We had no choice but to disappoint him.

March 22, 2015 9:14 AM

As doctors, we are taught to do no harm. It may be time to redefine what we really mean by harm. Two surgeons from the University of Wisconsin’s transplant program explore whether we should allow terminal patients to donate their organs.
posted by k8lin (15 comments total)

Although his muscles had failed him, his brain was entirely intact. He knew that he would never get off a ventilator, and he also knew that his organs could allow several other people to go on living. He wrote out goodbyes to his wife and children, they hugged him, and then, with his family surrounding him, his doctors removed his breathing tube. Once he had taken his last, labored breath, our team rushed him into the operating room. We were just in time to recover his kidneys and liver. In the midst of their heartbreak, his family was able to find some comfort in the idea that their husband and father had died heroically, saving three people’s lives.

That is...an astonishing testament to humanity. Thanks for posting this.
posted by Johnny Wallflower at 9:26 AM on March 22, 2015 [8 favorites]

I will never understand what kind of society would condemn this man to a slow, agonizing, frightening, and pointless death. I hope like hell things are more humane when it comes my time to die.
posted by Horace Rumpole at 10:27 AM on March 22, 2015 [3 favorites]

Moreover, healthy people could incorporate this imminent-death standard into advance directives for their end-of-life care. They could determine the conditions under which they would want care withdrawn, and whether they were willing to have it withdrawn in an operating room, under anesthesia, with subsequent removal of their organs.

Personally, I think I'd be willing to include such a clause in my advance directive if I were reasonably sure it would be honored. I've already chosen to donate my organs, after all, and I'm not opposed to increasing the chances that such a donation would be effective.

That said, I think the authors' assertion that they can't imagine doctors ever pushing the limits and valuing the organs over the care of the patient currently in possession of them is optimistic at best, dangerously naive at worst. There will always need to be oversight.
posted by metaquarry at 10:35 AM on March 22, 2015 [9 favorites]

what kind of society would condemn this man to a slow, agonizing, frightening, and pointless death.

Let's not get carried away. Even the article makes the point that the rules exist for a lot of good reasons. You really don't want a shady organ transplant industry, right?

So this is about catching up with improved technology and capacity and ability, and tuning a system which exists for pretty good reasons, not about a horrible society that doesn't care about people. Kind of the opposite.
posted by freebird at 11:00 AM on March 22, 2015

You really don't want a shady organ transplant industry, right?
In a society where everything has a price, "a slow, agonizing, frightening, and pointless death" is the lesser of two evils? Yipes.

I saw this a couple days ago and it is TOTALLY related: A doctor discovers an important question patients should be asked. It speaks volumes about our "system of care" that this is not one of the first, most obvious questions to ask: “What are your goals for your care?” “How can I help you?”
posted by oneswellfoop at 11:10 AM on March 22, 2015 [16 favorites]

a slow, agonizing, frightening, and pointless death" is the lesser of two evils?

False dichotomy. Sometimes the world has changed, and the rules and systems put in place to help prevent bad things have to change with it. The former precedes the latter of necessity - this doesn't mean society is horrible or we have to choose between allowing everything and allowing nothing. It just means it can take a bit to catch up.

Why does it have to be society not caring or being horrible? Can't it just be that some regulations need updating in the presence of new technology?
posted by freebird at 11:18 AM on March 22, 2015 [2 favorites]

That said, I think the authors' assertion that they can't imagine doctors ever pushing the limits and valuing the organs over the care of the patient currently in possession of them is optimistic at best, dangerously naive at worst. There will always need to be oversight.

I agree -- if there was ever a slope made slippery by the blood of the powerless, this would seem to be it.
posted by jamjam at 11:59 AM on March 22, 2015 [2 favorites]

oneswellfoop: Atul Gawande's Being Mortal is an excellent read about those exact issues of working with the patient to determine their goals and other end-of-life issues.
posted by dr_dank at 12:12 PM on March 22, 2015 [1 favorite]

On the issue of WB representing a high risk to the transplant centre based on his likely outcomes skewing statistics against them, that would seem to be containable by getting a waiver from the accreditting agency. It's not hard to see the issue for the transplant centre, which suggests that it shouldn't be hard to get the accreditting agency to agree to exclude his outcome just to remove this particular roadblock. Down the road they could define a class of high-risk donors who are handled differently in evaluating a transplant centre.
posted by fatbird at 1:38 PM on March 22, 2015 [1 favorite]

they ought to make med students get that little essay tattooed on their body, fatbird
posted by thelonius at 5:38 PM on March 22, 2015

Fascinating about how donation doesn't work if you don't die just right- the article is a good reminder that it's not just as simple as getting "organ donor" printed on your driver's licence. And I love oneswellfoop's link about doctors asking "what are your goals for this care?"
posted by Secretariat at 6:23 PM on March 22, 2015 [1 favorite]

I think about organ donation a lot: death is easier to accept emotionally when there is concrete evidence that "you live on as long as someone remembers you." Knowledge that another person will survive because of organ donation is a very visible way of effecting that -- as long as the family has the strength to respect the wish of the donor.

At the end of the article the doctors admit that they may not be as courageous as the donor W.B., and I wonder what it would take to get them to try. Some sort of waiver from their accrediting body? An IRB approval? A mandate from NIH?One person dying young of ALS is a waste and a tragedy, but adding other lives to that tally is simply cruel.
posted by wenestvedt at 6:21 AM on March 23, 2015

That said, I think the authors' assertion that they can't imagine doctors ever pushing the limits and valuing the organs over the care of the patient currently in possession of them is optimistic at best, dangerously naive at worst. There will always need to be oversight.

I agree -- if there was ever a slope made slippery by the blood of the powerless, this would seem to be it.

Honestly, in the modern American medical system I think there is no single flat or sloped surface which is not already well-lubricated by the blood of the powerless. How many people on that organ transplant list have not had this resolution to their journey hastened because of financial considerations? How many are not on it at all because of lack of access, or because behaviors they lack the personal ability to cope with - say, addiction - preclude them from consideration?
posted by phearlez at 1:00 PM on March 23, 2015

This article was difficult for me to read.

When my mother died, there was about 24 hours where we kept her on life support while we waited to see if her residual brain activity would cease and make her eligible for organ donation. It did, but after turning her care over to the organ coordinators, it was determined that her organs were too damaged to be viable for transplanting.

I doubt that that 24 hour period made much of a difference on that front. But if there had been the option to move things faster and improve the chances of a better outcome, I think she would have wanted that.

If we had had to take her off life support without moving to evaluation for organ donation for the sake of some residual brainstem activity, that would have made a difficult period even harder.
posted by vibratory manner of working at 2:34 PM on March 23, 2015

...his doctors removed his breathing tube. Once he had taken his last, labored breath, our team rushed him into the operating room. We were just in time to recover his kidneys and liver.

If they agreed to let him die and save his organs for donation, why not skip the delay and just anesthetize him and save the organs while they're all still healthy and alive? Having to officially disconnect his life support, wait until death, and only then start surgery is unnecessarily maintaining the fiction of not killing people for their organs.

To be clear: I do believe that he had the right to make this agreement and that it's a good thing which ends up helping people. But pretending that "he chose to die, did so, and then we saved organs from his dead body" instead of admitting that "he chose to die, so we saved his organs in the process of killing him," ends up with fewer viable organs.
posted by Rangi at 5:16 PM on March 23, 2015 [1 favorite]