Abstract
Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.
Highlights
The way we die has changed significantly during the past half-century
The ICU has come to play multiple important roles in contemporary healthcare – providing access to advanced life support, supporting organ donation and tissue transplantation programs, and providing end-oflife care for those in whom any further treatment is futile [9]. While these functions are generally managed without difficulty, they may, at times, create an unavoidable tension, when intensivists must mediate between professional and social obligations to provide patients with a good death [10,11], to effectively use scarce health resources and to support organ transplantation through the identification and management of people who are, or may become, brain dead
In itself, creates a unique challenge because, where brain death is anticipated, the interests of the patient, and the public benefit that accrues from the organs potentially removed from that patient may diverge, creating tension regarding the most appropriate approach to the management of the patient’s death
Summary
The way we die has changed significantly during the past half-century. Once a sudden and unexpected event, death has become an actively managed and often prolonged process that occurs more often in hospitals than in the community [1,2]. One option available to countries with low deceased donation rates is to try to raise rates of brain death by redefining what is considered appropriate treatment in end-of-life care – to normalize the widespread application of technology at the end of life and to continue cardiorespiratory support in patients who currently have treatment withdrawn as part of the active management of their dying [40] The impact of such a move (as has been recently proposed in the UK [41,42]) would be profound – increasing expenditure at the end of life, increasing ICU admission rates and the number of ICU beds required, privileging intensive care over palliative and chronic care, readjusting our expectation of advance care planning to accommodate interventions that maximize organ donation potential, adjustment of public health policies to encourage hospital-based and intensive care, and changing social attitudes and expectations regarding where and how we should die. Author details 1The Centre for Values, Ethics and the Law in Medicine (VELiM), Level 1, Medical Foundation Building K25, 92-94 Parramatta Road, University of Sydney, Sydney, NSW 2006, Australia. 2Haematology Department, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065, Australia. 3The Centre for Health Governance, Law and Ethics, Sydney Law School, Building F10, Eastern Ave, University of Sydney, Sydney, NSW 2006, Australia
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