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Exploring Australian intensive care physicians clinical judgement during Donation after Cardiac Death: an exploratory
Nicole L Coleman1, Ann Bonner2
1John Hunter Hospital, Newcastle, NSW, Australia.
Insights
Intensive care physicians prioritize patient well-being and family wishes when considering organ donation after cardiac death (DCD). Clear policies are needed to reduce uncertainty in DCD decision-making for healthcare professionals.
Area of Science:
- Medical Ethics
- Organ Transplantation
- Intensive Care Medicine
Background:
- Donation after Cardiac Death (DCD) offers a solution to global organ shortages.
- Intensive care physicians play a crucial role in DCD success but face reluctance from healthcare professionals.
- Physicians' clinical judgments are central to DCD candidate selection.
Purpose of the Study:
- To investigate the clinical judgments intensive care physicians use when identifying potential Donation after Cardiac Death candidates.
- Understanding physician decision-making processes in DCD is key to improving organ donation rates.
Main Methods:
- Qualitative study employing interpretative exploratory methods.
- Interviews conducted with six intensive care physicians across three Australian hospital sites.
- Thematic analysis applied to verbatim transcriptions of interview data.
Main Results:
- Physicians focus on reducing harm and maximizing benefit, accepting DCD when patient/family consent is clear.
- Defensible decisions involve careful sequencing, separation, timing, consensus, collaboration, trust, and communication.
- Minimizing uncertainty and discomfort in predicting survival post-withdrawal of life-sustaining treatment is crucial.
Conclusions:
- DCD decision-making occurs amidst uncertainty regarding survival prediction.
- Physicians adopt cautious, collaborative strategies due to uncertainty in end-of-life and DCD discussions.
- Nationally consistent policies are essential to enhance certainty and support intensive care staff in DCD processes.
Background:
Donation after Cardiac Death (DCD) is one possible solution to the world wide organ shortage. Intensive care physicians are central to DCD becoming successful since they are responsible for making the clinical judgements and decisions associated with DCD. Yet international evidence shows health care professionals have not embraced DCD and are often reluctant to consider it as an option for patients.
Purpose:
To explore intensive care physicians' clinical judgements when selecting a suitable DCD candidate.
Methods:
Using interpretative exploratory methods six intensive care physicians were interviewed from three hospital sites in Australia. Following verbatim transcription, data was subjected to thematic analysis.
Findings:
Three distinct themes emerged. Reducing harm and increasing benefit was a major focus of intensive care physicians during determination of DCD. There was an acceptance of DCD if there was clear evidence that donation was what the patient and family wanted. Characteristics of a defensible decision reflected the characteristics of sequencing, separation and isolation, timing, consensus and collaboration, trust and communication to ensure that judgements were robust and defensible. The final theme revealed the importance of minimising uncertainty and discomfort when predicting length of survival following withdrawal of life-sustaining treatment.
Conclusion:
DCD decisions are made within an environment of uncertainty due to the imprecision associated with predicting time of death. Lack of certainty contributed to the cautious and collaborative strategies used by intensive care physicians when dealing with patients, family members and colleagues around end-of-life decisions, initiation of withdrawal of life-sustaining treatment and the discussion about DCD. This study recommends that nationally consistent policies are urgently needed to increase the degree of certainty for intensive care staff concerning the DCD processes.
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