Page 112 - ACCCN's Critical Care Nursing

Ethical Issues in Critical Care 89

coma, absent motor response, and absent brainstem even longer: for example, in the case of a pregnant
reflexes. Apnoea testing, using a PCO 2 target, was recom- woman, so that the fetus can reach viable independent
mended in 59% of the surveyed countries. This reflected existence.
uniform agreement on the neurologic examination with Donation of organs and tissues after death takes place
the exception of the apnoea test, however, it found other within a legal context. All states and territories of Austra-
major differences in the procedures for diagnosing brain lia, and New Zealand, provide a legislative basis for the
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death in adults and recommended standardisation. removal of organs and tissues after death for the purpose
Organ donation provides the only hope for some patients of transplantation. In most of these jurisdictions, but not
awaiting a new heart, lung or liver. It also improves the Western Australia or New Zealand, death is defined
quality of life for patients on dialysis, and it restores sight in law.
to injured or blind patients. For an organ to be donated
in Australia or New Zealand, the process involves certifi- The Australian and New Zealand Human Tissue Acts pro-
cation of death, lack of objection from the deceased/ hibit trading in human organs or tissue. There are many
senior available next-of-kin, consent of the coroner (if countries including Australia and New Zealand that
applicable), and permission of the designated officer of believes that:
the hospital (see Chapter 27). Certification of brain death
is pivotal and inextricably linked to the organ donation ● no person, organisation or company should profit
and transplant process, as it allows the retrieval of well- financially from organ or tissue donation
perfused organs in good condition from patients who ● neither the estate of an organ or tissue donor nor his
have already been certified dead (namely the ‘beating- or her family should incur any cost from the processes
heart donor’). Diagnosis of brain death must be unequiv- that occur to facilitate organ and tissue donation.
ocal, thorough and transparent, so that it is regarded by
family and healthcare team as an absolute diagnosis Transplantation is an important part of modern medicine
without question. 66 and, in some cases, the only treatment for a range of
conditions.
Death requires documentation from a legal and social
position, although advances in modern technology have Important medical innovations have transformed the
blurred the distinction between life and death. The pro- outcomes for patients and aided the work of doctors. For
gression to development of specific brain death criteria example, clinical and critical care procedures have been
was to ensure unequivocal concordance in its diagnosis. improved and better anti-rejection drugs introduced. In
Brain death is established by documentation of irrevers- the UK, the NHS Organ Donation Report 2008–09 reports
ible coma, loss of brainstem reflexes and respiratory that while 90% of the UK population says that they
centre function, or by the demonstration of cessation of support organ donation, only 27% have joined the NHS
intracranial blood flow (see Chapter 27). Organ Donor Register.
ANZICS recommends that death be determined to have People who donate following brain death remain the
occurred when all of the following features are present: ‘gold standard’ for organ donation. They are the only
source of viable hearts after death and are able to provide
● immobility much better livers for transplantation. Notably, the
● apnoea increase in donation after cardiac death (DCD) is helping
● absent skin perfusion to increase the numbers of kidneys available for trans-
● absence of circulation as evidenced by absent arterial plantation substantially. However, the limitations of this
pulsatility for a minimum of two minutes, as mea- potential donor source need to be recognised alongside
sured by feeling the pulse or, preferably, by monitor- the complexities and sensitivities of the process. In
ing the intra-arterial pressure. Australia a national DCD Protocol, led by the
When all of these criteria have been met, the patient is National Health and Medical Research Council, has
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determined to be dead and therefore organ removal may been progressed.
proceed. 62 There are four guidelines developed by the National
Health and Medical Research Council (NHMRC) of Aus-
ORGAN DONATION tralia that are useful resources for critical care clinicians
to consider:
According to ANZICS, dying is a process rather than an
event. The determination and certification of death 1. Organ and Tissue Donation by Living Donors: Guide-
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indicate that an irrevocable point in the dying process has lines for Ethical Practice for Health Professionals:
been reached, not that the process has ended. Determina- outlines ethical practice for health professionals
tion of death by any means does not guarantee that all involved in living organ and tissue donation and
bodily functions and cellular activity, including that of provides guidance on how these principles can be
brain cells, have ceased. Several tissues can be retrieved put into practice. 67
for transplantation long after death has been determined 2. Living Organ and Tissue Donation: Guidelines for
by cessation of circulation. Similarly, after death has been Ethical Practice for Health Professionals: aims to help
determined by loss of whole brain function, the circula- people think through some ethical issues and
tion can be maintained for hours or days to enable organs make decisions about living organ and tissue
to be retrieved. Maintaining the circulation can continue donation. 68