Beyond the Billboard: The Facebook-Based Application, Donor, and Its Guided Approach to Facilitating Living Organ Donation.

Living donor solicitation can raise ethical concerns, regardless of the medium used: newspaper, television, pulpit, billboard or Internet. Moving the search for a living donor into the social media realm introduces the risk of unguided and coercive patient narratives as well as decoupling or even total absence of information that could aid the consent process. The Facebook application (app) for living donors, called Donor (restricted to patient use), aims to address these concerns in several ways: (i) by directing the patient's initial appeal to friends and family; (ii) by guiding the patient's narrative; and (iii) by providing a library of clinical, ethical and regulatory information that informs the consent process. In this paper, we explored these features and contrasted them with billboard solicitation activities and current independent social media efforts. We concluded that the proactive ethical design of the Donor app is a permissible way to help satisfy the shortfall of deceased donor livers and kidneys.

A Smartphone App for Increasing Live Organ Donation.

The incidence of live donor transplantation has declined over the past decade, and waitlisted candidates report substantial barriers to identifying a live donor. Since asking someone to donate feels awkward and unfamiliar, candidates are hesitant to ask directly and may be more comfortable with a passive approach. In collaboration with Facebook leadership (Facebook Inc., Menlo Park, CA), we developed a mobile application-an app-that enables waitlisted candidates to create a Facebook post about their experience with organ failure and their need for a live donor. We conducted a single-center prospective cohort study of 54 adult kidney-only and liver-only waitlisted candidates using the Facebook app. Cox proportional hazards models were used to describe donor referral on behalf of candidates using the app compared with matched controls. The majority of candidates who used the app reported it to be "good" or "excellent" with regard to the installation process (82.9%), readability (88.6%), simplicity (70.6%), clarity (87.5%) and the information provided (85.3%). Compared with controls, candidates using the Facebook app were 2.43 6.6117.98 times more likely to have a donor come forward on their behalf (p < 0.001). The Facebook app is an easy-to-use instrument that enables waitlisted candidates to passively communicate with their social network about their need for a live donor.

Family refusals of registered consents: the disruption of organ donation by double-standard surrogate decision-making.

Some countries such as Australia, Spain, Norway, Italy and Canada allow next of kin to override the consent of registered organ donor candidates if they personally do not concur with the donation desire of their relative. This form of surrogate decision-making represents a double standard in terms of the principle of substituted judgment (the surrogate's duty). Further, double-standard surrogate decision-making in the setting of organ donation is a slippery slope to unethical surrogate decision-making while patients are alive. Concerns about family distress and donor candidate revocation of consent can still be managed without permitting double-standard surrogate decision-making.

Managing patients whose family members are physicians.

The ethical complexities involving physicians who treat their own family members are well known and it is generally accepted that such practice should not occur. We present three anonymous cases in which patient family members who worked as physicians complicated the medical care of their hospitalized relatives. When a health care worker's family member becomes a hospital patient, the situation can be emotionally charged due to the medical insight the multiple parties have, as well as the desire of relatives to be protective of their family members. Clinician-relatives need to allow the medical team to assume the role of caretaker when their family members are hospitalized. Teams may need to employ limit setting in order to ensure fair and consistent care for all patients on the ward, and to prevent escalation of emotionally charged situations.

The ethical complexities of online organ solicitation via donor-patient websites: avoiding the "beauty contest".

The proliferation of the Internet has spurred the creation of websites dedicated to facilitating living directed organ donations. We argue that such sites potentially devolve into "beauty contests" where patients in need are evaluated on the basis of their personal appearance and biography-variables which should have no relevance to organ allocation. Altruism should be the guiding motivation for all donations, and when it does, there is no place for a beauty contest. The power of the Internet is optimally used when it facilitates Good Samaritan donations-donations to any stranger, rather than handpicked ones. Social networking sites which aim to match potential donors and patients should mask personal identifying information, allowing the ethical principles of altruism and justice to guide organ allocation.

Optimising the documentation practices of an Ethics Consultation Service.

A formal Ethics Consultation Service (ECS) can provide significant help to patients, families and hospital staff. As with any other form of clinical consultation, documentation of the process and the advice rendered is very important. Upon review of the published consult documentation practices of other ECSs, we judged that none of them were sufficiently detailed or structured to meet the needs and purposes of a clinical ethics consultation. Thus, we decided to share our method in order to advance the practice of ethics consultation. Here, we describe a method of ECS documentation practice, including use of a formal consult report template, as well as a log for maintaining a chronological record of the consultations performed. These two documents facilitate order and organisation of the ECS. They also enable the ECS to keep an account of professional time and experience, enable quick consult trend assessments (by consult theme or ward, for example) and establish a potential registry of consults for future research study. This method of documentation, we believe, not only contributes significantly to the primary purpose of the consultation-namely, the evincing and sharing of ethical opinion about a case-but also enables consultants to improve their practice and to pursue research on clinical ethics consultation.

Checklist: passport, plane ticket, organ transplant.

Recently, active and proposed US medical insurance programs are taking steps to address the problems of organ availability, long waiting times, and high medical and surgical costs by promoting transplant tourism. Such programs are created explicitly to encourage policy holders to travel to a foreign country for the purpose of obtaining a transplant. Some medical insurance programs have gone as far as to bundle exotic travel and healthcare-transplantation not excluded-into one package. This article details some of the safety and ethics issues with these programs.

When psychiatry and bioethics disagree about patient decision making capacity (DMC).

The terms "competency" and "decision making capacity" (DMC) are often used interchangeably in the medical setting. Although competency is a legal determination made by judges, "competency" assessments are frequently requested of psychiatrists who are called to consult on hospitalised patients who refuse medical treatment. In these situations, the bioethicist is called to consult frequently as well, sometimes as a second opinion or "tie breaker". The psychiatric determination of competence, while a clinical phenomenon, is based primarily in legalism and can be quite different from the bioethics approach. This discrepancy highlights the difficulties that arise when a patient is found to be "competent" by psychiatry but lacking in DMC by bioethics. Using a case, this dilemma is explored and guidance for reconciling the opinions of two distinct clinical specialties is offered.

Questioning the decision-making capacity of surrogates.

When patients are unable to make medical decisions for themselves due to cognitive impairment, surrogate decision makers are often called on to guide the medical team. Important to any decision made on behalf of the patient is that the decision reflects the values and preferences of the patient in light of the patient's clinical status and prognosis. Challenges arise for the medical team when surrogates themselves have questionable decision-making capacity due to psychosocial issues, conflict of interest, or the obvious projection of their own personal values and treatment preferences instead of the patient's. Even if an alternative surrogate is available, there is no consensus on when and how to switch from the primary surrogate to the alternative surrogate. This paper uses a clinical case to explore the notion of surrogate decision-making capacity, offering guidance for determining when it is appropriate to defer to an alternative surrogate, as well as guidance for managing the process of appointing the alternative as the new primary decision maker.

Left ventricular assist devices and the slippery slope of ageism.

The use of left ventricular assist devices is growing each year, as is the size of the United Network for Organ Sharing cardiac waiting pool. Notably, the geriatric waiting pool (age 65 and older), although small, is growing each year and this growth is predicted to increase as geriatric population projection curves soar. While left ventricular assist devices have clinically proven benefit, their use in geriatric patients raises ethical issues. Where these devices are currently not approved as destination therapy, their use must be reflected upon in conjunction with allograft transplantation. Age-based organ allocation policies could facilitate left ventricular assist devices as a bridge to nowhere for some geriatric patients. Specifically, the extended use of a left ventricular assist device by older patients could, in theory, put them in a position of not being able to get an allograft due to the fact that they have aged while on the waiting list. Unless these devices are approved as destination therapy, or age-based organ allocation policies contain exception clauses, an older person's cardiac dilemma could be confounded as an assist device recipient. Without these measures one might argue the devices themselves should be subject to age-based allocation procedures. Is this the slippery slope of ageism?

Resisting the blame game: visualizing the high cost of dying and accepting the duty of technology stewardship for all patient populations. A review.

This article explores the concepts of therapy withholding and withdrawal as expressions of technology stewardship. With the world's geriatric population growing sharply, and advances in medical technology announced almost weekly, the time is ripe for the application of technology stewardship to patients of all ages, rather than arbitrary allocation limits for older persons. In life and in death, health care costs are expensive, and while society often views older people as too expensive to take care of alive, their death can be even more costly. For patients of all ages, death under the influence of technology is more expensive than life, yet it is geriatric intensive care medicine that grabs society's economic attention. While possibly not the financial bargain that arbitrary allocation limits have been proposed to be, technology stewardship fosters beneficence and autonomy as human values instead of mere variables subservient to economics.

When withdrawal of life-sustaining care does more than allow death to take its course: the dilemma of left ventricular assist devices.

BACKGROUND: Left ventricular assist devices (LVADs) are a relatively new technology that is increasingly used to preserve cardiac function. These devices work by a mechanism that may complicate ethical decision-making for patients who subsequently lose decision-making capacity and are no longer considered transplant candidates. METHODS: Using a clinical case from our medical center, we explored the complex ethical issues associated with the discontinuation of LVAD therapy by discussing how this device is distinct from the withdrawal of other treatments. RESULTS: While halting an implanted LVAD may permit a patient to die, the deactivated device itself may contribute to patient death due to the potential for blood backflow and pooling, as well as the disruption of heart contractility. Inadequate informed consent and failure to appoint a surrogate decision-maker in advance of the implant procedure resulted in a complex ethical dilemma for the patient's family and the medical team. CONCLUSIONS: Clinicians and families must consider the benefits and burdens of LVAD therapy as they do when considering removal of other life-sustaining treatment. The informed consent process associated with LVADs as bridging technology should include extensive consideration of the purpose of the device, future circumstances in which it may be halted, and how such situations would be recognized and handled. Appointment of a surrogate decision-maker before the surgical procedure is essential.

Scientific breakthroughs: cause or cure of the aging 'problem'.

Could it be that society's construction of what it means to be elderly has created and now fuels the current immortality revolution? Have we defined aging in such a manner that we 'need' technological breakthroughs in order to fight the 'problem' of the soaring geriatric population? This fight may indeed improve quality of life and increase longevity, but while doing so, society must accept that this strategy will result in an ever increasing elderly population, a population that cannot be expected to let beneficient medical technology (comfort or cure oriented) pass them by. Society's medical breakthroughs are creating a population that ethically we cannot turn our backs on.

Why an alternate recipient list for heart transplantation is not a form of ageism.

Numerous studies have shown that the use of marginal hearts for organ transplantation produces clinically favourable results, however the association of these marginal hearts with a separate list of potential recipients, often the elderly, is ethically disturbing for some transplant facilities. Examination of the outcome data alone is not enough to justify the use of an alternate recipient list (ARL) as an ethical practice. However, upon analysis and reflection on the allocation process and the goals of medicine, the operating principles of medical ethics clearly emerge. Based upon this ethical analysis, an ARL for heart transplantation is not a form of ageism but rather a method of technology stewardship that operates by way of facilitating transplant eligibility to those with the capacity to benefit.