Organ donations after medical assistance in dying (MAiD) have risen in Québec and accounted for 14% of total deceased donations in 2022, new research revealed.
“Seeing that 14% of our deceased donation activity was coming from donation after MAiD was surprising,” study author Matthew J. Weiss, MD, medical director of donation at Transplant Québec in Montréal, told Medscape Medical News. “We suspected it was going to be a fair amount. But to see it calculated in Black and White was quite surprising because it’s a new procedure that requires a lot of logistical support from the organ donation coordinators and the Transplant Québec sites.
“When things are new and difficult, you always wonder how uptake is going to occur,” he acknowledged. “In this case, we’ve had a steady rise in the number of referrals and the number of completed cases.”
The study describes organ donations after MAiD in the first 5 years after implementation in Québec. It was published online on January 29 in the Canadian Medical Association Journal.
MAiD Donations Increased
MAiD legislation was approved in Québec in 2015 and federally in 2016. Eligibility criteria are defined by provincial legislation and policy. Since 2018, physicians who provide MAiD have been encouraged to discuss organ donation with eligible patients after the decision to pursue MAiD is finalized. If the patient expresses interest, then the physician refers him or her to Transplant Québec.
For the descriptive study, the researchers retrospectively reviewed all cases referred for donation after MAiD in Québec from January 2018 to December 2022. Unlike some Canadian jurisdictions, Transplant Québec is responsible only for deceased donation of solid organs and not of tissue (eg, corneas or heart valves).
Therefore, during the study period, only lungs, liver, and kidneys were considered for recovery and transplantation after the determination of circulatory death, whether the mechanism of death was MAiD or the withdrawal of life-sustaining measures.
Overall, Transplant Québec received 245 referrals for donation after MAiD, of which 82 (33.5%) were retained. Retained referrals are those that progress past initial telephone conversations, and these patients are subject to further evaluation.
Of the 163 nonretained referrals, 152 (93.2%) had a recorded reason, including 91 (55.8%) for medical unsuitability on initial screen (eg, organ dysfunction or medical history), 34 (20.8%) for patient refusal, and 21 (12.9%) because patients withdrew from the MAiD process. In addition, six patients died before MAiD.
Further analysis showed that 18 of the 82 retained cases were canceled later in the process, almost all (94.4%) because of a medical contraindication discovered during the donor evaluation.
A total of 64 patients became donors after MAiD during the study period, increasing from 8 in 2018 to 24 in 2022. Donors’ average age was 60 years, and 64% of donors were men. The most common diagnosis among donors was a neurodegenerative disorder (84.3%), the most frequent of which was amyotrophic lateral sclerosis. Other diagnoses included terminal cardiopulmonary disorders, chronic pain syndromes, and spinal cord injuries.
The conversion rate from referral to donation was 26.1%, and 182 organs (116 kidneys, 20 livers, and 46 lungs) were transplanted after MAiD.
Overall, MAiD donors represented 8.0% of total deceased donors in Quebec during the study period. This proportion increased from 4.9% in 2018 to 14.0% in 2022. The average number of transplanted organs per donor (2.9) is equivalent to that of all standard criteria donors after circulatory death in Québec in 2021 (2.8).
Rapid and Predictable
“Our findings demonstrate that the pathway for donation after MAiD results in a rapid and predictable form of donation after circulatory determination of death,” the authors wrote. “The longest warm ischemic time was 43 minutes, and no donation was canceled because of prolonged warm ischemic time.”
The study’s limitations included its retrospective design, missing data, the fact that the new system was evolving during the study, and that donation after MAiD was “deeply affected” by pandemic shutdowns during 2020 and 2021.
The team’s next step will be to investigate what happens to the organ referrals, said Weiss. “The current study was really the lowest hanging fruit: the basics of how many cases we were doing. Now, we need to know how these organs perform posttransplant, compared with both organs that are recovered from brain-dead donors and from donations after circulatory determination of death.
“A few reports out of Ontario about kidneys seem to confirm what surgeons have told me anecdotally: That the organs are performing quite well,” he said. “But we need to investigate further.”
In addition, Transplant Québec wants to help ensure that physicians who are providing MAiD are aware of the donation option and mention the possibility to anyone who is eligible. “We would like to develop a reporting system that would show that donation was offered, and if it was declined, why? And feedback on what we might change on our end to improve the system and decrease barriers to make it more likely that someone who does want to donate can do so more easily.”
American Differences
Arthur L. Caplan, PhD, Mitty Professor of Bioethics and founding director of the Division of Medical Ethics at the New York University Grossman School of Medicine, New York City, commented on the findings for Medscape Medical News. Caplan, who was not involved in the study and recently provided a commentary on MAiD for Medscape Medical News, said he was surprised by the 26% conversion rate in the study.
“It may be that the Québec criteria for using MAiD are more liberal or wider than [those that] prevail in the US, because people who use MAiD here are usually terminally ill, older, and frail,” said Caplan. “I don’t think we would get anything close to that. The overwhelming majority who use MAiD here are dying of cancer, and not people you would look to for organ donation.” Although most patients who used MAiD in Québec also had metastatic cancer, those individuals were not eligible for organ donation.
For donation after MAiD to work most effectively in Canada and elsewhere, Caplan advised, “you have to have very clear protocols in place.” For example, no one who pronounces death should have anything to do with organ procurement, which is done by a separate group of people.
“In addition,” he said, “there cannot be any change in the care of the dying person, because people will be wondering ‘Are they accelerating my death because they want organs?’ It must be clear in the organ donation policies that there is no deviation from standard of care to maximize the chance of organ procurement.”
Furthermore, people should not be pressured into MAiD because of society’s need for more transplantable organs.
“Overall, this is a trust issue,” Caplan said. “We can’t change things. We can’t hurry things. We can’t have different people approaching patients because they’re in this MAiD world. This all needs to be laid out and then taught, making sure the public understands what’s going on. It’s not just about having rules, but also making sure that everyone knows the rules and why they’re being implemented.”
Funds donated from the McGill University Health Centre and held by one of the authors were used to pay publication fees. Weiss declared that he is a paid consultant to Transplant Québec. Caplan has served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use. He also serves as a contributing author and advisor for Medscape.