23. CASE: Reaching the Limits

Mr. Stanley, a divorced 55-year old journalist with a history of epilepsy, was admitted to the medical ICU after an unwitnessed (presumably prolonged) episode of status epilepticus at home. Investigations, including an MRI study, revealed that he had sustained watershed cortical infarcts and a diagnosis of severe anoxic encephalopathy was made.

Mr. Stanley did not regain consciousness during the first three weeks of his ICU admission. Although formal criteria for brain death were not met, the attending critical care specialist, Dr. Hamilton, was of the opinion that Mr. Stanley would not regain sufficient functional status to allow him to meaningfully communicate with others and to live outside of an extended care facility. A consultant neurologist agreed with Dr. Hamilton’s opinion. The unit’s transplant coordinator was aware of Mr. Stanley’s clinical circumstances and had a brief hallway chat with Dr. Hamilton.

After a long discussion with Dr. Hamilton, two of Mr. Stanley’s three adult sons, both of whom were living in the area, made the difficult decision to withdraw their father’s life support. The youngest brother, who was angry with his father about his parents’ divorce, was living in the UK and had not been in contact with Mr. Stanley during the past two years. Speaking to his brothers over the telephone, he strongly objected to the withdrawal of his father’s life-sustaining treatment. He informed them that he had heard of miraculous recoveries in similar circumstances.

A telephone call to the provincial organ donation registry revealed that Mr. Stanley had not indicated “yes” on his MSI card donor certificate. However, one of his Halifax-based sons recalled a brief discussion in which his father had stated that he wished to donate his organs after death.

The transplant coordinator had a prolonged, sit-down discussion with the two locally-based sons. They decided to provide consent for DCD – organ donation after cardiac death. In the day and a half prior to the scheduled discontinuation of mechanical ventilation, several tests were performed to assess the viability of Mr. Stanley’s organs. In addition, two intravenous medications were administered to ensure the continued viability of his organs until the organ donation/ transplantation procedure could take place.

Mr. Stanley’s youngest son arrived on the scene and witnessed the performance of these tests and interventions. He asked Dr. Hamilton to explain why these were being performed and requested a detailed description of the DCD process. He became very upset and left the unit to seek the advice of a lawyer.

The next morning, Mr. Stanley was removed from life support in the ICU with the two locally-based sons present. His heart stopped thirty-five minutes later. Five minutes after this, he was quickly transferred to a nearby surgical unit where his organs were surgically procured for transplantation to a number of waiting hospital patients in end-organ failure.

  • How would you feel about these circumstances as a health care provider assigned to Mr. Stanley’s care?
  • What are some of the relevant ethics issues?
  • Does the practice of DCD challenge our usual understandings of death and/or informed consent/ choice?
  • Do you think the right decision was made?

 

Some Values and Ethics Issues to Consider

  • Informed consent
  • Personal directives and advance care planning
  • Patient-family relationships
  • Respect for patient autonomy
  • Substitute decision-making
  • Moral distress among health care providers
  • End-of-life decision-making
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