Refusing Organ Donation

Organ Donation - In the BMJ this week Dr Shaw writes an article which I have no doubt will stir up some debate. He tackles the complex ethical issues of organ donation and particularly the situation when a family choose to over-rule a deceased patient's decision to donate their organs. Veto by the family is the main impediment to an increase in organ donation in this country and at least 10% of families refuse to allow organ donation in cases where the deceased has expressed an intention to donate their organs, eg. by carrying an organ donor card. 

While the family's wishes are respected in these situations, legally they have no grounds to over-ride the dead person's wishes. Clearly the stress and emotion of the situation affects the decision, but families often regret the decision not to allow the donation within two days. Dr Shaw argues that doctors who allow this to happen are not doing their jobs properly(!). The doctor's concerns about causing more distress to the family by pressing the issue may cause greater consequences in the long run if up to seven more lives are not saved due to the failed organ donation. Of course the family cannot be blamed for refusing to allow donation under such an awful situation, but the same cannot be said of the doctor. Ethically this is difficult because we have to consider the patient who has died, their family and the patients on the organ donor list who could die without a donation. As doctors we have a duty to promote the health of the public, and that includes patients on the organ donor register. However it must be an extremely difficult conversation to have with a family to persist in recommending that they allow the organs to be donated against their wishes. If the family have no legal grounds for over-ruling the patient's wishes, and there is evidence to show that those refusing donation later regret their decisions, perhaps we should be looking at whether families should play a part at-all in this complex end-of-life decision making. Although on the other hand, taking away the families' input into this process would seem harmful to the relationship between the public and the profession which would likely be a bad thing. In summary I think that although there is no easy answer, there is ample material for debate.

Implementing a National Early Warning Score - In order to help identify patients early who become acutely unwell in a hospital ward, the Royal Collect of Physicians has now introduced a national early warning score. The idea of this tool is that patients at risk are identified early through monitoring of basic clinical observations such as pulse rate and respiratory rate. Having a national early warning score system allows an adequate standard of care to be delivered to all patients, regardless of their geographical location. The hospital I work in now has an "Emergency Response Team" which can be called to patients who nurses or doctors feel may be deteriorating. The effect of this identification process has also been called "critical care outreach". This is the idea that a critical care department may help with deteriorating patients in the ward environment. Having just moved to work in a new hospital, I feel that standardising the approach to the acutely unwell patient is an important idea, which could ultimately mean that there is a common method for describing and acting on unwell patients throughout the UK.