Physician-Assisted Death, Organ Donation after Cardiac Death, and the ICU

(what’s the big deal?)

James Downar, MDCM, MHSc (Bioethics), FRCPCCritical Care and Palliative Care, UHN

Assistant Professor, Department of Medicine, University of Toronto

Disclaimers

• I have an opinion about PAD and DCD• (we all do)

• Former co-chair of Physicians’ Advisory Committee of Dying with Dignity

• PAD = Physician-Assisted Death•Physician-Assisted Suicide

•Euthanasia

Objectives

• Appreciate the ethical issues around PAD and organ donation

• Review the (limited) experience with PAD in organ donation and the ICU

• Refocus conscientious objection towards ensuring the right of access

Take a deep breath…

Donation afterCardiac Death

Physician-Assisted Death

How often will this come up?

Cause of Death Netherlands Belgium US

Cancer 79% 80% 80%

CV 4% 4% 3%

Respiratory - 5% 4%

CNS - 7% 8%

Other 16% 4% 5%

Annual Cases 3800 2800 100

Onwuteaka-Philipsen et al. Lancet 2012; 380: 908–15.Chambaere et al. CMAJ 2010;182:895-901.Loggers et al. NEJM 2013;368:1417-24.

How often will this come up?Cause of

death2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Accident 475 423 471 459 385 417 385 388 352 385

Natural 1389 1536 1612 1480 1621 1704 1742 1649 1546 1572

Suicide 59 42 29 47 43 46 50 53 53 63

Other 22 20 27 17 25 20 13 16 24 21

Total 1945 2021 2139 2003 2074 2187 2190 2106 1975 2041

www.eurotransplant.org

• Belgium accounts for ~14% of ET organs

Case Series

• 2009 - 4 patients•2 liver, kidneys, pancreas only

•2 LKP plus lungs

• 2011 – 4/17 DCD Lung procurement•Warm ischemic time ~50 min to ~60 min

•1 died in ICU of “valve condition”, 3 discharged

• ISHLT Lung Registry 2003-2013•4298 transplants, 306 DCD

•4 donations following euthanasia

Ysebaert et al. Trans Proc, 41, 585–586 (2009)Van Raemdonck et al. App Cardiopulm Path 15: 38-48, 2011.Cypel et al. JHLT 2015;34:1278-82.

Ethical Concerns

Ethical Issues – PAD and DCD

• PAD and DCD are controversial to some

– Need to quantity and quality

– Respect donor autonomy

• Additive concerns of PAD + DCD

– Incentive for organ procurement teams

– Motivation of donor to request PAD

– Acceptability of PAD to recipient

– Venue for PAD- ICU? OR? PACU?

Eurotransplant Policy

• Euthanasia must be legal in donor country• Euthanasia and organ retrieval should be kept

as separate as possible• Allocation should follow the NHBD allocation

rules in the donor resp. recipient country.• Organs shall only be allocated to countries

that accept the transplantation of this type of donor organ.

• DCD Classification Category V (Euthanasia) added in 2012

Eurotransplant Annual Report 2008Evrard et al. J Trans Proc 2014;46, 3138-3142

What about PAD in the ICU?

• Carter vs. Canada AG (SCC 2015)

– Competent adult who:

•Clearly consents to the termination of life

•Grievous and irremediable medical condition (including an illness, disease or disability)

•Enduring suffering that is intolerable to the individual in the circumstances of his or her condition.

• Multiple requests separated by time

• Stable, not dependent on life-support

PAD in the ICU

• Survey of US ICU RNs (1996)•16% admitted to euthanasia at family’s request

•4% reported pretending to provide LST that had been ordered

• ETHICUS (2003)•94/4248 (2%) deaths – “Shortening of dying process”

•Mostly at one centre

•Opioids - Morphine 13mg/h (5-200mg)

•Benzodiazepines - Diazepam 13 mg/h (20-200mg)

•Barbiturates 6/94, NMBs 4/94

Asch D. NEJM 1996;334:1374-9.Sprung et al. JAMA 2003;290:790-7.

What is our intention?

• Survey of European ICU MDs (2006)•66% have explicit intention of shortening life

during WDLS

• Review of “life-ending acts without explicit consent”

Bosshard et al. Wien Klin Wochenschr 2006;118: 322–6. Chambaere et al. CMAJ Open 2014.

Term used to describe act N (%) n=66

Symptom treatment 13 (20%)

Palliative Sedation 45 (68%)

Compassionate Life-ending 4 (6%)

Euthanasia 0

Other 4 (6%)

• There is no clear ethical distinction between withholding/ withdrawing supportive therapy and increasing doses of sedative/opioid substances in patients in whom further treatment is no longer considered beneficial.

• The plans for end-of-life care in each individual patient should be discussed with and understood by the relatives…. However, it must be made clear that the final decision is made by the care team and not by the relatives.

Vincent et al. J Crit Care 2014;29:174-5.

• Shortening the dying process with use of medication, such as analgesics/sedatives, may sometimes be appropriate, even in the absence of discomfort, and can actually improve the quality of dying.

• Through the entire process, the intention must not be interpreted as killing but as a humane act to accompany the patient at the end of his/her life.

Vincent et al. J Crit Care 2014;29:174-5.

• …there is a moral obligation to anticipate on distressing symptoms for comfort during the dying process, but there is no moral obligation to hasten it.

• Increasing the doses of analogo-sedation to shorten the dying process, especially when the patient is already comfortable, should not have a place in end-of-life care on the ICU.

Kompanje et al. J Crit Care 2014;29:455-6.

Bottom Line – PAD in ICU

• Hard to envisage a “Carter-eligible” patient spending any time in the ICU

• Cultural issues important

– Non-voluntary euthanasia

• ICU staff performing PAD for conscientious objectors?

Conscientious Objection

Reasonable Accommodation

• Physician Autonomy Wins

Patients only get what I think is “moral”

• Patient Autonomy Wins

All physicians must provide everything

• Finding middle ground- Pluralistic society

Reasonable Accommodation

• Minimal impingement on others’ rightsNo “right” to zero discomfort

• Pts accommodate MD right to object

Delay, inconvenience, suffering

• MDs accommodate Pts desire for PAD

Referral to other MD, agency?

Reasonable Accommodation• Institutional Conscientious Objection

– Moral Pain?– Why would we need it?– Who decides the morals of a public hospital?

• Obligations to the patient– Shared between practitioner and institution– Minimal impingement– Cannot be defined by a single action

• Illness, Social function, Technical facility, Geography

After Carter: Physician Assisted Death in Canada Joint Centre for Bioethics Task Force Report, October 2015

Reasonable Accommodation

•Self referral?

– What would you reasonably expect a terminally-ill, suffering, bedbound patient to do without assistance?

“I'm not afraid to die, I just don't want to be there when it happens.”

Objectives

• Appreciate the ethical issues around PAD and organ donation

• Review the (limited) experience with PAD in organ donation and the ICU

• Refocus conscientious objection towards ensuring the right of access

The Data: What is the effect on…

• …vulnerable populations?

• …non-voluntary ending of life?

• …Palliative Care?

Can we protect the vulnerable?

Characteristic Washington Oregon

Number 255 935

Age 85+ 15% 11.9%

White 95.2% 97.6%

High school graduate 94.1% 93.2%

No health insurance 2.7% 1.7%

EOL concerns

Loss of autonomy 90.6% 90.9%

Inability to engage in enjoyable activities 88.6% 88.3%

Burden on family 38.6% 36.1%

Financial implications of treatment 4% 2.5%

Loggers et al. NEJM 2013;368:1417-24.

Can we protect the vulnerable?

• Demographics of Swiss receiving Assisted Death

– Higher income

– Higher education

– Non-institutionalized

Characteristic Logistic Regression Odds Ratio (Age 65-94)

Education

Compulsory 1

Secondary 1.74

Postsecondary 2.71

Type of Household

2+ People 1

1 Person 1.44

Institutionalized 0.84

Socioeconomic Position

Lowest Quartile 1

Second Quartile 1.36

Third Quartile 1.90

Highest Quartile 2.68

Steck et al. Int J Epidemiole-published Feb 18, 2014

Non-voluntary ending of life

• Assisted Death in the Netherlands

End of Life Decision-Making. Royal Society of Canada, 2011.Onwuteaka et al. Lancet 2012;380:908-15.

1990 1995 2001 2005 2010

VoluntaryEuthanasia

1.7% 2.4% 2.6% 1.7% 2.8%

Assisted Suicide 0.2% 0.2% 0.2% 0.1% 0.1%

Life-terminatingacts without explicit request (LAWER)

0.8% 0.7% 0.7% 0.4% 0.2%

Total 2.7% 3.3% 3.5% 2.2% 3.1%

Does prohibition of PAD prevent LAWER?

Van der Heide et al. Lancet 2003;362:345-50.Mitchell and Owens. N Z Med J 2004;117:U934.Douglas et al. Med J Aust 2001;175:511-5.

• Visibility is a better safeguard than criminalizationCountry LAWER Assisted Death

Australia 3.5%

Belgium (pre-legal) 3.2%

New Zealand 2.7%

Belgium (post-legal) 1.7%

Denmark 0.67% 1.82%

Switzerland 0.42%

Netherlands 0.4%

Sweden 0.23% 0.23%

Italy 0.06% 0.1%

Does PAD replace PC?Cause of Death

2001 2005 2010

Cancer 7.4% 5.1% 7.6%

CV Disease 0.4% 0.3% 0.5%

Other 1.2% 0.4% 1.1%

TOTAL 2.8% 1.8% 3.0%

Cause of Death

2001 2005 2010

Cancer 33.4% 37.1% 47.7%

CV Disease 11.1% 14.3% 21.5%

Other 17.1% 24.1% 36.0%

TOTAL 20.1% 24.7% 36.4%

Physician Assisted Death

“Intensified Alleviation of Symptoms”

(Netherlands)Onwuteaka et al. Lancet 2012;380:908-15.

16%

0.2 %

Does PAD replace PC?EOL Practice 1998 2001 2007 2013

“Palliative Care” 34.8% 44.8% 58.6% 53.2%

“Intensified Alleviation of Symp.” 18.4% 22.0% 26.7% 24.2%

WHLS/WDLS 16.4% 14.6% 17.4% 17.2%

Continuous Deep Sedation -- 8.2% 14.5% 12.0%

Physician Assisted Death 4.4% 1.8% 3.8% 6.3%

Euthanasia 1.1% 0.3% 1.9% 4.6%

Assisted Suicide 0.12% 0.01% 0.07% 0.05%

LAWER 3.2% 1.5% 1.8% 1.7%

Chambaere et al. NEJM 2015;372:1179-81.

19%

1.9%

Effect of PAD on EOL Care

Economist Intelligence Unit, 2010

Effect of PAD on EOL Care

• Availability of PC in US hospitals

1. Vermont (100%) - A

2. District of Columbia (100%) - A

3. Nebraska (93%) - A

4. Maryland (90%) - A

5. Minnesota (89%) - A

6. Oregon (88%) - A

7. Rhode Island (88%) - A

8. Washington (83%) - A

9. South Dakota (78%) - B

10. Virginia (78%) - B

http://www.capc.org/reportcard/topten

Slippery Slopes

• NOT slippery slopes• Increases in legal use of PAD

•Democratic changes in PAD laws

• A slope is defined by 2 points•What was the baseline incidence?

•What happens where PAD is illegal?

Hippocratic Oath

• Original Hippocratic Oath…• …swears by the original Greek gods

• …bans giving a “deadly drug”

• …bans giving women “an abortive remedy”

• …suggests that only males be taught medicine.

• Tradition, modified to reflect modern beliefs

• CMA Code of ethics revised 19 times since 1868

http://en.wikipedia.org/wiki/File:HippocraticOath.jpg

http://en.wikipedia.org/w/index.php?title=Hippocratic_Oath&oldid=591885698