An article by Dr. Michael DeVita, Director of Critical Care Services at NYC Health + Hospitals/Harlem, about the ethics of life-saving protocols has been accepted for publication in The American Journal of Bioethics.
The article offers guidelines for how emergency room doctors should handle two similar and relatively new procedures to induce hypothermia in critically ill patients.
One procedure, called Emergency Preservation and Resuscitation (EPR), is used to super-cool critically-ill patients and prepare them for surgery. The second procedure, called uncontrolled Donation after Circulatory Determination of Death (uDCDD), is used when a patient has died in the emergency room and the body needs to be cooled to prepare for organ donation.
“Imagine a hospital that does both procedures,” says Dr. DeVita, who is a national expert on critical care and ethical issues. “Which way are you going to go? What are the ethics behind the procedure? A doctor has to make a split-second decision on whether to do a procedure to save the patient’s life or instead declare the patient dead and then, in essence, perform the same procedure to enable the patient to become an organ donor. In the first situation, you save the patient’s life. In the second, you can save up to five people’s lives.”
In both procedures, blood is removed from the body and replaced with a very cold organ preservation solution to order to preserve brain function and protect the body’s organs. It is because the protocols for both EPR and uDCDD are so similar that they present ethical issues for emergency room doctors. These decisions are made even more difficult by the very tight time frames and the fact that life or death hangs in the balance.
Currently, this is just a potential ethical issue for most hospitals. The EPR procedure is experimental and is being tested in just five hospitals in the United States that also do organ donations. But if the procedure becomes more widespread, then more emergency room doctors could be faced with these difficult ethical decisions.
“Our article discusses why this is such an important issue and gives some proposed rules for decision-making,” Dr. DeVita says.
The procedures could raise other ethical issues. “If a hospital gets rated based on the number of organs it is saving, someone might want to save five organs and save five lives,” he says. “The needs of the one could give way to the needs of the many. You could save one life or save five lives. That’s a potential conflict.”
There is also the issue of trust, he says. For example, a patient may decide which hospital to go to based on its policy for trauma patients. Patients want to know that physicians are doing all they can to save the patient’s life.
“There need to be rules in advance so we don’t put physicians in the position of making such an important decision without rules,” Dr. DeVita says. “If there were no rules, we thought that would be a problem.”
The American Journal of Bioethics will post the article for commentary in early January and the article and comments will be published in the May 2017 issue.
Dr. DeVita’s co-authors were Arjun Prabhu, a medical student at the University of Pittsburgh, and Dr. Lisa Parker, Associate Professor at the Center for Bioethics and Health Law at the University of Pittsburgh.