A Good Death

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From the course by University of Cape Town

Organ Donation: From Death to Life

53 оценки

University of Cape Town

Organ Donation: From Death to Life

53 оценки

Considering someone for organ and tissue donation at the end of life is complicated. The boundary between life and death is more complex than ever before and it falls to medical professionals to help clarify a situation at an often confusing and emotionally stressful time. In this course you will learn about the science behind death determination and when it is possible for deceased organ donation take place. The lectures will cover medical standards at the end of life - from brain death testing, to requesting informed consent from a grieving family. By improving knowledge of good ethical practices, cultural and religious considerations and the logistics of the organ donation process this course will empower the interactions and discussions of medical professionals and the general public at an often confusing time. This course will help you to ensure that the option of organ donation is compassionately explored in all appropriate situations at the end of life in the best way possible. Watch the course trailer here https://www.youtube.com/watch?v=Ak-kVtmZGRs The course is certified for continuing professional development (CPD) points in South Africa. Send your completion certificate to organdonation@uct.ac.za together with your HPCSA number for 25 general and 5 ethics points. For another interesting course on organ donation and transplantation, see Clinical Kidney, Pancreas and Islet Transplantation from Leiden University https://www.coursera.org/learn/clinical-kidney-transplantation

From the lesson

Donation after Circulatory Death

Not all end of life decisions in the Intensive Care Unit and the discussions that go with them can rely on the clarity of a brain death diagnosis. Just under half of all deaths in Intensive Care Units involve non-beneficial treatment being withdrawn or withheld. In less well resourced countries limited access to ICU means these decisions as to when treatment is futile frequently occur earlier, outside of the ICU setting. In week 2 we will discuss end of life care and the ethical principles which help guide us in making difficult decisions in the ICU. What do we do when interventions may prolong suffering with no reasonable chance of recovery? We will see how the dead donor rule can be applied after circulatory arrest and that in certain patients it may be possible to honour their wish to be an organ donor. We will cover the different types of donation after circulatory arrest and go over the process of donation after circulatory death in detail. We will end the week by covering tissue donation and what happens to the body of the donor after the organ donor operation is complete.

Introduction to Week 21:24

A Good Death4:37

Principles in Medical Ethics6:41

Withdrawal of Treatment7:32

An Approach to Withdrawal of Non-beneficial Treatments2:59

Meet the Instructors

David Thomson
Dr
Critical Care Specialist and Transplant Surgeon

[MUSIC]

So what defines a good death?

Well, it depends on who you ask.

Patients, their families, or the healthcare professionals.

We are all in agreement that ideally the patient should have control over

the dying process, where, when and with who.

And that they should be free from pain and suffering at the time of death.

Some elements of a good death, such as death with dignity and living in hope

until the end, are more important for family members than for patients.

The sentiment is that we should burn as brightly as we have done in life,

right up until that final moment.

My favorite poem by Dylan Thomas,

written to his dying father, has the timeless refrain.

Do not go gentle into that good night, old age should burn and rave at close of day.

Rage, rage against the dying of the light.

For patients at the end of life, feeling empowered, spirituality, having

a sense of life completion, and being able to say goodbye are most important.

Unfortunately, dying often involves a loss of control.

95% of deaths in ICU involve unconscious patients.

And invariably, there is a degree of pain and suffering.

Often, advanced medical directives, or living wills, are not in place, or

not clear enough to cover all situations.

For example, I don't want to be on prolonged mechanical ventilation.

How long is prolonged?

Two weeks, two months, six months, a year?

Families are frequently asked to be surrogate decision makers for

patients at this critical point.

Added to this is the fact that the medical team can't predict with complete certainty

what will happen.

They are, however,

in the best position to give advice on what the treatment options are.

And what the likely outcomes could be.

Differences of opinion between patients and family members and

medical teams can lead to conflict and much unhappiness and angst.

At the center of this, there is always a patient.

You can not read the cases of Terri Schiavo, Baby K and

Karen Quinlan at the end of their lives and not feel for all of those involved.

Each was the patient at the center of a family trying to come to terms with

terrible circumstances.

The key to successful end-of-life care is effective communication and

the establishment of realistic goals.

The patient's best interests and wishes must be at heart.

There may, however, come a point when the best medical therapy

can no longer offer a meaningful chance of recovery.

And can be prolonging a patient dying with no quality of life.

Merely adding days to the patient's life cannot be the sole measure of success.

It is the quality of those days that is the true measure of success.

And these must be in keeping with the patient's own goals, not the doctor's or

the family's.

The term medical futility has been used to describe treatments with no or

extremely limited chance of success.

This term is, however, open to broad interpretation.

Some guidelines now use the term potentially inappropriate treatment,

instead of futile treatment.

I prefer to term non-beneficial,

because it forces us to give the rationale behind the treatment.

All treatments are a balance of risks and benefits.

And when the benefits are no longer achievable, or come at too great a cost,

we must reassess.

Medical care in the hospital in ICU is primarily geared to save people's lives,

and not to facilitate the dying process.

The hospital environment is not conducive to a good death.

This is why terminal cancer patients are referred to hospice,

where the unit of treatment is the patient and their family together.

And the primary focus is on preventing suffering and

providing all the support required for a good death.

A dying patient is not always a failure of the medical system, but

not supporting the dying process absolutely is.

To recap,

the majority of patients dying in ICU will have treatment withdrawn or withheld.

A good death depends on many factors, which everyone involved, patient, family,

healthcare professionals, needs to actively address.

Communication is key.

Ideally, advanced medical directive should be in place to help the family and

clinicians honor the patient's wishes.

[MUSIC]

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