Cameron Stewart

An International Comparison of the Effect of Policy Shifts to Organ Donation following Cardiocirculatory Death (DCD) on Donation Rates after Brain Death (DBD) and Transplantation Rates

During the past decade an increasing number of countries have adopted policies that emphasize donation after cardiocirculatory death (DCD) in an attempt to address the widening gap between the demand for transplantable organs and the availability of organs from donation after brain death (DBD) donors. In order to examine how these policy shifts have affected overall deceased organ donor (DD) and DBD rates, we analyzed deceased donation rates from 82 countries from 2000–2010. On average, overall DD, DBD and DCD rates have increased over time, with the proportion of DCD increasing 0.3% per year (p = 0.01). Countries with higher DCD rates have, on average, lower DBD rates. For every one-per million population (pmp) increase in the DCD rate, the average DBD rate decreased by 1.02 pmp (95% CI: 0.73, 1.32; p<0.0001). We also found that the number of organs transplanted per donor was significantly lower in DCD when compared to DBD donors with 1.51 less transplants per DCD compared to DBD (95% CI: 1.23, 1.79; p<0.001). Whilst the results do not infer a causal relationship between increased DCD and decreased DBD rates, the significant correlation between higher DCD and lower DBD rates coupled with the reduced number of organs transplanted per DCD donor suggests that a national policy focus on DCD may lead to an overall reduction in the number of transplants performed.

Implementing a One Health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions

Background‘One Health’ represents a call for health researchers and practitioners at the human, animal and environmental interfaces to work together to mitigate the risks of emerging and re-emerging infectious diseases (EIDs). A One Health approach emphasizing inter-disciplinary co-operation is increasingly seen as necessary for effective EID control and prevention. There are, however, socio-political, ethical and legal challenges, which must be met by such a One Health approach.DiscussionBased on the philosophical review and critical analysis of scholarship around the theory and practice of One Health it is clear that EID events are not simply about pathogens jumping species barriers; they are comprised of complex and contingent sets of relations that involve socioeconomic and socio-political drivers and consequences with the latter extending beyond the impact of the disease. Therefore, the effectiveness of policies based on One Health depends on their implementation and alignment with or modification of public values.SummaryDespite its strong motivating rationale, implementing a One Health approach in an integrated and considered manner can be challenging, especially in the face of a perceived crisis. The effective control and prevention of EIDs therefore requires: (i) social science research to improve understanding of how EID threats and responses play out; (ii) the development of an analytic framework that catalogues case experiences with EIDs, reflects their dynamic nature and promotes inter-sectoral collaboration and knowledge synthesis; (iii) genuine public engagement processes that promote transparency, education and capture people’s preferences; (iv) a set of practical principles and values that integrate ethics into decision-making procedures, against which policies and public health responses can be assessed; (v) integration of the analytic framework and the statement of principles and values outlined above; and (vi) a focus on genuine reform rather than rhetoric.

Untested, unproven, and unethical: the promotion and provision of autologous stem cell therapies in Australia.

An increasing number of private clinics in Australia are marketing and providing autologous stem cell therapies to patients. Although advocates point to the importance of medical innovation and the primacy of patient choice, these arguments are unconvincing. First, it is a stark truth that these clinics are flourishing while the efficacy and safety of autologous stem cell therapies, outside of established indications for hematopioetic stem cell transplantation, are yet to be shown. Second, few of these therapies are offered within clinical trials. Third, patients with chronic and debilitating illnesses, who are often the ones who take up these therapies, incur significant financial burdens in the expectation of benefiting from these treatments. Finally, the provision of these stem cell therapies does not follow the established pathways for legitimate medical advancement. We argue that greater regulatory oversight and professional action are necessary to protect vulnerable patients and that at this time the provision of unproven stem cell therapies outside of clinical trials is unethical.

ANZSN Renal Supportive Care Guidelines 2013

• Nephrologists seek to provide dialysis to those who will benefit most while being honest and direct with those who are unlikely to benefit or even be harmed by dialysis; these can be difficult decisions. • A ‘conservative’ or ‘not for dialysis’ pathway is an important option for the management of end-stage kidney disease (ESKD) patients who are elderly, have significant comorbidity, poor functional status, malnutrition or who reside in a nursing home. • Such a pathway is best underpinned by a specific renal supportive care programme in each unit. • Nephrologists need to lead realistic discussions about likely survival with patients and their families before dialysis is instituted. • Key ethics principles are a good aid in this decision-making process • A ‘non-dialysis’ renal supportive care programme is a very positive way of offering holistic care for patients and their families; many of these patients live much longer without dialysis than might have been expected. Perhaps the most difficult decision facing nephrologists today is that of ‘selecting’ which patients will benefit from dialysis in an overall person-centred sense, not just in terms of days survived or achievement of target haemoglobin, Phosphate, Kt/V or other outcomes. The overall aim is to help and direct patients and their families so as to encourage those who will benefit most from dialysis to have this while being honest and direct with those who are unlikely to benefit or even be harmed by dialysis. Consequently it is imperative that we have mechanisms in place that support those who do not receive dialysis in such a way that they have good symptom control and quality of life (QOL). While the discussions below apply to every potential dialysis patient regardless of age, in practice most ‘younger’ patients (below 70) are likely to be offered dialysis; these considerations below become far more relevant for discussions with patients who are over 70 years old with stage 4 or 5 end-stage kidney disease (ESKD). We are therefore looking at three potential pathways for patients with ESKD: 1 Not for dialysis or transplantation – a clear decision based on medicalandethicalgroundsincorporatingthepatient’swishes. 2 For dialysis or transplantation. 3 Indeterminate – that group for whom the treating nephrologist and the patient are unable to come to a clear decision. For people in this group, seeking a second opinion and ideally, discussing the case at a multidisciplinary team meeting (similar to those discussions surrounding acceptance onto the transplant waiting list) are paths to follow. A very important principle is that these planning discussions need to take place early in the course of a patient’s management, probably when estimated Glomerular Filtration Rate (eGFR) reaches 25 mL/min. There are some key principles that can help nephrologists, patients and their families make these decisions: 1 Nephrologists need to lead these discussions – these are very difficult discussions but it is imperative that as nephrologists we do not shy away from them as this is to the ultimate detriment of the patient and their family. In some centres it may be that nephrologists do not see the same patients regularly and the temptation here will be either to use dialysis as the default choice for all patients or else to leave these discussions to other medical or nursing staff. It is inappropriate for these discussions to be delegated to more junior medical staff but advanced trainees and Junior Medical Officers (JMOs) should be present as part of their training. Initial discussions are generally best if done with the nephrologist and his/her medical team, and then followed by more detailed discussions with nursing staff and allied health staff. Ideally a renal supportive care (RSC) programme team will help facilitate these ongoing discussions with a patient and their family when a conservative not-for-dialysis pathway is chosen and a pre-dialysis team will assist those for whom dialysis is considered the correct management pathway. Many nephrologists have already made it part of their usual practice to offer a ‘non-dialysis’ pathway to selected patients but many are also understandably troubled when making such decisions. This issue has become more prominent because of the increasing number of aged patients with comorbidities, frailty, or poor functional status who present with end stage kidney disease, for whom decisions need be made as to the appropriateness of dialysis. 2 Nephrologists need to have realistic discussions about likely patient survival on dialysis – data are available from Australian and New Zealand Dialysis and Transplant Association (ANZDATA) to guide this. We need to be aware that these discussions are likely to be aimed at frail, ‘marginal’ patients of any age although most of the available data deal specifically with those over the age of 75 years: a. Current data show that patients starting dialysis in the 75–84 years age group, presumably already selected to some extent by their nephrologists as suitable bs_bs_banner

A test for mental capacity to request assisted suicide.

The mental competence of people requesting aid-in-dying is a key issue for the how the law responds to cases of assisted suicide. A number of cases from around the common law world have highlighted the importance of competence in determining whether assistants should be prosecuted, and what they will be prosecuted for. Nevertheless, the law remains uncertain about how competence should be tested in these cases. This article proposes a test of competence that is based on the existing common law but which is tailored to cases of assisted suicide. The test will help doctors, other health professionals and lawyers determine whether the suicidal person was able to competently request assistance. Such knowledge will help to reduce some of the current uncertainty about criminal liability in cases of assisted suicide.

The deadly business of an unregulated global stem cell industry

In 2016, the Office of the State Coroner of New South Wales released its report into the death of an Australian woman, Sheila Drysdale, who had died from complications of an autologous stem cell procedure at a Sydney clinic. In this report, we argue that Mrs Drysdales death was avoidable, and it was the result of a pernicious global problem of an industry exploiting regulatory systems to sell unproven and unjustified interventions with stem cells.

Single-centre cross-sectional analysis of advance care planning among elderly inpatients.

Advance care planning (ACP) has been shown to provide beneficial outcomes for elderly patients; however, it may not be commonly implemented.

Attitudes of the general public towards the disclosure of individual research results and incidental findings from biobank genomic research in Australia.

Over the past decade, managing the disclosure of findings of genomic research has been the subject of extensive scientific, ethical and legal commentary and is a major challenge for biobanks.

Open disclosure: ethical, professional and legal obligations, and the way forward for regulation.

Open disclosure (OD) after adverse health care events is the subject of a national standard that has been implemented in state health policy documents, and is included in the Medical Board of Australias code of conduct for doctors. Nevertheless, doctors have been slow to embrace the practice of OD. There is a strong ethical case for implementing OD in the primary interests of patients, and additionally from a medicolegal risk management point of view. There are no statutory requirements in relation to OD, but common law judgments have imposed a duty of OD in tort and contract. There are a number of barriers to the better uptake and implementation of OD, including perceptions of legal risk, lack of education and training, reluctance to admit error, uncertainty concerning what and how much to disclose, and the variations in state and territory “apology laws”. The implementation of OD could be improved by making apology laws consistent across jurisdictions, including providing “blanket” cover for admissions of fault; by preventing insurers voiding contracts when apologies are made, either through self‐regulation or legislation; and by inserting OD obligations into different structures within the health system.

Intimacy or utility? Organ donation and the choice between palliation and ventilation

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this persons death might be best managed to be of benefit to others.