In recognition of Organ and Tissue Donation Awareness Week, we interviewed Dr. Jennifer Hancock — a critical care physician and a donation physician for Nova Scotia’s organ donation organization, Legacy of Life — about medical assistance in dying and organ donation.
Please tell us a little about yourself and your medical practice
I am an adult intensivist - a physician working in critical care (ICU) - at the QEII Health Sciences Centre in Halifax, NS, and the provincial education lead and a donation physician for Nova Scotia’s organ donation organization, Legacy of Life.
How did you become involved in medical assistance in dying provisions?
Several years ago, we had a patient who wanted to explore the possibility of organ donation following her medical assistance in dying (MAID) provision, as an enduring act of kindness to help others live a healthier life. In my role as a donation physician, I helped facilitate her decision to become an organ donor after her MAID procedure.
MAID and organ donation are two very different and technical medical procedures. How often do they both come up in conversation with patients?
Both organ and tissue donation are an integral part of high-quality, end-of-life care and should be considered for every patient regardless of their cause of death.
Organ donation following MAID is still relatively new in Canada. Each province is still working through the best process to ensure all MAID patients are provided the opportunity to consider organ donation, should that align with their wishes. At present, I suspect the rates at which these conversations happen vary across Canada.
A potential concern with these two procedures is that a patient may choose to pursue MAID because of a desire to become an organ donor. To minimize this risk, it is important that the referral for organ donation assessment be made after the patient has been approved for medical assistance in dying.
What should a person consider if they think they want to pursue both MAID and organ donation?
It is important for a patient who is considering organ donation following their MAID procedure to consider how a donation may impact their final days. The organ donation organization team will provide specific information about what to expect in their province when discussing consent for donation.
To ensure the safe transplant of healthy organs and/or tissues, a potential donor will need to have a number of tests and investigations. While some procedures (like blood tests) may be able to occur at home, certain things (like x-rays and ultrasounds) will require a visit to the hospital. The patient must take this into consideration when providing their consent. The medical team should do everything possible to minimize the impact these investigations have on the patient. In addition, the choice of location for their MAID procedure will likely be limited to the hospital if they choose to become an organ donor.
It is also important for a MAID patient considering a donation to remember that their gift of kindness comes with offering the opportunity of donation. It is possible that through testing they may find that either their organs and/or tissues are not safe for transplantation or there may not be any recipients for their organs at that time.
Finally, it is important that the patient understand that they may withdraw consent for either MAID or donation at any time. If they withdraw consent for donation this does not affect their consent for or access to their MAID procedure.
Can you tell us about the measures that need to be in place for organ donation after a MAID provision?
As you have already mentioned, organ donation and medical assistance in dying are two separate processes, each with its own policies and procedures to ensure the safety and protection of patients. It is important that all of the ethical principles and policies for both procedures are followed. I have touched on several of them.
For example, it is essential that a patient is first approved for their MAID procedure prior to any investigations into the safety of their organs and/or tissues for donation. Once approved for MAID, the patient’s MAID provider, their primary care physician, and the organ donation organization must work closely together to ensure the testing is complete for safe transplant of healthy organs and/or tissues, while at the same time recognizing the impact this has on the patient at the end of their life. In addition, ahead of the procedure date, it is important to ensure that all health care providers who will be involved in the process have been informed so that they have time to exercise a conscientious objection to MAID, when applicable.
Have you encountered a situation in your practice where organ donation after MAID was not possible?
I have encountered situations in which it was determined that organs were not safe for transplantation, as well as situations where patients have decided that the organ donation process does not align with their wishes for their final days.
Is there any work being done around regulating MAID and organ donation?
Nationally, there has been much work done around organ donation following MAID. Canadian Blood Services, led by Dr. James Downer, published a guidance policy for deceased donation after medical assistance in dying in the Canadian Medical Association Journal in June 2019. This work evolved from a collaboration between patients, medical assistance in dying providers, ICU physicians, neurologists, organ donation organization team members, ethicists, and legal experts. It provides guidance for the ethical and legal issues, as well as clinical considerations for the patient and the organ donation and transplantation team. Work is underway to update the document to reflect the recent changes in legislation regarding medical assistance in dying.
What do you think the future of MAID and organ donation might look like?
I wouldn't presume to guess what the future may look like. However, my hope would be that the opportunity for organ and tissue donation is integrated into all forms of end-of-life care including medical assistance in dying.
Is there anything else you would like to share with readers on this topic?
Organ donation following MAID, unlike other types of organ and/or tissue donation, allows for the patient themselves to provide first-person consent. It is an important opportunity that may bring some peace and comfort to the patient and their family and should be considered in all cases of end of life.