Ethical Considerations and End-of-Life Care in Donor and Transplant Critical Care

Abstract

Advances in organ transplantation and mechanical circulatory support technologies have deepened the ethical complexity of care for critically ill patients across the donation-transplant continuum, especially at the end-of-life. This narrative review is structured around four clinical scenarios faced by bedside intensivists: patients awaiting transplantation, patients for whom transplant is no longer an option, patients who may become organ donors, and transplant patients at the end-of-life. Across these contexts, clinicians must navigate prognostic uncertainty, steward scarce resources, and address potentially nonbeneficial treatment, while respecting patient values. Through case-based analysis, we offer practical ethical guidance and emphasize the critical role of skilled communication, ethics consultation, and palliative care in supporting bedside decision-making.

Keywords

transplant critical care end-of-life communication intensive care ethics organ transplantation mechanical circulatory support

Introduction

In the United States (US) nearly one in five deaths occurs during or shortly after an ICU admission, placing ethical questions about goals of care, treatment limits, and clinician responsibility at the center of everyday ICU practice.¹ These questions can be even more complex for ICU patients across the donor-transplant continuum: patients awaiting transplants, those who have received transplants, and those who may be organ donors. In this setting, clinicians remain primarily responsible to the patient in front of them, yet frequently encounter ethical questions shaped by the broader transplant system, including organ scarcity, allocation policies, and stewardship concerns.²

Transplant programs operate under institutional and performance pressures, including close regulatory assessment of one-year graft and patient survival rates, that can influence bedside ethics.³ For example, there can be tension between protecting program success rates and offering transplantation to the sickest or most complex patients or between maximizing survival measures and supporting the withdrawal of life-sustaining treatments when continued intervention no longer aligns with the patient's goals.

Scope and Organization

This narrative review does not aim to provide a comprehensive account of all ethical issues arising in critical care or transplantation, but instead concentrates on clinician-facing, ethically complex, bedside decisions that arise in caring for critically ill patients within the donation-transplant continuum. Where possible, we cite systematic reviews, clinical guidelines, and professional society opinions and provide commentary and synthesis based on our experience.

The perspectives presented in this review are informed by the collective experience of four clinically active physicians with expertise spanning critical care, surgery, palliative care, and clinical ethics. Collectively, we have decades of experience caring for critically ill patients, participating in complex transplant-related decision-making, and providing clinical ethics consultation in academic medical centers across multiple regions of the United States. The topics included in this review were selected based on both a review of the literature and our shared experience of the ethical challenges most frequently encountered in the care of patients across the donation-transplant continuum. Given this experience, we will focus on the United States, and when possible, acknowledge how ethical situations may differ in other contexts where resource availability or allocation may differ. This review should be applicable to intensivists who care for patients in the donation-transplant continuum in many different settings, including surgical ICUs, medical-surgical ICUs, or dedicated transplant ICUs.

This review is broken into four sections, centered around cases that are representative from our collective clinical experience. The first three deal with different patient populations that may be encountered by an ICU clinician: those awaiting transplants, those for whom transplant is no longer an option, and those who may become organ donors. The fourth section addresses conflict or disagreement in these settings and discusses the role of communication and ethics or palliative care consultation.

Section 1: Ethical Challenges with Patients Awaiting Transplants

Case 1: Mr Henry is a 68-year-old man with a history of alcohol induced cirrhosis. He is well known to the ICU team for frequent admissions related to his liver and kidney disease. He has struggled with relapses of his alcoholism in the past, but has currently been sober for the past 3 months. He is currently listed for a combined liver and kidney transplant and has been in the ICU for nearly a month awaiting suitable organs. The ICU team is suddenly called to the ED to consult on Mr Smith, a 24-year-old in acute liver failure following a successful liver transplant 6 months ago for acute hepatitis. Dr Gold is the intern on the ICU team and she wonders if it's fair for Mr Smith to receive a second organ before Mr Henry has had one, but also expresses a worry that an organ might be “wasted” on Mr Henry, given his history of alcoholism.

Key Ethical and Clinical Issues in Organ Allocation and Transplant Candidacy

While most intensivists do not directly participate in decisions around organ allocation or transplant candidacy, they often experience the ethical tensions while caring for these patients. Organ allocation systems work to optimize two main priorities: equity in access to scarce organs and utility in producing the greatest overall benefit. The OPTN (Organ Procurement and Transplantation Network) Ethics Committee's conclusion is that given no allocation system can fully satisfy both aims, policy must intentionally balance them, acknowledging that some trade-offs are unavoidable.⁴

Ethical Considerations in Retransplantation

Should Mr Smith receive a second liver transplant before Mr Henry has had one? Retransplantation (the allocation of a second organ to a patient whose prior graft has failed) raises ethical questions about fairness, benefit, and utility.^5,6 In 2018, retransplants represented 3.1% of heart transplants, 2.5% of lung transplants, 4.3% of liver transplants, and 10.3% of kidney transplants, and therefore remain a focus of distributive justice concerns.⁷

More recently, ethical analysis has emphasized prognosis and anticipated utility, asking whether retransplant recipients derive similar benefit to primary transplant candidates. For example, heart retransplants demonstrate one-year survival rates near those of primary transplants, whereas early liver retransplantation, particularly within 30 days, carries substantially higher perioperative risk.^8,9 However, positive prognostic data in some organ contexts do not resolve the underlying fairness concerns and key considerations include the cause of graft failure, whether there are modifiable clinical factors, the patient's current clinical status, and the likelihood of meaningful benefit with repeat transplantation.⁶

Transplant Candidacy in Patients with Nonadherence or Substance use Disorders

Will Mr Henry benefit from an organ transplant if he continues to struggle with alcoholism? Patients with prior nonadherence or substance use history often raise concerns about graft longevity and post-transplant reliability, however, the evidence shows outcomes are often favorable when needs are anticipated and structured support is in place. For example, a meta-analysis of 54 studies found that relapses to illicit drug or heavy alcohol use after transplantation were under 5 cases per 100 persons per year.¹⁰ They also found relapse hard to predict. Even widely used selection criteria, such as requiring six months of abstinence, were only weak predictors.¹⁰ While candidacy decisions are inherently subjective, all efforts should be made to separate true medical risk from moral judgment. Requirements with poor predictive validity and significant potential for bias and stigma should be avoided.¹¹

Case 1 Conclusion: Dr Gold reviews the OPTN guidelines and shares her understanding of the complicated and subjective effort it takes to balance equity and utility. She explains that neither prior receipt of an organ nor a history of alcoholism singularly determines who should receive the next available transplant. Rather, both patients should be evaluated according to established allocation criteria, with priority determined by objective measures of medical urgency, expected benefit, and organ-specific allocation policies. Knowing that Mr Henry will have better transplant outcomes with structured support for his history of alcoholism, she also suggests early social work involvement for him while he waits for a potential organ.

Section 2: Ethical Challenges with Patients who are no Longer Transplant Candidates

Case 2: Mr Jones is a 52-year-old man with end-stage heart failure who is admitted to the transplant ICU in cardiogenic shock and placed on venoarterial extracorporeal membrane oxygenation (ECMO) as a bridge to transplant. Over the following weeks, he develops progressive renal failure, hemorrhagic stroke, and recurrent infections. He is unable to receive a destination VAD given his inability to tolerate anticoagulation and deemed no longer a transplant candidate with no meaningful prospect of myocardial recovery. Although physiologically stable on ECMO, Mr Jones lacks decision-making capacity. His family insists that “as long as the machine is working,” ECMO should be continued, expressing hope that “something will change.” The ICU team believes ongoing support is prolonging the dying process and worries about a “waste of resources.”

Ethical Challenges and Best Practices in Mechanical Circulatory Support (MCS)

Many patients awaiting organs never make it to a successful transplant and their clinical course can be long, challenging, and uncertain.

Mechanical circulatory support (MCS) technologies, including temporary and durable devices such as ECMO, left ventricular assist devices (LVADs), and total artificial hearts (TAHs), have transformed care for patients with advanced organ failure. Up to half of heart transplant candidates are supported by some form of MCS, most often LVADs.¹² Despite improved survival rates, morbidity associated with MCS from bleeding, stroke, and infection remains significant, and many patients ultimately die with their devices in place. This has given rise to a growing subset of patients facing complex end-of-life decisions involving MCS withdrawal or deactivation.¹³

These cases illustrate the intersection of prognostic uncertainty, technological intensity, and end-of-life decision-making and demand careful navigation of professional responsibilities, requiring clinicians to balance compassion, transparency, and respect for patient values while also acknowledging broader stewardship obligations.¹⁴ In our view, the ethical work in these cases is less about resolving a direct conflict between individual and societal duties and more about recognizing the limits of medical interventions and supporting patients and families through their grief.

Concerns About Stewardship

Given ECMO's resource intensity and relative scarcity, concerns about justice and stewardship frequently arise. In most clinical settings, however, these concerns remain largely abstract: while ongoing ECMO may appear disproportionate or non-beneficial, true material scarcity is uncommon in the US outside of disaster periods such as the COVID-19 pandemic. Resource constraints may also differ in other jurisdictions or health systems outside the US. In general, decisions about limiting or allocating life-sustaining therapies, including ECMO, should not be made ad hoc at the bedside, but instead should be guided by institutional or regional policies designed to promote fairness, consistency, and transparency.¹⁵

Preparedness and Advance Care Planning

Preparedness planning prior to initiation of MCS is required or strongly encouraged by many different professional societies and regulatory bodies. While some of these interventions are helpful in counseling and may improve patient knowledge or values clarification, they have not demonstrated consistent improvements in downstream outcomes, such as reduced decisional conflict or concordance between stated values and the care ultimately received.^12,16,17

Despite these limitations, we still recommend that prior to initiation of MCS, clinicians engage patients and families in careful discussions that include naming a primary decision maker, eliciting goals and values, and documenting advance directives when possible.^12,16 These discussions remain best practice for all patients with serious illness, even if in they do not fully mitigate downstream conflict. For temporary MCS, the goals, intended duration, and criteria for success or failure of therapy should be explicitly delineated prior to initiation. Importantly, the ethical value of these discussions lies less in their ability to predict or determine future decisions than in ensuring that initiation of MCS is grounded in the principles of informed consent that explicitly engages patient goals, values, and acceptable trade-offs.

Ethical Issues with “Bridge to Nowhere” Situations

Despite preparedness efforts, there may be scenarios where MCS becomes a “bridge to nowhere,” where previously articulated preferences may no longer map cleanly onto the clinical reality, and advance directives may offer limited guidance for a way forward. In these circumstances, we recommend approaching ongoing MCS support as one would other life-sustaining therapy in critical care. This includes clearly defined therapeutic goals, explicit clinical and ethical criteria for reassessment, and anticipatory discussion that non-achievement of agreed-upon milestones may warrant reconsideration or withdrawal of MCS.

Fundamentally, discontinuation of MCS forces patients, families, and sometimes clinicians to confront the reality of dying and what it might look like in the context of advanced therapies. All efforts should be made to improve communication, mitigate moral distress, and support alignment of treatment with patient values.

Withdrawing and Withholding MCS

In the U.S., it is ethically and legally permissible to withdraw any life-sustaining treatment (LST), including MCS, provided the intent is to relieve burdens rather than hasten death.¹³ However, the legal right to do so lies with the patient or their surrogate, not with the clinician. A clinician's ability to unilaterally withhold or withdraw treatments is extremely limited, but does vary by state law. Ultimately these decisions should be grounded in the patient's goals and values, not those of the clinician.

Some clinicians experience moral discomfort when withdrawing devices such as TAHs or LVADs, particularly when these technologies have become deeply integrated into a patient's body and physiology.¹³ Similarly, some clinicians find it morally complicated to deactivate pacemakers at the end-of-life.¹⁸ Ethical analysis consistently situates withholding or withdrawing MCS alongside other forms of life-sustaining therapy and distinguishes it clearly from physician-assisted death.¹³ Although MCS is sometimes described as “replacement therapy,” true replacement treatments, such as organ transplantation or bioprosthetic valves, function independently of external control and respond autonomously to the body's physiologic changes. In contrast, surgically implanted MCS remains externally powered and dependent on ongoing human intervention, rendering it more ethically analogous to ventilatory support or artificial nutrition.¹³

Most clinical ethicists find withdrawing or withholding treatments to be morally equivalent, a position long supported in U.S. bioethics and professional guidance, though some religious or cultural traditions may view the issue differently.^19-21 Some advocate for waiting to withdraw interventions once the prognosis is more clear, urging caution about withholding or withdrawing during periods of greater uncertainty.²²

Concerns About Non-Beneficial Treatment in Transplant Critical Care

When treatments become less effective at the end of life, clinicians, patients, and families are forced to confront the limits of medical care and the reality of mortality. These increasingly ineffective treatments have been called many things, including “futile”, “non-beneficial”, or “inappropriate”.^15,23,24 It is generally accepted that physicians are not obligated to offer or provide ineffective treatments. However, determining what “ineffective” means can be challenging.

For example, the official policy statement from the American Thoracic Society (ATS), Society for Critical Care Medicine (SCCM), and others suggests using the term “potentially inappropriate treatments” to reflect “treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them.¹⁵” Alternatively, additional guidance from the SCCM Ethics Committee instead considers inappropriate ICU interventions to be ones where “there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment.²⁴” It's important to note that this latter definition may conflict with discrimination law in the US designed to protect people with disabilities.

In the particular case described above, the ICU physicians feel that continuing ECMO is potentially inappropriate because Mr Jones has no path to recovery. However, the ECMO continues to have its intended physiologic effect and arguably provides some benefit, if the prolongation of life is in itself a goal for Mr Jones. Patients may reasonably hold values and goals that differ from those of their clinicians, including different understandings of suffering, acceptable quality of life, and the benefits of continued life-sustaining treatment. Respect for patient self-determination requires making space for this moral pluralism in end-of-life decision-making.^25,26 Determinations of potentially inappropriate treatments are inherently subjective, shaped by clinicians’ experience, interpretation of available data, and their own values, biases, and understanding of professional obligations.

Decisions in this context are often emotionally charged, characterized by prognostic uncertainty, and reliant on surrogate decision-making. This can make eliciting patient-centered goals and values difficult, underscoring the value of early advance care planning. Conflict commonly arises when clinicians conclude that ongoing support no longer serves the patient's best interest, and families disagree, as illustrated by the case of Mr Jones. In these situations, clinicians should remain curious about the sources of disagreement, which may include deeply held religious or moral commitments, anticipatory grief, differing interpretations of suffering, or difficulty with limiting treatments that feel to families like hastening the patient's death. Many clinicians spend considerable time and energy focusing on the medical facts of the case and information sharing with families when instead a focus on trust, listening, and emotional support for surrogates may help resolve conflicts.²⁷

When disagreement persists despite good-faith communication efforts, clinicians should follow a structured conflict-resolution pathway rather than relying on ad hoc bedside decisions. Professional society guidance recommends first pursuing shared decision-making, including repeated exploration of the patient's values and goals, while providing clear clinical recommendations. When conflict remains unresolved, early involvement of palliative care and clinical ethics consultation can help clarify the sources of disagreement, improve communication, and ensure that both patient values and professional obligations are appropriately considered. In rare cases of intractable conflict, hospitals should have transparent policies that outline a formal review process, which may include multidisciplinary review, ethics committee involvement, administrative oversight, opportunities for transfer of care, and, where permitted by local law and policy, mechanisms for limiting treatments deemed potentially inappropriate. Such processes promote consistency, procedural fairness, and institutional accountability while helping to preserve trust between families and clinicians.¹⁵

Case 2 Conclusion: Recognizing the anticipatory grief and emotional burdens experienced by Mrs. Jones, the ICU team works to build trust and provide support. The focus of the next family meeting is less about how poorly Mr Jones is doing and instead about who he is as a person and what was important to him before his hospitalization. After a few days of conversations with the medical team, the palliative care team, social work, and chaplaincy, Mrs. Jones is able to accept that her husband won’t ever be able to hike or bike again, which she knows would be unacceptable to him. With the extra time, they have been able to gather family at the bedside to be with him as he dies peacefully in the hospital after withdrawal of ECMO.

Section 3: Ethical Challenges with Patients who may Become Organ Donors

Case: Mrs. Byers is a 41-year-old woman with severe anoxic brain injury who is admitted to the ICU following cardiac arrest. After several days without neurologic improvement, withdrawal of life-sustaining treatment is discussed with the family. Once the family agrees to a comfort-focused approach, the patient is identified as a registered organ donor and the organ procurement organization (OPO) is notified. During subsequent discussions about donation, including the potential use of normothermic regional perfusion (NRP) to optimize organ viability, some team members express discomfort, worrying that donation-related considerations may be influencing the overall approach to end-of-life care.

Ethical Tensions in Managing Critically Ill Patients who are Potential Organ Donors

Clinicians frequently encounter ethical tensions when caring for potential organ donors.²⁸

One significant challenge involves the ways in which organ donation potential may influence end-of-life care practices that are often guided by institutional policy and clinical guidelines.²⁹ For example, potential donors sometimes experience faster palliative extubation timelines. Although such practices may improve organ viability, they risk introducing conflicts of interest if donation-related considerations influence the timing or manner of WLST.^30,31

To safeguard against this any deviation from standard end-of-life care must be justified as promoting the patient's comfort and goals, not for organ optimization.³² Transparency plays a central role in preventing conflicts of interest. Families should be fully informed when proposed interventions, such as pre-mortem heparin administration or transferring the patient to an operating room prior to death, serve only the purpose of organ preservation.³²

Role separation can help mitigate ethical tensions. Best practice is to ensure that the ICU team leads discussions around prognosis and WLST and do not introduce organ donation potential. Organ procurement personnel become involved only after an independent decision to withdraw life-sustaining therapy has been made or after a patient has been declared dead by neurologic criteria.²⁸ This sequencing aims to prevent even the perception that the decision to withdraw treatment was influenced by potential for organ donation.

Finally, we recognize that systemic pressures can influence individual clinicians and OPO personnel. Hospitals face public reporting metrics, OPOs face federal expectations for donor yield, and transplant programs deal with chronic organ shortages, each creating incentives that may subtly shift focus away from the individual patient.²⁸ The duties of beneficence and respect for persons insist that such pressures should never shape the care of a dying patient. Furthermore, the Dead Donor Rule, which requires that organ recovery never cause or hasten death, remains foundational and must guide all practices.³¹ Ultimately, ethical care for potential donors such as Mrs. Byers, requires that clinicians maintain a strict patient-centered stance, ensure transparent communication, clearly separate roles, and remain vigilant against the influence of systemic pressures. Upholding these principles preserves both the dignity of the potential donor and the public's trust in the donation and transplant enterprise.²⁷

Novel Methods of Organ Recovery: Ethical Issues with Normothermic Regional Perfusion (NRP)

Normothermic regional perfusion (NRP) represents an emerging practice that blurs the boundary between end-of-life care and organ recovery, making it ethically salient for intensivists involved in donor management.³³ In NRP, after a patient dies by circulatory criteria, surgeons establish extracorporeal circulation to reperfuse the donor's organs with warm, oxygenated blood. Abdominal NRP (A-NRP) limits this circulation to organs below the diaphragm (eg liver, kidneys), whereas thoraco-abdominal NRP (TA-NRP) also re-establishes perfusion to the heart and the lungs.³⁴

Under U.S. law, death can be declared after irreversible cessation of circulatory function. Critics argue that NRP undermines the “irreversibility” of death; the donor's circulation is deliberately restarted, which invalidates a death declaration.³⁵ In essence, if the heart and organs are resuscitated (even regionally), is the patient truly dead when organs are taken? Opponents contend that TA-NRP violates the spirit, if not the letter, of the dead donor rule, which prohibits causing a donor's death or procuring organs before death.³⁶ Both abdominal and thoracoabdominal NRP require measures to prevent cerebral reperfusion after death determination. In A-NRP this is typically achieved by occluding the thoracic aorta above the diaphragm, whereas TA-NRP generally requires ligation or clamping of the aortic arch vessels before regional circulation is restored.³⁷

On the other hand, proponents of NRP emphasize that the donor is legally declared dead before any perfusion is initiated, and that standard DCD criteria, including a 2-5 min “no-touch” period to rule out auto-resuscitation, are rigorously respected.³⁴ In their view, TA-NRP simply represents an innovative post-mortem intervention, akin to conventional organ preservation techniques, albeit internally applied.

To proceed responsibly, the donation and transplant community must forge consensus on standards that uphold the dead donor rule, or if those standards were ever reconsidered, doing so openly and with broad societal engagement. Rigorous adherence to protocols, full disclosure and informed consent for patients and families, and ongoing ethical review will be essential to integrate NRP without compromising foundational ethical principles and public trust.³⁸

Case 3 Conclusion: The ICU team focused on supporting the family through end-of-life decision-making and ensuring that the decision to withdraw life-sustaining treatment remained grounded in the patient's values. After this decision was made, the OPO engaged the family in discussions about organ donation, including transparent disclosure of procedures such as NRP and their purpose. Clear role separation and open communication helped the family understand the distinction between end-of-life care and organ preservation, allowing them to make an informed decision aligned with the patient's wishes.

Section 4: Managing Disagreements and Conflicts in Transplant Critical Care

Case: Ms. Roberts is a 67-year-old woman with decompensated cirrhosis who is admitted to the transplant ICU with refractory septic shock and multiorgan failure. She is no longer eligible for liver transplantation. Despite maximal support, her prognosis is poor. During family meetings, clinicians describe the severity of her illness and ask the patient's daughter whether she would want to continue dialysis and further escalation of life-sustaining treatment. Her daughter responds tearfully, “I just want to make sure everything is done,” later expressing distress about being asked to decide when to stop treatments.

Ethical Conflicts and Communication in the ICU

Up to 63% of ICU cases have perceived conflict by either the physician or surrogate decision maker, largely stemming from miscommunication or misperceptions.³⁹ Conversations in the ICU about the end-of-life can be especially challenging and time consuming.⁴⁰ When these conflicts are managed effectively, they can improve psychological outcomes for surrogates, raise morale of staff, and help collaboration between all parties to understand each other's perspectives.⁴¹

Working with Surrogate Decision-Makers

Clinicians have an ethical responsibility to help surrogates ground decisions in substituted judgment (ie asking what the patient would want if able to speak for themselves). When patient preferences are unknown or unclear, surrogates are asked to consider the patient's best interests. Although the best-interest standard is commonly used in these situations, it provides limited guidance in the ICU, where clinical uncertainty and differing views of acceptable quality of life complicate assessments of benefit and burden. Attention to the emotional needs of surrogates and support in navigating moral responsibility are equally important.

Breaking Bad News

Having goals of care (GOC) conversations with surrogate decision makers involves assessing decision-maker perception of the situation, asking permission to provide information, and sharing the patient's clinical status . Breaking bad news is often best delivered in a “headline” format, concise, clear, and focused on the salient medical information. When speaking to Ms. Roberts’ family, a potentially good headline could be: “Unfortunately, despite all the things we have tried to help Ms. Robert, her organs are not working and she is no longer able to get a transplant. We believe she is dying and that her time is short no matter what we do.” Expecting emotion, responding to that emotion with empathy, and allowing time for surrogates to process the information is crucial.

Time-Limited Trials

Uncertainty about prognosis frequently complicates decisions regarding high-intensity interventions such as dialysis or ECMO. In these settings, a time-limited trial (TLT) framework can help clinicians assess treatment utility while also preparing for potential de-escalation of care.^40,42 A TLT includes creating a collaborative plan between critical care clinicians, patients, and/or surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to the therapy determines next steps. Next steps may include lengthening the critical care trial, advancing to a recovery route, or transitioning to a comfort-focused approach.

For Ms. Roberts, a TLT could involve continuing vasopressors for 72 h with explicit markers of improvement, such as improved laboratory values or greater clinical responsiveness, followed by reassessment and based on her clinical status a new plan. TLTs have been shown to improve the quality of family meetings and reduce the intensity and duration of aggressive ICU care at the end of life.^40,42-44

Responding to Requests to “Do Everything”

Even after a patient shows only a modest response to a time-limited trial of critical care, families may request that clinicians “do everything,” a statement that frequently reflects uncertainty or distress rather than an informed desire for ongoing life-prolonging treatment. It is important to explore what “everything” means and assess what values are behind that statement.^45-47

Case 4 Conclusion: The ICU team explored with Ms. Roberts’ daughter Rhonda, what she means by “do everything.” With support from the palliative care team, conversations were reframed to focus on Ms. Roberts’ values and acceptable quality of life, while also addressing Rhonda's emotional distress and need for guidance. An ethics consultation helped clarify the goals of treatment and supported a shared understanding of medically appropriate options. She was able to share that she had seen her mother open her eyes and if the patient could get to the point of interacting with her in any way, she would want to continue all interventions. It was collaboratively decided to continue interventions for one week to see if Ms. Roberts showed any meaningful neurologic recovery (eg purposeful movements or following commands), otherwise Rhonda would consider shifting to comfort focused care.

The Role of Palliative Care Consultation

Palliative care can serve as a liaison between teams and assist with care coordination among multiple consultants in these difficult cases. Palliative care consultation can be described to surrogates as an extra layer of care that focuses on providing relief and improving quality of life for those dealing with a serious illness.⁴⁸ In general, clinicians should consider a specialty palliative care consultation when expert communication is needed, difficult symptoms (ie dyspnea, intractable pain, anxiety) need to be managed, or when there are complicated care transitions at the end of life.

Despite advanced illness and significant symptom burden, patients on the donation-transplant continuum are less likely to receive palliative care consultation early in their disease trajectory, leading to delayed discussions about end of life preferences and more aggressive medical care at the end-of-life.^49-52 Palliative care consultation has been shown to be helpful to improve patient and family centered care and to result in earlier consensus around goals.^44,53-57

The Role of Clinical Ethics Consultation (CEC)

Clinical ethics consultation (CEC) aims to assist patients, families, and clinicians in navigating ethically complex healthcare decisions. Most US hospital systems now have access to a dedicated ethics committee or ethics consultants, many of whom have specialized training in bioethics.⁵⁸ Schneiderman et al found that formal ethics consultation in ICUs significantly reduced non-beneficial life-sustaining treatment and decreased ICU length of stay by approximately five days without increasing mortality.⁵⁹ A systematic review found similar results, showing that ethics consultation improved communication, facilitated consensus, and reduced conflict.⁶⁰

Beyond individual cases, ethics consultation plays an important role in addressing broader institutional and policy-level issues, including policy and process around novel technologies, institutional guidelines regarding non-beneficial treatment, clinical candidacy for advanced therapies, and ICU triage policies. Embedding ethics rounds and unit-based education can increase early recognition of ethics issues and improve integration of ethics with clinical services.⁶⁰

Conclusion

Across the donation-transplant continuum, intensivists must navigate tensions between individual patient-centered care and broader obligations of stewardship and justice. As much as possible, clinicians’ decisions should be guided by clear, transparent and publicly developed guidelines. The increasing use of MCS technologies has expanded therapeutic possibilities while also increasing the frequency of prolonged, high-burden care when recovery is no longer feasible. Similarly, the management of potential organ donors and practices such as NRP introduce ethical complexity.

A central lesson across these scenarios is that ethical conflict in transplant critical care is less about balancing competing ethical principles than about how uncertainty, responsibility, and moral burden are communicated and shared between clinicians and families. Intensivists therefore have an ethical obligation not only to respect patient and family values, but also to provide clear, values-based recommendations grounded in clinical realities.

Effective communication, integration of time-limited trials, and early, iterative goals-of-care discussions are thus core competencies in transplant critical care. Palliative care and clinical ethics consultation play essential roles in supporting these processes, helping to clarify values, reducing non-beneficial treatment, and facilitating consensus when disagreements arise. At the institutional level, ethics expertise is equally critical for developing policies around candidacy, mechanical support, donor management, and emerging technologies, ensuring that systemic ethical pressures are addressed proactively rather than at the bedside alone.

Footnotes

ORCID iDs

Krishna A. Chokshi

Antoinette R. Esce

Ankita Mehta

Robert M. Arnold

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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