From the Massachusetts Nurse Newsletter
April 2011 Edition
Written by the members of the
MNA Center for Ethics and Human Rights
The Center for Ethics and Human Rights has researched and developed ethical guidelines to assist nurses in the care of transplant patients and their families, in response to inquiries to the MNA Board of Directors regarding the ethics involved in organ transplantation. This article addresses the chief moral concerns regarding the nursing care of patients involved in organ transplantation.
For nearly 60 years, the U.S. health care system has had the incredible ability to offer countless terminally and chronically ill/injured patients a precious gift: the gift of organ donation, the very gift of life.
Although once considered a rarity, the process of organ donation is now well established. According to the Organ Procurement and Transplantation Network, 14,141 organ transplants were performed in the U.S. in the first nine months of 2010. Another 108,000 candidates still wait.
The residents of Massachusetts are fortunate to have access to information provided by the New England Organ Bank, which collaborates with the health care facilities, organ donors, organ recipients and their families in the process of organ procurement.
Nursing’s chief moral concerns: three questions to ask
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Is the donor patient’s death being hastened?
The decision to withdraw life-sustaining treatment could be affected by the desire to make organs available and could interfere in various ways with responsible end of life decision making. In order for caretakers to avoid this conflict of interest, the Institute of Medicine (IOM) makes two recommendations:
- Decisions, actions and personnel involved in the withdrawal of treatment and declaration of death should be kept separate from the decisions, actions, and personnel involved in the recovery of organs.
- The decision to withdraw treatment should be made prior to any staff initiated discussion of organ and tissue donations.
- How well informed is the informed consent?
- A patient seeking a “good death” may, as a donor, receive a more technologically invasive death than the patient and family understand.
- It is obligatory to inform the patient how their care will change as a donor.
- Is the family able to be with the patient donor at the moment of death?
- Arrangements should be made to have treatment withdrawn in the ICU, with the family present, or in the operating room until the patient dies.
- The staff should try to create the most family-supportive environment possible during the final hours of a loved one’s life.
Guidelines for nurses who work in areas where organ donations occur
- The nurse’s first obligation is the well-being of the patient entrusted to our care.
- Provision 1 of the Code of Ethics for Nurses states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”
- In the case of the organ donor, the nurses have a duty to protect the patient’s dignity and make the patient’s comfort and well being their first priority.
- The act of procuring organs should never be the explicit cause of a person’s death.
- Provision 1.3 of the Code of Ethics states, “The nurse should provide interventions to relieve pain and other symptoms in the dying patient, even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patient’s life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations.”
- Bound by this moral rule, in organ donation defining death is morally essential. It is vitally important that nurses who serve the patient population who are potential donors are educated in the acceptable definitions of death.*
- Nurses understand the good of organ donation itself.
- Provision 1.4 of the Code of Ethics addresses the patient’s Right to Self Determination (Autonomy). “Patients have the moral and legal right to determine what will be done with their person; to be given accurate, complete and understandable information in a manner that facilitates an informed judgment.”
- A patient’s wish to be a donor gives people a novel way to die well by making their death a benefit to the living.
Definitions of death
Brain Death: Brain death refers to a person whose whole brain has died and who is thus declared dead within standards of medical practice. This definition has been widely criticized. The Institute of Medicine states that it seems to present an ambiguity between a “dead organism,” i.e., a person who is declared dead due to brain injury and a “dead organ,” i.e., the brain itself. IOM recommends the modified term “donation after neurological determination of death.”
Cardiac Death: Cardiac death is death due to the permanent and irreversible cessation of heart and lung function. IOM recommends “donation after cardiac determination of death.”
Summary
It is clear that organ transplantation is an integral part of modern medicine. Nurses must be aware of the moral challenges inherent in the care of transplant patients and their families. In addition to the Nurses’ Health Care Institution’s Policies and Procedures and Ethics Committees, the MNA Center for Ethics and Human Rights is available for consultation. For more information, visit www.massnurses.org.
References
Fowler, Marsha, Ed. Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MD. American Nurses Association, 2008.
Institute of Medicine. Non-Heart-Beating Organ Transplantation: Practice and Protocols. Washington, D.C. National Academy Press, 2000.
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