Advertisement

The Nonviable Patient and Organ Procurement

  • Frederic J. ColeJr.
  • Jay N. Collins
  • Leonard J. WeireterJr.

Abstract

The current state of medical technology and critical care support is such that people who never had a chance of survival a generation ago routinely leave the hospital and return to productive lives. The unfortunate side effect of this remarkable advance is that not all patients fare so well. The patient rapidly delivered to tertiary care for resuscitation only to be found to have a lethal central nervous system disease is a common occurrence on trauma and critical care services. The concept of the nonsalvageable patient and the role of futile care has become a regular part of conversations among medical staff at all levels—physician, nursing, resident, medical student, and allied health professional. Recognition of this patient is not always simple. We will argue these issues among ourselves. Who is nonsalvageable? What care is futile? How do we broach this with the families of these patients?

Keywords

Intensive Care Unit Brain Death Diabetes Insipidus Disseminate Intravascular Coagulation Organ Procurement 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Nelson JE, Danis M. End-of-life care in the intensive care unit: where are we now? Crit Care Med 2001; 29(Suppl):N2–N9.CrossRefPubMedGoogle Scholar
  2. 2.
    Knaus WA. Prognosis with mechanical ventilation: the influence of disease, severity of disease, age, and chronic health status on survival from an acute illness. Am Rev Repir Dis 1989; 140:S8–S13.Google Scholar
  3. 3.
    Cohen IL, Lambrinos J. Investigating the impact of age on outcome of mechanical ventilation using a population of 41,848 patients from a statewide database. Chest 1995; 107:1673–1680.CrossRefPubMedGoogle Scholar
  4. 4.
    Rivera S, Dong K, Garone S, et al. Motivating factors in futile clinical interventions. Chest 2001; 119:1944–1947.CrossRefPubMedGoogle Scholar
  5. 5.
    Cohen NH. Assessing futility of medical interventions—is it futile? Crit Care Med, 2003; 31(2):646–648.CrossRefPubMedGoogle Scholar
  6. 6.
    Fetters MD, Churchill L, Danis M. Conflict resolution at the end of life. Crit Care Med 2001; 29(5):921–925.CrossRefPubMedGoogle Scholar
  7. 7.
    Burt RA. The Medical futility debate: patient choice, physician obligation, and end-of-life care. J Palliative Med 2002; 5(2):249–254.CrossRefGoogle Scholar
  8. 8.
    Veatch RM, Spicer CM. Medically futile care: the role of the physician in setting limits. Am J Law Med 1992; 18(1–2):15–36.PubMedGoogle Scholar
  9. 9.
    Brennan TA. Physicians and futile care: using ethics committees to slow the momentum. Law Medicine Health Care 1992; 20(4):336–339.Google Scholar
  10. 10.
    Ayres SM. Who decides when care is futile? Hosp Pract 1991; 26(9A):41–53.PubMedGoogle Scholar
  11. 11.
    Miles SH. Medical futility. Law Medicine Health Care 1992; 20(4):310–315.Google Scholar
  12. 12.
    Loefmark R, Nilstun T. Conditions and consequences of medical futility—from a literature review to a clinical mode. J Med Ethics 2002; 28:115–119.CrossRefGoogle Scholar
  13. 13.
    Stroud R. The withdrawal of life support in adult intensive care: an evaluative review of the literature. Nursing Crit Care 2002; 7(4):176–184.Google Scholar
  14. 14.
    Blake DC. Bioethics and the law: the case of Helga Wanglie: a clash at the bedside–medically futile treatment v. patient autonomy. Whittier Law Rev 1993; 14:119–128.Google Scholar
  15. 15.
    Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals, 2004; Ethics, Rights and Responsibilities Standards. Washington, DC: JCAHO, 2004.Google Scholar
  16. 16.
    Levy MM. Conflict resolution at the end of life. Crit Care Med 2001; 29(2S):N56–N61.CrossRefPubMedGoogle Scholar
  17. 17.
    Levy MM. Compassionate end-of-life care in the intensive care unit. Crit Care Med 2001; 29(2S):N1–N2.CrossRefPubMedGoogle Scholar
  18. 18.
    Brody H, Campbell ML, Faber-Langendoen K. Withdrawing intensive life-sustaining treatment—recommendations for compassionate clinical management. N Engl J Med 1997; 336(9):652–657.Google Scholar
  19. 19.
    Clarke EB, Curtis JR, Luce J M, et al. Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 2003; 31(9):2255–2262.CrossRefPubMedGoogle Scholar
  20. 20.
    Nelson JE. Saving lives and saving deaths. Ann Intern Med 1999; 130:776–777.PubMedGoogle Scholar
  21. 21.
    SUPPORT Principal Investigators. A controlled trial to improve care fro seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 1995; 274(20):1591–1598.CrossRefGoogle Scholar
  22. 22.
    Levy MM. End-of-life care in the intensive care unit: can we do better? Crit Care Med 2001; 29(2S):N56–N61.CrossRefPubMedGoogle Scholar
  23. 23.
    Truog RD, Cist AFM, Brackett SE, et al. Recommendations for end-or-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001; 29(12):2332–2348.CrossRefPubMedGoogle Scholar
  24. 24.
    Wilson WC, Smedira NG, Fink C, et al. Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients. JAMA 1992; 267:949–953.CrossRefPubMedGoogle Scholar
  25. 25.
    A definition of irreversible coma: report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968; 205:337–340.Google Scholar
  26. 26.
    Uniform Determination of Death Act, 12 Uniform Laws Annotated (U.L.A.) 589 (West 1993 and West Supp. 1997).Google Scholar
  27. 27.
    The Quality Standards Subcommittees of the American Academy of Neurology. Practice parameters for determining brain death in adults. Neurology 1995; 45:1012–1014.Google Scholar
  28. 28.
    Wijdicks EF. Determining brain death in adults. Neurology 1995; 45:1003–1011.PubMedGoogle Scholar
  29. 29.
    Wijdicks EF. The diagnosis of brain death. N Engl J Med 2001; 344:16:1215–1221.CrossRefPubMedGoogle Scholar
  30. 30.
    American Academy of Pediatrics Task Force on Brain Death in Children. Report of special task force: guidelines for the determination of brain death in children. Pediatrics 1987; 80:298–300.Google Scholar
  31. 31.
    Petty GW, Mohr JP, Pedley TA, et al. The role of transcranial Doppler in confirming brain death: sensitivity, specificity and suggestions for performance and interpretation. Neurology 1990; 40:300–303.PubMedGoogle Scholar
  32. 32.
    Novitzky D, Hicomb WN, Cooper DKC, et al. Electrocardiographic, hemodynamic and endocrine changes occurring during experimental brain death in the Chacma baboon. J Heart Transplant 1984; 4:63–69.Google Scholar
  33. 33.
    Bittner HB, Chen EP, Kendall SWH, et al. Brain death alters cardiopulmonary hemodynamics and impairs right ventricular power reserve against an elevation of pulmonary vascular resistance. Chest 1997; 111:706–711.CrossRefPubMedGoogle Scholar
  34. 34.
    Darracott-Cankovic S, Stoven PGI, Wheeldon D, et al. Effect of donor heart damage on survival after transplantation. Eur J Cardiothorac Surg 1989; 3:525–532.CrossRefPubMedGoogle Scholar
  35. 35.
    Owen VJ, Buston PBJ, Michel MC, et al. Myocardial dysfunction in donor hearts. Circulation 1999; 99:2565–2570.PubMedGoogle Scholar
  36. 36.
    Novitzky D. Donor management: state of the art. Transplant Proc 1997; 29:3773–3775.CrossRefPubMedGoogle Scholar
  37. 37.
    Ririe DG, Butterworth JF, Royster RL, et al. Triiodothyronine increases contractility independent of beta-adrenergic receptor or stimulation of cyclic 3-5-adenosine monophosphate. Anesthesiology 1995; 82:1004–1012.CrossRefPubMedGoogle Scholar
  38. 38.
    Timek T, Bonz A, Dillman R, et al. The effect of triiodothyronine on myocardial contractile performance after epinephrine exposure: implications for donor heart management. J Heart Lung Transplant 1998; 17:931–940.PubMedGoogle Scholar
  39. 39.
    Novitzky D. Selection and management of cardiac allograft donors. Curr Opin Cardiol 1996; 11:174–182.CrossRefPubMedGoogle Scholar
  40. 40.
    Gramm HJ, Meinhold H, Bicket U, et al. Acute endocrine failure after brain death. Transplantation 1992; 54:851–857.CrossRefPubMedGoogle Scholar
  41. 41.
    Howlett TA, Keogh AM, Perry L, et al. Anterior and posterior pituitary function in brain-stem-dead donors. Transplantation 1989; 47:828–834.CrossRefPubMedGoogle Scholar
  42. 42.
    Powner DJ, Hendrich A, Lagler RG, et al. Hormonal changes in brain dead patients. Crit Care Med 1990; 18:702–708.PubMedCrossRefGoogle Scholar
  43. 43.
    Debelak L, Pollak R, Ruland C. Arginine vasopressin versus desmopressin for the treatment of diabetes insipidus in the brain dead organ donor. Transplant Proc 1990; 22:351–352.PubMedGoogle Scholar
  44. 44.
    Hirsch L, Matzner MP, Huber WO, et al. Effect of desmopressin substitution during organ procurement on early renal allograft function. Nephrol Dial Transplant 1996; 11:173–176.Google Scholar
  45. 45.
    Guesde R, Barrou B, Leblanc I, et al. Administration of desmopressin in brain dead donors and renal function in kidney recipients. Lancet 1998; 352:1178–1181.CrossRefPubMedGoogle Scholar
  46. 46.
    Powner DJ, Kellum JA, Darby JM. Abnormalities in fluid, electrolyte and metabolism of organ donors. Prog Transplant 2000; 10:88–96.PubMedGoogle Scholar
  47. 47.
    Androgue HJ, Madias NE. Management of life threatening acid-base disorders First of two parts. N Engl J Med 1998; 338:26–34.CrossRefGoogle Scholar
  48. 48.
    Androgue HJ, Madias NE. Management of life threatening acid-base disorders second of two parts. N Engl J Med 1998; 338:107–111.CrossRefGoogle Scholar
  49. 49.
    Powner DJ, Kellum JA. Maintaining acid-base balance in organ donors. Prog Transplant 2000; 10:98–105.PubMedGoogle Scholar
  50. 50.
    Powner DJ, Reich HS. Regulation of coagulation abnormalities and temperature in organ donors. Prog Transplant 2000; 10:146–153.PubMedGoogle Scholar
  51. 51.
    Powner DJ, Darby JM, Stuart SA. Recommendations for mechanical ventilation during donor care. Prog Transplant 2000; 10:33–40.PubMedGoogle Scholar
  52. 52.
    Brower RG, Morris A, Schoenfeld D, et al. for the ARDS network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301–1308.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Frederic J. ColeJr.
    • 1
  • Jay N. Collins
    • 1
  • Leonard J. WeireterJr.
    • 1
  1. 1.Department of Surgery, Eastern Virginia Medical SchoolSentara Norfolk General HospitalNorfolkUSA

Personalised recommendations