Acute Care 2 (End of life, ADs, LPA)

Question 1

Significance of the Tracey Ruling?

Answer 1

If a patient has capacity to engage in the discussion, then there is a presumption of involvement of the patient in any discussion about DNACPR.

If NOT done: would breach the patient’s right to have their private life respected (Article 8).

o Duty to consult pt in relation to DNACPR unless think that patient will be distressed by being consulted and this distress might cause the patient physical or psychological harm; even if doctors decide there is no medical indication anymore for CPR, this still needs to be

o Judge went on to say that if a professional failed to address end-of-life issues for someone with a terminal illness, and they ended up being inappropriately resuscitated, this too could breach their human rights!

Question 2

Significance of the Winspear Ruling?

Answer 2

If patient lacks capacity, presumption of involvement of their designated family member / carer. This does not mean there is an obligation to provide CPR.

Question 3

Who instigates a DNACPR?

Why might it be considered?

Answer 3

Requested by patient or made by most senior member of team or GP after discussion with patient where appropriate and potentially also with their relatives. Must be signed by responsible senior officer / clinician, often GP / consultant / senior nurse if training. Kept in medical records usually on special recognisable form.

• Good practice accompany pt + consult them before coming to a decision, always if pt has capacity (lower likelihood of causing distress to adults)
• If don’t have capacity to decide , and haven’t made an AD to refuse treatment, healthcare team may consult with next of kin about what they know of your wishes to make a decision in your best interest
• Not permanent, can change your mind and your DNACPR status at any time

Usually multifactorial: blanket decisions should not be made e.g. >80 years. Some examples of when a decision is appropriate: CPR is unlikely to restart the patient’s heart, patient is in terminal stages of illness and believed that quality of life is such that the benefit of CPR would not improve their quality of life – review date should also be added in case patient’s circumstances improve and DNACPR then re-evaluated.

Many patients may never have been asked how and where they would like to die, so where possible, time should to be given to allow the patient a chance to reflect on these decisions and discuss them with their loved ones before they are put in place. Explaining what is meant by CPR (some think it equates to stopping medical treatment!) – detail what Tx they would or would not want at end of life and counter this with what would and would not be clinically effective or appropriate.

Question 4

How to deal with disagreement about DNACPR?

Answer 4

Even a patient with capacity cannot insist on CPR if medical professional feels not in best interests (futile treatment) – Tracey ruling (Court of Appeal) imposes obligation on clinicians to DISCUSS decisions with patients (presumption in favour of patient involvement) unless would cause physical / psychological harm.

Where DNACPR decision made on grounds that CPR will not work, and patient or relatives do not accept decision, second opinion should be offered! In reality, if patient and relatives were adamant that the patient wanted to be resuscitated, it is likely that the medical professional would agree to this, as enforcing a DNACPR against someone’s wishes would inevitably lead to a breakdown in the doctor-patient relationship.

Question 5

Resuscitation Council: guidelines for recording CPR decisions? (2015)

Answer 5

• Effective recording of decisions about CPR in a form that is recognised and accepted by all those involved in the care of the pt
• Effective communication with and explanation of decisions about CPR to patient, or clear documentation of reasons why that was impossible or inappropriate
• Effective communication with and explanations of decision about CPR to family / friends / carers / reps, or clear documentation of why this was not possible/ appropriate
• Effective communication of decisions about CPR among all healthcare workers and organisations involved with the care of the patient

Question 6

What is an advance decision?

Statement of general wishes?

Answer 6

Advance decision: a statement which sets out what treatment a person would not want to receive or have continued at such a time when they no longer have capacity. (Sometimes known as ADRT or living will).

Statement of general wishes: could include what treatment a person would like to receive, the food they like / don’t like, what they want to happen to their cat etc. when they no longer have capacity

Advance decisions were developed in response to fears that medical profession may want to keep people alive or not withdraw treatment in circumstances that person themselves would not want. Enabling patients themselves to say what they would want when they still have the capacity to do so – patient’s autonomous decision making vs paternalism.

Question 7

When is an AD legally binding?

Answer 7

Legally binding (under MCA) if:

• > 18 and had capacity when being made
• Specifies (in lay terms if necessary), specific treatment or medical procedure + circumstances in which it applies (must be explicitly stated)
• Person making decision has not subsequently withdrawn decision
• Person has not subsequently done anything clearly inconsistent with the decision
• Can be oral or written, BUT for life-sustaining treatment, AD must be in writing, signed and witnessed, and state the decision will apply ‘even if my life is at risk’

If legally binding, takes precedence over best interests decisions made by other people

Question 8

When may an advance decision NOT be valid?

Answer 8

• Person withdrew the decision when they had capacity
• Had given authority to someone to give or refuse consent to the Tx to which the advance decision relates AFTER the advance decision was made
• They have done something which is inconsistent with the AD which would cast a doubt over the decision’s validity
• There are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of the advance decision and which would have affected their decision had they anticipated them

Judge ruling: where there is ‘alerting background’ of previous mental illness, rather than relying on the presumption of capacity at that time, the person making an ADRT should demonstrate that they had capacity at the time of making it; MCA Code of Practice states that if the person making an ADRT is clearly suicidal, may raise questions about their capacity to make it at that time.

Question 9

Ethical issues surrounding AD?

Answer 9

• Did they have capacity at time of writing
• Can we be sure they really thought about ALL circumstances
• Did they really mean ALL treatment – did they think about AHN? New treatment they didn’t know about the time – might offer some recovery?
• Did they change their mind after they made the AD?
• What to do in an emergency?

• Can person in Time1 really predict that they want in Time2? Are they even the same person? Is their continuity in identity? Would they have different interests? If so, which interests should take priority? Should T2 be bound by previous choices?

‘If little or no psychological connectedness + continuity exists between the individual at the two points in time, then there is no particular reason why the past person, as opposed to any other person, should determine the present person’s fate’ – Dresser 1986

• Can we / should we, apply the principle of respect for autonomy to individuals who lack capacity?

Question 10

What is an LPA?

Answer 10

Legal document: person (>18) gives another (>18) authority to act on his / her behalf: personal welfare (including health) and property + financial affairs. Only applicable if registered with the Office of the Public Guardian. Person appointed MUST act in person’s best interests – not just power to consent on the pt behalf.

Power only extends to decisions about life sustaining treatment (receiving or continuing to receive) if the documents clearly state this.

Life-sustaining treatment = any Tx doctor considered necessary to keep you alive, if don’t allow attorneys to give or refuse consent on your behalf, doctors will make the decision. Attorneys can only make decisions about life-sustaining treatment if you don’t have mental capacity. Sign and date option (A or B) on printed LPA doc, signature must be witnessed.

Question 11

LPA - what must be done before acting

Answer 11

Before acting under an LPA, attorneys must make sure the LPA has been registered with the Public Guardian and take all practical / appropriate steps to help the donor make the particular decision for themselves. When acting under an LPA – must ensure MCA acts 5 statutory principles are followed – if person has capacity personal welfare LPA cannot be used, but a property and affairs LPA can be used even if they have capacity.

Anything done under authority of LPA must be in person’s best interest, anyone acting as an attorney must have regard to guidance in Code of Practice that is relevant to the decision to be made, and they must fulfil their duties and responsibilities to person who lacks capacity.

Question 12

Role of Court of Protection for LPAs?

Answer 12

Decides if someone has capacity, makes declarations / decisions / orders on financial / welfare matters for those lacking capacity, appoint deputies to make these decisions, decide whether LPA or EPA is valid, and remove deputies or attorneys who fail to carry out their duties.

Question 13

History of LPA

Answer 13

Prior to enactment of MCA (2007), power of attorney was restricted to financial affairs (Enduring Power of Attorney - EPA).

The attorney or done under a power of attorney can make decisions that are as valid as those made by the donor, before EPA Act (1985) every power of attorney became invalid as soon as donor lacked capacity, but the EPA act allowed the attorney to make decisions about property + financial affairs even if donor lacks capacity. The MCA replaced EPA with LPA, and increased the range of decisions people can authorise others to make on their behalf: can now cover personal welfare (including healthcare and consent to medical treatment). Donor can choose one person or several to make different kinds of decisions.

Question 14

What are issues surrounding use of LPA?

Answer 14

• Responsibility that might not have predicted
• Disagreements between attorney and HCPs over best interest of patient
• What really is the role of the attorney? Is the attorney really just an advisor in a best interest assessment rather than someone with authority to make decisions on behalf of others?

Wrigley A (2007): Proxy consent: moral authority misconceived

While the intentions are to increase the autonomous decision making powers of those unable to consent, author argues that the whole notion of proxy consent collapses into a paternalistic judgement regarding the other person’s best interests, and that the new legislation introduces only an advisor, not a proxy with the moral authority to make treatment decisions on behalf of another.

1. “good empirical evidence that people are poor proxy decision makers with regards to accurately representing other people’s desires / wishes, therefore this is a pragmatically inadequate method of gaining consent”
2. “philosophical theory explaining how we represent other people’s thought processes indicates that we are unlikely ever to achieve accurate simulations of others’ wishes in making a proxy decision”
3. “even if we could accurately simulate other people’s beliefs and wishes, the current construction of proxy consent in the MCA means that it has no significant ethical authority to match that of autonomous decision making. Instead, it is governed by a professional, paternalistic, best-interests judgement that undermines the intended role of a proxy decision maker. Author argues in favour of clearly adopting the paternalistic best-interests option and viewing the proxy as solely an advisor to the professional medical team in helping make best-interests judgements”.

Question 15

History of law surrounding withdrawal of ANH?

Answer 15

Withdrawal of ANH (artificial nutrition + hydration) in a PVS (persistent vegetative state i.e. >4 weeks) or minimally conscious.

• Bland case set precedent for all such cases to go to court
• Recent Supreme court judgement: now no requirement in law for withdrawal of ANH to be taken to court where there is no dispute that it is in the patient’s best interest
• Court of Protection decision still required when there is a disagreement

Question 16

GMC End of Life Guidance?

Answer 16

(2010): ‘following established ethical + legal (including human rights) principles, decisions concerning potentially life-prolonging treatment must not be motivated by a desire to bring about the patient’s death, and must start from a PRESUMPTION in FAVOUR of prolonging life’

GMC end of life (2010): ‘for children or adults who lack capacity to decide, when reaching a view on whether a particular Tx would be more burdensome than beneficial, assessments of the likely QoL for the pt with or without that Tx may be one of the appropriate considerations’

Sometimes, not practical or appropriate for court to make single declaration or decision. In such cases, can appoint deputy to act for and make decisions for person.

If a deputy needs to be appointed, it should be limited in scope and for short as time as possible.Deputy is likely to be family member or someone who knows person well but in some cases court may decide to appoint deputy who is independent of the family (e.g. where person’s affairs or care needs are particularly complicated).

Question 17

Passive vs active euthanasia?

Arguments for having this distinction?

Answer 17

Passive euthanasia: withholding or withdrawal life-prolonging treatment (omission)

Active euthanasia: act resulting in death (act)

Active euthanasia illegal in UK under all circumstances; passive euthanasia is permitted in certain circumstances – therefore law draws difference between acts and admission. Legal system: bridge divide between complex ethical arguments and practical real dilemmas

• Passive more morally acceptable for many as act ‘interferes’ with natural course of events
• Omission provides a safeguard against a wrong diagnosis whereas action obliterates any chance of recovery

Question 18

Arguments against treating passive euthanasia different to active euthanasia?

Answer 18

On compassionate grounds act preferable – quick resolution / end of suffering, all interventionist medicine dealing with disease and death disrupts nature anyway.

• Autonomy seems to explain why distinction exists – where individual cannot express their own autonomy there is a need to act in their best interest. To allow active euthanasia allows action open to misuse by those who act dispassionately without patients consent

o Same argument could be applied to withdrawing, but idea that someone dies who would have died is more acceptable than ending life of someone who would have lived

o Supreme Court (2013): if not in the best interest of a patient lacking capacity to continue receiving life-prolonging Tx it would be unlawful not to withdraw it – adds weight to the idea that acting (by introducing life-prolonging treatment) not always in best interests of patient who lacks capacity to choose

o Doctrine of double effect: traditionally states that an action which has a good objective may be performed even though can only be achieved at expense of corresponding harmful effect > opioids pain relief where dose required for pain relief may inadvertently contribute to death but no intention to kill. Remains controversial and many feel that with advances in palliative care and careful prescribing – no role in ethics of end-of-life care. ‘No circumstances in which the prescription of a lethal dose of opioid is necessary to control suffering, and therefore there is no need to invoke the doctrine of double effect’.

Question 19

Ethical principles when applied to decisions about QoL and withholding Tx?

Answer 19

If disagreement about QoL between clinicians and family – legal advice
- Avoid personal views about QoL and judgements based on assumptions about healthcare needs of particular groups e.g. older people, disabilities.

• Heavy burden on those advocating course leading to death that QoL so poor that further Tx would only prolong suffering – MCA code of practice may be best interests in limited number of cases not to receive life-sustaining treatment ‘where treatment is futile, overly burdensome to the patient or where no prospect of recovery – even if non-provision of treatment is likely to result in death.”
• Doctrine of sanctity of life: human life has intrinsic value and therefore wrong to intentionally deprive person of life even to avoid extreme suffering. Religious version of the doctrine: as life is God given, only God can take it away
• Secular version: all humans are equal therefore nobody has the authority to determine another’s life is not worth living
• Even if human life has infinite value, justice / beneficence / non-maleficence still important?

Threshold at which sanctity of life yields to quality of life difficult to assess – how to define / measure minimum quality of life? Social / emotional / physical wellbeing – carry out tasks and intellectual capacity should be taken into consideration. Acceptable QoL depends on perspective – decision maker or the patient?

Question 20

What is basic care vs CANH?

Answer 20

The provision of food seems a ‘quintessential example of kindness and humanity that it is hard to imagine a case in which it would be morally right to withhold it’ – Airedale vs Bland

• ‘Basic care’ includes offer of food and water by mouth, should always be offered to patients
• CANH – invasive means of providing nutrition + fluids e.g. PEG, NG, IV; if capacity may refuse CANH but decision to provide it is a clinical one and pts cannot demand that doctor administers a Tx which the doctor considers adverse to patient’s clinical needs

Question 21

Ethical issues surrounding whether to provide CANH?

Answer 21

• If lack capacity – decision maker must consider whether provision of CANH is in best interests – presumption in favour of prolonging life and will normally mean that all reasonable steps are taken to prolong a patient’s life
• CANH may prolong life but may be burdensome – benefits, burdens risks as approach end of life is not clear cut; if simply prolongs dying may not be in best interests; sanctity of life not infringed by ceasing to give invasive treatment that confers no benefit to the patient
• No obligation to provide FUTILE treatment; ethically controversial concept as Tx considered futile relative to its goal: if the goal is to prolong life then CANH achieves this and would not be considered futile, but may not return the patient to QoL they consider worthwhile
• Article 2 ECHR: positive obligation to give life-sustaining treatment in circumstances where it is in the best interests of the patient but does not impose an absolute obligation to treat if such Tx would be futile

Question 22

What is futile treatment?

When is it provided / not provided?

Answer 22

Treatment has been considered futile if it cannot cure or palliate the disease or illness from which the patient is suffering.

Supreme Court: treatment is not futile if it provides benefit to the patient ‘even though it has no effect on the underlying disease or disability’ – Aintree Case
- Judge: he was not persuaded that Tx would be futile or overly burdensome, or that there was no prospect of recovery (criteria in the MCA Code of Practice). He took recovery to mean return to a quality of life the patient would regard as worthwhile, rather than return to full health.

• If Tx allows pt to continue living what they regard as a worthwhile life, Tx has some benefit and could not be said to be futile. Pt decides what is futile not the doctor?
• No legal obligation to provide Tx with no clinical benefit; pt decides if futile but doctor decides if clinically indicated and therefore provided to patient.
• Ethical duty for good clinical care: includes physical and psychological

Question 23

Ethical issues surrounding switching off a ventilator?

What if fetus involved?

Answer 23

Legally permissible to switch of ventilator as continued ventilation futile

In practice agreement should be sought from next of kin – husband does not think ventilation futile; clinical uncertainty for fetus taken into account; fetus no legal status and no interests which outweigh mother in pregnancy – Case law provides that altruistic wishes of the patient can be relevant in determining best interests, even if the patient has no awareness of and no reaction to the fact that such wishes are being respected. Another court judgement: person in permanent vegetative state ‘has no best interests of any kind’ – dignity in death is key concern. (utilitarianism vs means to another’s end), utilitarianism – joy to family and baby; ITU expensive – no hope for recovery – provide resources for other patients with prospect of survival?

Question 24

What is the legal position in the UK for assisted suicide and voluntary euthanasia?

Answer 24

Euthanasia: act of deliberately ending a person’s life to relieve suffering

Assisted Suicide: act of deliberately assisting or encouraging another person to end their life (final gesture should be made freely by the person committing suicide).

• Both illegal under the UK law

Suicide itself is not a crime but encouraging or assisting suicide is a criminal offence: up to 14 years imprisonment (Suicide act 1961)

Euthanasia regarded as ether murder or manslaughter, max. penalty is life imprisonment

Question 25

What is the suicide act 1961?

Answer 25

A person (“D”) commits an offence if—

(a) D does an act capable of encouraging or assisting the suicide or attempted suicide of another person, and
(b) D’s act was intended to encourage or assist suicide or an attempt at suicide.

Question 26

2 types of euthanasia?

Answer 26

Active Euthanasia – deliberately intervening to end someone’s life- e.g. injecting them with a large dose of sedatives

Passive – causing someone’s death by withholding or withdrawing treatment that’s necessary to maintain life.

• Not to be confused with withdrawing life sustaining treatment in a person’s best interest.

Question 27

Issues to be aware of regarding dignitas?

Answer 27

Dignitas > Organization in Switzerland offering assisted suicide, including to non-residents. Friends/family taking individual to Dignitas may face prosecution for assisting suicide even though final act takes place abroad.

For healthcare professionals: more likely to be prosecuted if there’s an existing relationship of care and HCP has exerted some influence.

BMA Guidance: Advices doctors to avoid all actions that might be interpreted as assisting/encouraging suicide attempt doctors should NOT:
o Advise patients on what constitutes a fatal dose 

o Advise patients on anti-emetics in relation to a planned overdose 

o Suggest the option of assisted suicide abroad 

o Write medical reports specifically to facilitate assisted suicide abroad 

o Facilitate any other aspects of planning a suicide 


HCP should always act with compassion to person who raises issue of suicide and assistance.

Question 28

What affects likelihood of being prosecuted for assisted suicide?

Answer 28

Landmark case in 2009: guidance issues setting out factors tending toward a prosecution being brought + factors against

Against: voluntary, clear, settled and informed decision to commit suicide, family sought to dissuade, wholly motivated by compassion and actions only of minor assistance

Doctor / nurse more likely to be prosecuted if existing relationship of care and healthcare professional exerted some influence: BMA issued guidance about responding to patients request relating to assisted suicide: avoid all actions that might be interpreted as assisting, facilitating or encouraging a suicide attempt:

How to act with compassion to patient who has broached issue while not moving into territory of encouraging or assisting? If asked to provide a medical report for patient so they can receive assisted suicide – legal liability is unclear – BMA state no doctor has been prosecuted for providing a report, should be aware of possible legal implications as might be seen as encouraging / facilitating process – test case if brought will clarify the position.

Question 29

For and against legalising euthanasia / assisted suicide?

Answer 29

For law change: respect autonomy for deciding what QoL is acceptable to them, enabling them to end suffering – good quality palliative care may ameliorate suffering but may not fully address fears of loss of dignity and choice

Arguments against: undermine trust between doctor-patient, value accorded to life would be diminished and that the vulnerable in society may feel pressured to ask for assistance to die.

Question 30

On what basis should decisions be made about treatment in resource-limited circumstances?

Answer 30

Resource allocation: utilitarianism (part of consequentialism theory) – ethically correct action will be that which results in the max overall benefit.

Does not take into account need for health care intervention but relies on cost effectiveness e.g. may favour preventative cholesterol lowering treatment to prevent CAD compared to renal dialysis for end stage renal failure. Approach favours resources being allocated to less expensive treatments/services.

Practical application – QALYs (Quality Adjusted Life Years)
Assesses number of years and QOL of those year that treatment would give patient. 1 year of life in perfect health =1. Cost per QALY is then calculated once costs known.

Patient factors to think about:
Future societal contribution
Patient’s lifestyle contributing to ill health
Lifestyle enhancement vs ill health
Right to demand treatment?

Question 31

Objections to QALY use?

Answer 31

Ageist: older person will have quality life years to gain. Tx for younger people likely to give better QALY

Subjective – what one person may experience as an > in QOL, another person may not

Denies Tx to people who are suffering but in whom Tx will only marginally improve suffering (terminally ill)

Question 32

Objections to resources allocated based on lifestyle and social worth?

Answer 32

Implies that patient who is responsible for own health is less worthy of receiving Tx than someone who is blameless.

Examples: denying operations to those who are clinically obese or smoke (modifiable risk factors). Patient have control over these.

GMC: It is unethical to withhold or otherwise change the Tx a patient receives as a result of their lifestyle

Question 33

Ethics of the flu vaccine?

Answer 33

Advertising targets front life staff, occup health visit wards and sometimes incentives (choc, pens); strongly encouraged but not compulsory.

Benefits: prevent transmission to patients, protect healthcare workers (sick leave – detrimental during winter pressures). Moral obligation – duty of care; non-maleficence?. Harms to staff outweighed by benefits – risk of such harms for benefit of patients = ‘virtuous’ HCP – virtues of selflessness, altruism, professionalism and commitment to work.

Effectiveness disputed; new evolving strains of flu which immunisations may be less effective for. Autonomous therefore no moral obligation, just like a patient. Patients benefit more than she does. Hep B compulsory but more effective at reducing transmission + harms more serious.

Question 34

What is the human tissue act (2004)?

Answer 34

UK – “storage and use of tissue from the living and for the removal storage and use of tissue and organs from the dead – appropriate consent is central governing principle of the act”.

Human Tissue Authority (HTA): regulatory body – removal storage use and disposal of human tissue (excluding embryos and gametes) – other responsibilities of HTA include licensing establishments that carry out actions under the act. Codes or practice on consent, examination of body after death and donation of organs, tissue, stem cells.

Question 35

Commercialisation of organ donation?

Ethical issues?

Answer 35

HTA: ILLEGAL TO BUY SELL OR HAVE ANY COMMERCIAL DEALINGS IN SALE OF HUMAN ORGANS.

Fine and up to 3 years imprisonment.

Buying a kidney is denying person natural dignity given to all individuals, Kantian principle of not using individual simply as a means to another’s end.

Financial reward = exploitation of poor and vulnerable – should only have purely altruistic motive – imposition of other’s moral sensibilities – surely if person can benefit life of another and can be better in their own life as a result – should be allowed; denying them right to sell what is theirs infringes their autonomy.

Question 36

Types of organ donation?

Answer 36

2 types of donation: deceased and living

Genetically / emotionally related donation –recipient known to the donor – this is the most common form of organ donation.

Paired / pooled donation – between 2 or more people due to relatives not being compatible

Altruistic non-directed donation: organ donation to a stranger
- directed if through social media (identified person)

Question 37

What criteria must be met for organ donation to take place?

Answer 37

All living organ donations must be approved by the HTA before donation can take place: evident that valid consent has been given; no coercion and no reward given – if genetically / emotionally related transplant approvals team will make final decision on the case.

Paired / pooled donation and all altruistic non-directed: assessed by HTA panel of 3 authority members.

If potential living donor is child / adult lacking capacity – must be approved by court of law to ensure best interests to donate.

Question 38

In the UK how is organ donation maximised?

Answer 38

Lack of donors – many die; current system is opt in.

Specialist Nurses-Organ Donation (SN-ODs) senior nurses from a clinical background, usually in intensive care or emergency medicine – support doctors caring for someone who recently died and could be a potential organ donor. Highly trained to communicate with next of kin about benefits of donation.

Wales: opt-out system does not apply to children, people without capacity or those not living in Wales. Permission still needed from family – counselling by specialist organ transplant team.

Another idea: make donors eligible to receive organs if they then need one?

Question 39

If patient may be potential organ donor - how to proceed?

If family disagree?

Answer 39

HTA 2004: check medical records, look for donor card or check ODR. If evidence of consent to donation by competent adult, legally can proceed.

Relatives of pt should be informed of prior consent to donation – if object every effort should be made to ask them to respect the wishes of the deceased, they should sensitivity be informed that they cannot legally veto the consent.

However, in practice where there is real objection to donation – unusual for it to go ahead.

Question 40

Can somebody else consent for organ donation on behalf of someone else?

Ethical issues surrounding this?

Answer 40

When no consent prior to death has been given, a person in a ‘qualifying relationship’ can give consent. HTA ranks qualifying relationship e.g. spouse before offspring.

Children can consent to posthumous organ donation if they are Gillick competent: essential that decision discussed with person who has PR and to take their wishes into account before proceeding. Where child lacked capacity or no prior consent expressed, consent should be sought from the person with PR.

Consent and autonomy key principles of HTA, however, also has utilitarian element as allows recently deceased to be preserved while consent to posthumous organ donation can be established or refused.

Concept that proxy-consent to posthumous organ donation can be given has interesting ethical arguments – in every other aspect of medicine consent to Tx cannot be given by another adult unless LPA – act also permits ventilation after death has been confirmed -questions whether Tx is in best interest? Does dead person have any interests? Can any harm be caused to dead patient? If no – ethically justified that consent not needed? Deontological theory: morally unacceptable as no person should be used solely as a means to another’s end!

Question 41

What is directed altruistic donation?

Answer 41

If no pre-existing relationship, but found through social media: legal approval for DAD cases to proceed if satisfied no evidence of coercion or reward for donor, should be sufficiently autonomous and medical and psychosocial risks and benefits should be considered – however, inherent uncertainty about coercion:

British Transplantation Society (22013) guidance – transplant units should not accept cases for living donor assessment that arise from websites where potential recipients pay a fee to register their need – not illegal to place advert online or in newspaper but seeking a living organ donor as long as no offer of reward, payment or material advantage to potential donor.

• Donation can only be DIRECTED to an identified recipient; not permitted to direct to a particular group of potential recipients on the national waiting list e.g. age, ethnicity or gender.

Question 42

Pros of directed altruistic donation?

Answer 42

350 / year die while waiting for kidney transplant, living donors more successful than posthumous – last longer and can be done when recipient is healthy > better outcomes for recipient.
- Prevents costly dialysis and reduces inequity arising from mere chance of having relative who matches

Question 43

Cons of directed altruistic donation?

Answer 43

• Not all will have the know-how to build a personal ‘brand’ to attract potential donors – become a ‘beauty consent’ not based on need or capacity to benefit but pulling of heart strings.
• Recipients advertising share personal information out of necessity
• Potential donor may not be a match – disappointment for both
• Greater risk of coercion if recipient initiating process – nondirected altruistic donation is preferred option according to BTS as it maximises equity of access to living donor transplantation.