Conflicts of interest in the context of end of life care for potential organ donors in Australia.

End-of-life (EOL) care has become an integral part of intensive care medicine and includes the exploration of possibilities for deceased organ and tissue donation. Donation physicians are specialist doctors with expertise in EOL processes encompassing organ and tissue donation, who contribute significantly to improvements in organ and tissue donation services in many countries around the world. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring organ and tissue donation is considered according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by clinicians, institutions and health care networks. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU. In this paper we review current controversies around EOL care in the ICU, including the use of palliative analgesia and sedation specifically with regards to withdrawal of cardiorespiratory support, the usefulness of the so-called doctrine of double effect to guide ethical decision-making, and the management of potential or perceived conflicts of interest in the context of dual professional roles.

Expedited organ donation in Victoria, Australia: donor characteristics and donation outcomes.

Background: Deceased organ donation work-up typically takes 24 hours or more. Clinicians may thus discount the possibility of donation when the potential donor is physiologically unstable or family requirements do not allow this length of time. This may lead to loss of transplantable organs. In 2015, we introduced an expedited work-up guideline with the aim of facilitating donation in these circumstances and maximising donation potential. Objective: To determine the number of expedited work-up (consent to retrieval procedure of 6 hours or less) donors from 2015 to 2018, compare their clinical and demographic characteristics with standard donors, and assess the outcome of transplanted organs and organ recipients. Design: We performed a retrospective audit of the electronic database for all Victorian donors from 2015 to 2018. We obtained transplant outcome data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). Results: Overall, 38 expedited pathway donors donated 78 organs for transplantation (70 kidneys, four lungs, three livers, one pancreas). Of these, 55 retrieved kidneys were successfully transplanted. The lungs, livers and pancreas retrieved were all transplanted. For the kidney recipients, early graft dysfunction requiring dialysis was more common than with organs from the standard pathway (71% v 38%; P < 0.0001); however, short and medium term graft and patient survival were similar. Three recipients from the expedited pool experienced graft failure and two subsequently died. Of the two lung recipients, one died at day 622 of chronic rejection. Conclusions: Expedited pathway donation is feasible with acceptable donation outcomes. Clinicians should consider donation even when physiological instability or family requirements preclude standard organ donation work-up times.