Attitudes and experience
The time elapsing from withdrawal of neurointensive treatment to final cessation of cerebral circulation may vary from some hours to several days. When the patient’s life cannot be saved, three out of four respondents were willing to initiate organ-preserving treatment (Table 1). The positive attitudes among doctors to organ-preserving treatment concur with the findings in a Canadian study (14). A circular from the Ministry of Health and Care Services (5) specifies that prevailing health and privacy legislation places major emphasis on the patients’ right to co-determination and information. If it is known or if the next of kin believe that the dying person wished to become an organ donor after his/her death, this should be a deciding factor in whether organ-preserving treatment is initiated and continued until a total cessation of cerebral circulation has been established.
Wilkinson and Trough have described that the doctor’s age, religion, race and personal attitudes may be decisive for whether organ-preserving treatment is initiated and that the patient’s own values may easily be overruled in the process (15). Hynninnen and collaborators point out the absence of internal guidelines for withdrawal of treatment in Scandinavian intensive-care units (16). There is reason to assume that this also applies to the decision to prolong respirator treatment to facilitate an organ donation. Our experience indicates that practice regarding decisions to prolong or discontinue treatment may vary from one department to another, as well as within each intensive-care unit.
One in three respondents would most often/sometimes choose to discontinue respirator treatment in the face of expected death, instead of waiting until clinical diagnostics of total destruction of the brain function can be undertaken (Table 1). Most likely, this is based on organisational, financial and ethical considerations. Some claim that organ-preserving treatment violates the ethical principle of always treating the patient for the patient’s own sake. Welin and collaborators (17) have shown that this is not necessarily the case, especially if the principle of autonomy, i.e. patient co-determination in matters pertaining to organ donation, is given greater weight in the ethical assessment.
Materstvedt and Hegvik (18) have argued that active treatment, including elective ventilation in view of organ donation, can be defended in light of ethically accepted ethical perspectives. This applies also when the patient’s attitude to organ donation is unknown.
Two out of five respondents stated that concern for the next of kin was the reason for discontinuing respirator treatment. This may reflect a patriarchal attitude in the doctors. The next of kin may thereby be deprived of the opportunity to fulfil the patient’s last wish (Table 1). One in three respondents stated that the reason was to reduce the patient’s suffering. This contrasts with the opinion held by a majority of the respondents, who believed that respirator treatment can be provided to a deeply unconscious patient without inflicting any suffering (Table 1). One possible explanation could be that at the terminal stage, the assessment of suffering is transferred from the patient to the next of kin.