Organ procurement and futile medical care

As Robert Sibbald and colleagues pointed out in their recent CMAJ study,1 there has been no increase in the rates of documented discussions of resuscitation status or do-not-resuscitate orders for patients who want to forego resuscitation, and there has been no decrease in the number of attempted resuscitations at the time of death since the Patient Self Determination Act became effective in the United States.1 However, revisions in 2006 to the US Uniform Anatomical Gift Act have added new barriers to appropriate end-of-life care for terminally ill patients who are resuscitated without explicit consent or with advance documentation of do-not-resuscitate wishes.

The Uniform Anatomical Gift Act was revised to increase the procurement of organs for transplantation from terminally ill patients on life support.2 The revised sections 14(c) and 21(b) permit the continuation of all medical measures (including the use of life support) necessary to maintain organ viability until procurement personnel have determined whether the patient is suitable to be an organ donor.2 These revisions were introduced to override patients' advance directives that life support systems be withheld or withdrawn at the end of life. The revised Act has added new barriers to appropriate end-of-life care for terminally ill patients, who will now be resuscitated without their explicit consent or contrary to their do-not-resuscitate wishes documented in advance directives.2

The real impact of the revised Uniform Anatomical Gift Act on the quality of palliation and end-of-life care for terminally ill patients in US intensive care units and their families is still unknown.3 Health care providers have expressed concerns about the possibility of euthanasia for organ procurement after life support is withdrawn from dying patients.4 Nevertheless, the revisions to the Act have been enacted in over 20 US states and may exacerbate the current crisis in which scarce intensive care resources are being used ineffectively and medically futile care is being delivered at the end of life. These revisions will pose new challenges to the Congressional Budget Office when it addresses the rising costs of health care in the United States.5