Should we use full analgesic dose of opioids for organ procurement in brainstem dead?

Abstract

Families facing the growing demand for organ removal from their loved ones are questioning the possible suffering of the brainstem dead patient. A frequent question they ask to coordinating doctors is: Are you sure he will not feel anything? Currently due to the risk of exacerbation of spinal reflexes and abnormal movements following surgical stimuli, it is recommended to use a curarization and an analgesic agent (most often morphine). The doses of opioids are less important than during usual anaesthesia, whereas the person is considered brainstem dead and there is no longer any cerebral integration of the pain. But what assures us that absolutely no more sensibility exists at this precise moment? Should the use of full analgesic dose of opioids not be continued anyway? Could this make the levies more "ethical"?

Key Words: Bioethics; Transplantation; Anaesthesiology; Brainstem dead

Core Tip: Families facing the growing demand for organ removal from their loved ones are questioning the possible suffering of the brainstem dead patient. A frequent question they ask to coordinating doctors is: Are you sure he will not feel anything? Currently due to the risk of exacerbation of spinal reflexes and abnormal movements following surgical stimuli, it is recommended to use a curarization and an analgesic agent (most often morphine). The doses of opioids are less important than during usual anaesthesia, whereas the person is considered brainstem dead and there is no longer any cerebral integration of the pain. But what assures us that absolutely no more sensibility exists at this precise moment? We propose that further neuroscientific analyses be conducted in order to improve our knowledge about such a sensibility. We ask to the medical community if we should rather use full analgesic dose of opioids, and question if this would make the levies more "ethical"?

INTRODUCTION

The definition of death is changing, driven by clinical physicians, physiologists and biomedical ethics specialists[1]. This evolution, both semantic and diagnostic, seems to be completely independent of religious influences, whether monotheistic or not. Recently, the concept of brain death has been called into question[2], with this underlying idea (and certainly provocative): What if the first motivation behind the introduction of this patho-physiological concept was not the extended possibility of access to graft organs, rather than death itself[3]?

ETHICAL AND PHYSIOLOGICAL CONSIDERATIONS

With this moving and fluctuating definition of death (the moment of death, but also the stage of death)[4], we see that the definition of a total insensitivity of the deceased is debated: It may not be so immediate, nor so complete as initially considered. In the context of the most ethical medical and surgical practice possible, particularly in the context of critical care medicine, it is legitimate to wonder about a possible evolution of our professional practices.

Families facing the growing demand for organ removal from their loved ones are questioning the possible suffering of the brainstem dead patient. A frequent question they ask to coordinating doctors is: Are you sure he will not feel anything? Currently due to the risk of exacerbation of spinal reflexes and abnormal movements following surgical stimuli, it is recommended to use a curarization and an analgesic agent (most often morphine). The doses of opioids are less important than during usual anaesthesia[5], whereas the person is considered brainstem dead and there is no longer any cerebral integration of the pain. In this context, what assures us that absolutely no more sensibility exists at this precise moment? Should the use of full analgesic dose of opioids not be continued anyway? Could this make the levies more “ethical”?

CONCLUSION

The distress of the families is understandable, but the administration of analgesics at usual dose could also create a confusion of the families and be a source of misunderstanding between the declaration of death of their relative and the use of analgesic during the procedure of organ extraction[6]. This question should be taken into account by an international college of anaesthesiologists and bioethics specialists. In addition, it is likely that neurosensory experiments are necessary, not only at the level of the cerebral stage, but also of the spinal cord.