Abstract
With interest, but also with concern, we read the recent article written by Dalle Ave and Shaw regarding controlled organ donation after circulatory death. 1 Like the authors, we do acknowledge the risk of occurrence of complicated ethical controversies in the process of controlled Donation After Circulatory Death (cDCD) organ donation after withdrawal of life support. However, we do not agree on the arguments and issues mentioned by the authors.
In the paragraph “Hastening death during withdrawal of life support,” they mention that “During withdrawal of life-sustaining measures sedatives and analgesics should not be increased, as it is unnecessary and has the goal of hastening death.” The withdrawal of life-sustaining measures, most commonly stopping mechanical ventilation, causes the death of the patient, in many cases immediately. Death is the intended consequence of the action: letting the patient, which is, as we know, dependent on life-sustaining measures, die. There is no intensivist of intensive care nurse who will be surprised that the patient dies within minutes after withdrawal of mechanical ventilation. In our communication to the relatives, we say that we will stop the mechanical ventilation and “allowing their loved one die.” When the intention of the withdrawal is to allow the patient to die (within minutes), why is the administration of sedatives or analgetics a problem? With or without, the patient dies shortly. Sometimes it will be necessary to increase the doses of opioids or sedatives for comfort measures. And even then there is no ethical problem, as there is no evidence at all that increasing the doses of opioids and sedatives during withdrawal of life-sustaining measures will shorten the dying process in already critically ill intensive care unit (ICU) patients. 2,3
Secondly, the authors describe the issue of “hastening death in the context of cDCD in countries where euthanasia is legal.” Although organ donation after cDCD following deliberate termination of life on the request of the patient (euthanasia) is possible en done in Belgium and the Netherlands, 4 this is not what the authors mean. There are very strict criteria for organ donation after euthanasia. Organ donation after euthanasia is planned en completely legal in these countries. The authors does not mean this; they mention that during normal cDCD procedures (without formal euthanasia), the dying process is hastened, especially in countries where euthanasia is legal. This is an absurd assumption. Why would the dying process specifically be hastened in countries in which euthanasia is legal? This risk is the same in noneuthanasia countries! These 2 issues are completely unrelated. Euthanasia can only be called euthanasia when it happens with repeated full consent of the patient self; this obligatory prerequisite makes euthanasia in the ICU extremely rare and almost impossible to occur. 5
Deliberate administration of medication that will let the patient die or will undoubtedly speed up the dying progress is therefore not a form of euthanasia because of the specific lack of consent and therefore it is no less illegal in Belgium or the Netherlands than in countries without regulated euthanasia.
The authors mention the cDCD procedure in Liege, Belgium. 6 In their article, they combined 2 different statements in 1 text block, making the impression that in Belgium by switching intravenous sedatives and opioids to volatile anesthetics (sevoflurane or desflurane) at a 1 to 1.5 minimum anesthetic concentration, hastening of death is intended. This is not what was stated originally. The sole reason that is chosen for this regimen is protection against ischemia–reperfusion in the donor organs, not hastening or inducing death. Volatile anesthetics at that dose do not hasten death at all.
They also misread the other article they cited. Vincent and Brimioulle wrote: “We believe that most patients would prefer the shorter option, which may necessitate use of large doses of sedatives and even muscle paralysis to prevent breathing efforts when the ventilator is turned off.” (p. 577) 7 Dalle Ave and Shaw “interpreted” this as: “Thus, if the patient does not die in the “allowed” time frame, higher doses of sedatives are used and even paralytic agents are given.”(p. 183)
Despite the interpretation Dalle Ave and Shaw gave of this “thought experiment,” there is no real evidence that the dying process is shortened in cDCD by the administration of high doses of sedatives, analgetics, paralytic agents, and anesthetics in the Netherlands or Belgium. Besides that, as already mentioned above, the current laws on organ donation and euthanasia do not give any space in any way for such a practice. We fear the authors were already somewhat prejudiced while reading the texts.