Meltzer, Ellen C.

Donation after circulatory death (DCD) has become a key avenue for expanding the organ donor pool. Many DCD protocols include premortem intravenous heparin to reduce microthrombus formation and preserve graft viability. This presents the plausible risk of premortem bleeding from an intervention that offers no direct therapeutic benefit to the donor. Ethical concerns and moral distress can arise when potential donors have a catastrophic intracranial hemorrhage with ongoing physiological concern for bleeding risk that is not survivable, but do not currently meet brain death criteria. While prior analyses describe premortem interventions in DCD in conceptual or protocol-driven terms, this case report considers the ethical concerns inherent in premortem heparin administration and illustrates how multidisciplinary teams can operationalize ethical safeguards, including transparent communication, attention to surrogate understanding, and separation of end-of-life decisions from donation-related interventions, to mitigate concerns and minimize moral distress. These issues are directly relevant to palliative care clinicians, who frequently support families during end-of-life crises and when there is consideration for organ donation. Through a multidisciplinary and ethically guided approach, this case illustrates how collaborative decision-making and transparent communication can uphold both donor dignity and transplant integrity.

Abstract Honoring a patient’s wishes for end-of-life care can be challenging if the patient loses decision-making capacity and the identified alternate decision-maker will not respect the patient’s wishes. This article discusses how to proceed ethically and legally when the alternate decision-maker and care team disagree about respecting a patient’s end-of-life preferences.