DOI: 10.1097/01.pcc.0000256610.02147.c6
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PMID: 17251891
Issn Print: 1529-7535
Publication Date: 2007/01/01
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Excerpt
First, and likely most provocative, the desire to increase the donor pool rests on the assumption that organ transplantation provides a worthwhile good. Although most of us believe that kidney and liver transplantation, especially in pediatrics, indeed delivers substantial clinical benefits, the picture seems less clear for lung transplantation. In children with cystic fibrosis, who make up a large fraction of the pediatric lung transplant waiting list, pretransplant colonization with resistant bacteria reduces short-term survival importantly (3). Survivors beyond the first several months then face the development of bronchiolitis obliterans as a manifestation of rejection, with diminution of quality of life and eventual death without retransplantation in more than half the patients surviving >3 yrs (3). Without major progress in overcoming this problem, it remains an open question whether one should pursue lung transplantation for children who cannot themselves, because of age and psychosocial development, decide to undertake the hardships and risks of surgery and immunosuppression. If transplanters were to attempt to use intestinal grafts after DCD, that would raise similar, if not more troubling, issues.
Assuming that pediatric DCD will continue, some of the issues raised by Dr. Kolovos and colleagues deserve formal research scrutiny. Because DCD in children will remain relatively uncommon, at least in the sense of not many donations from a given pediatric intensive care unit (PICU) per unit of time, the pediatric critical care community, along with organ procurement organizations and transplant programs, have an obligation to organize multiple-center studies to examine, among other things, a) the effects on families of participating, or not, in the DCD process, including attention to such variables as the location of withdrawal from life support, the times between declaration of death, separation of the body from the family, and movement to the operating room and/or incision; b) the relationship between timing of withdrawal and graft function, and whether prewithdrawal administration of drugs or biologics might enable parents to stay with the child's body somewhat longer; and c) whether the risk of autoresuscitation varies with age and prewithdrawal diagnoses.
Dr. Kolovos and colleagues do not mention what some of us have observed as a point of serious ethical concern on the part of pediatric intensivists since DCD became a matter of public discussion, namely conflicts of interest (4, 5). Here we should focus on one specific piece of potential conflict. PICU physicians, unlike many of their colleagues in the world of adult critical care where patients reside in subspecialty units, typically work in multidisciplinary PICUs, simultaneously caring for, among other patients, those with neurosurgical conditions and general medical conditions, such as liver failure secondary to metabolic disease or drug overdoses. In some cases, patients who may become donors are down the hall from others waiting on transplant lists, cared for by the same team. This raises the prospect of individuals or closely knit groups of intensivists facing both the reality and appearance of conflicts of interest.
