Dalle Ave Anne L, Shaw David M
1 Ethics Unit, University hospital of Lausanne, Lausanne, Switzerland.
2 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland.
J Intensive Care Med. 2017 Mar;32(3):179-186. doi: 10.1177/0885066615625628. Epub 2016 Jul 7.
Controlled donation after circulatory determination of death (cDCDD) concerns donation after withdrawal of life-sustaining therapy (W-LST). We examine the ethical issues raised by W-LST in the cDCDD context in the light of a review of cDCDD protocols and the ethical literature. Our analysis confirms that W-LST procedures vary considerably among cDCDD centers and that despite existing recommendations, the conflict of interest in the W-LST decision and process might be difficult to avoid, the process of W-LST might interfere with usual end-of-life care, and there is a risk of hastening death. In order to ensure that the practice of W-LST meets already well-established ethical recommendations, we suggest that W-LST should be managed in the ICU by an ICU physician who has been part of the W-LST decision. Recommending extubation for W-LST, when this is not necessarily the preferred procedure, is inconsistent with the recommendation to follow usual W-LST protocol. As the risk of conflicts of interest in the decision of W-LST and in the process of W-LST exists, this should be acknowledged and disclosed. Finally, when cDCDD programs interfere with W-LST and end-of-life care, this should be transparently disclosed to the family, and specific informed consent is necessary.
循环判定死亡后控制捐献（cDCDD）涉及撤除维持生命治疗（W-LST）后的捐献。我们根据对cDCDD方案和伦理文献的回顾，审视在cDCDD背景下W-LST引发的伦理问题。我们的分析证实，W-LST程序在不同的cDCDD中心差异很大，并且尽管有现有建议，但W-LST决策和过程中的利益冲突可能难以避免，W-LST过程可能会干扰常规的临终护理，而且存在加速死亡的风险。为确保W-LST的实施符合既定的伦理建议，我们建议W-LST应由参与W-LST决策的重症监护病房（ICU）医生在ICU中进行管理。在并非必然首选该程序时推荐为W-LST进行拔管，这与遵循常规W-LST方案的建议不一致。由于W-LST决策和过程中存在利益冲突风险，对此应予以承认并披露。最后，当cDCDD项目干扰W-LST和临终护理时，应向家属进行透明披露，且需要获得特定的知情同意。
