papers that address end-of-life ethics.
End-of-Life Decision Making
Our understanding of the process by which an individual makes decisions regarding end-of-life care is supported by little empirical research. We are often jaded into making gross generalizations about expectations for decision making based on a patient’s cultural or religious background. In a recent piece in BMC Medical Ethics that contradicts previous findings, Mark Schweda et al. explore the impact of culture and religion on endof-life decision making through assessment of public attitudes in focus groups in Germany, Israel and the U.S. Contrary to religious or cultural stereotypes about end-of-life decision making, the authors found that there are no clear-cut positions anchored in nationality, culture or religion, and that the process of decision making is both personal and nuanced. These findings should be considered during discussions of end-of-life care, as it is imperative to avoid making assumptions based on cultural or religious generalizations (BMC Med Ethics 2017; 18:13).
Orders for Life-Sustaining Treatment
In the United States, 27 states have implemented statutes for Physician Orders for Life-Sustaining Treatment (POLST), and 23 states are currently developing POLST. The goal of POLST is to ensure that even if a patient is unable to communicate their wishes, end-of-life treatment should be consistent with their preferences. Tarzian and Cheevers describe the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) and present data evaluating its use. They found that MOLST completion rates were high and errors were low. Use of POLST/MOLST can have favorable implications for the neurocritical care community, as increased usage of these orders will give us insight into patient preferences about code status, artificial nutrition, antibiotics and dialysis. However, while completion of POLST/MOLST provides general information about patient wishes, it does not require specification of management in the setting of various degrees of debilitation such as inability to walk, perform activities of daily living or communicate (J Palliat Med 2017; Epub ahead of print).
In conjunction with nurse donor coordinators and organ procurement organizations, several provinces in Canada have begun to designate donation physicians to be involved with donor care, education, training and advocacy. To assist donation physicians in navigating ethically complex situations, Sam Shemie et al. created an ethics guide that was endorsed by the Canadian Medical Association. Institutions that wish to centralize care for patients at the end-of-life who are candidates for organ donation may benefit from identification of donation physicians. Individuals who take on this novel position can benefit from Shemie et al.’s ethical framework (Transplantation 2017; 101: S41-47).