December 19th, 2005

Spay or Neuter

Code Blue, Special Care...Code Blue, Special Care...

Ran through Triage. "Not us," nursing comments, stopping me in my tracks. "We're all CBU." Code was cancelled by the time I'd made up my mind to go down to the ICU. All in all, this has been a slow OB day.

One morning R presented in Medicine rounds. Seventeen-year-old girl, smoke inhalation, V-fib on site, shocked back into rhythm, intubated and getting hyperbaric oxygen but not responding well. She should, technically, have gone to peds - but here she was, in the ICU, and R facing the family.
You grow attached to certain patients, O Best Beloved, patients you may never even have met. Other people's patients - you have to listen, you will be cross-covering them eventually.

17 years old. Baby died in the fire. Girl was dying, slowly, by bits and pieces - neuro exam changes, decreased cerebral blood flow, posturing and EEGs that were nothing but dismal. And finally, R went to the family and talked about a no-code status, and then talked about withdrawing support. And there she was, seventeen, smoke inhalation, brain dead, and the organ donation people came to talk to the family.
In Indiana, O Best Beloved, they ask you when you renew your license if you want to be an organ donor - and there it is on the driver's license, a little red heart for "Organ Donor". And most people, most of the time, think that that means you will be an organ donor when you die. She had it on her license. Little red heart. Little red gift of one seventeen-year-old heart, two kidneys, one liver, a pair of corneas and a pancreas. Discount the lungs; smoke-damaged and abused. Discount the blood and bone marrow - those are tricky. Seven organs left.
But she was seventeen, and when you are seventeen that little red heart means that your family must give consent. And her mother had come all the way from a very far away state to see her daughter dying, and it was her heartfelt wish that she not have to watch her little girl kept alive by machines, waiting for the harvest. And none of the family members would argue with her.
They withdrew support and let her die, O Best Beloved, and nothing at all was donated. And R came into the callroom and told us that there would be no donation, and told us why, and I was furious. I still am.

There are religious and personal beliefs that prohibit organ donation. I do not subscribe to them and I do not necessarily agree with them, but I am willing to respect them. I am willing to accept that you may not be able to come to grips with a young child's death - although I have seen parents who chose donation for their two-year-old's body - and I am willing to accept that you may simply not wish to give your organs. I will discuss it with you if you like. Many times refusal is rooted in fear, superstition, or misinformation. But we as physicians are not to discuss it; we must leave it up to the organ procurement people. Otherwise, people fear that we will treat them differently - withhold treatment - not try to save lives. Which is ludicrous, but I digress.
I understand all this, O Best Beloved. It would have been different if she had not elected donation on her license, if this seventeen-year-old girl had not already made a decision and expressed her wishes. For her mother to act in direct opposition to those wishes violates the autonomy of the patient and makes her decision an empty pledge - but the fact that it was pure selfish thought by a woman who did not even have custody of her child made me tremble. She did not make her decision with any consideration of her daughter's wishes or any thought as to the consequences - a decision made in grief and pain, I am certain, but a decision made selfishly nonetheless. And no-one else would say her nay.

People died because of that decision, and I think perhaps it is my moral rigidity on this issue that leaves me inflexible, judgmental. But I cannot shake my conviction that what happened there in the ICU was wrong, and I cannot shake the anger that still shivers through me.

In theory, if you are over 18 and you sign consent for donation, and your driver's license shows it, in theory that is all the permission we need - the organ procurement agency states that that is sufficient legal grounds for donation - but they will still address it with the family. Thus far, I have not seen it put to the test in an adult.