Organ and tissue donation in patients considering MAiD: new guidance helps navigate emerging area

A new publication in CMAJ (Canadian Medical Association Journal) aims to help health care teams navigate clinical and ethical issues that arise when patients choose to donate organs or tissue after medical assistance in dying (MAiD) or withdrawal of life-sustaining measures.

Deceased organ donation is a common practice that saves or improves lives worldwide, and accounts for more than 3 in 4 of all transplanted organs in almost 2000 Canadians every year.

"The ability of donors to give first-person consent for both MAiD or withdrawal of life-sustaining measures and organ donation creates emotional and moral challenges for health care professionals, and raises unprecedented ethical and practical challenges for patients, families, health care professionals and their institutions, as well as society," says lead author Dr. James Downar, a palliative care and critical care physician at the University of Ottawa.

Responding to requests from patients across Canada, Canadian Blood Services, along with the Canadian Critical Care Society, the Canadian Society of Transplantation and the Canadian Association of Critical Care Nurses, worked with medical, legal and ethics experts to develop recommendations for policy makers to support organ and tissue donation in patients who choose medical assistance in dying or withdrawal of life-sustaining measures. Patient partners brought valuable insight and unique perspectives in helping shape this work.

Key recommendations:

• Protection for patients—the decision whether to have medical assistance in dying or withdrawal of life-sustaining measures must occur before any discussion of organ donation. This mitigates the risk that the desire to donate organs would influence the type of end-of-life care that the patient requests.
• Choice—medically suitable, conscious, competent patients who provide first-person consent to end-of-life procedures should be given the opportunity to donate organs and tissues.
• Consent—the patient must be able to provide first-person consent and be able to withdraw consent for MAiD or donation at any time.
• Donor testing—physicians, transplant teams and other staff should try to minimize the impact and disruption of donating, such as testing, for the patient.
• Determination of death—the "dead donor rule" must be respected, meaning vital organs can only be removed from deceased donors after determination of death according to accepted criteria.
• Conscientious objection—health care professionals may choose not to participate in MAiD or withdrawal of life-sustaining measures, but they should work to support the patient's wishes to donate.

To help health care teams, the publication includes an easy-to-reference table with the complete recommendations.

"We hope this policy guidance and its recommendations will be essential tools for health care teams so they can ensure quality end-of-life care for patients, navigate medical, legal and ethical concerns, and honour the patient's wish to become an organ donor," says Dr. Downar.

"[T]he explicit focus must be on the patient undergoing MAiD. To preserve the confidence of the public, policies must clearly centre on protecting the patient who has chosen MAiD," writes Dr. Johannes Mulder, affiliated with the Dutch Family Doctors Association and the Dutch working group for the Guideline Organ Donation after Euthanasia, Zwolle Overijssel, the Netherlands, in a related commentary.

"The linked guidance for policy represents an important step toward creating a Canadian guideline to support health care workers for the benefit of the patient who chooses organ donation after MAiD," he concludes.