Feasibility of organ donation following voluntary assisted dying in Australia: lessons from international practice

To the Editor: We respond to the article by Bollen and colleagues.1 In 2021, the results of an international roundtable and in‐depth literature review on the worldwide status of organ donation after euthanasia (ODE), involving eight countries including Australia, were published.2 ODE is indeed both legally and clinically feasible in Australia.2 However, Bollen and colleagues appear to underestimate the serious procedural challenges that remain. In general, their article omits the perspectives of the patient and the provider.

The authors’ statements include “The process is essentially the same as DCD [organ donation after circulatory death] by patients in the intensive care unit (ICU) following withdrawal of life‐sustaining therapy”, “the patient should ideally undergo euthanasia in the hospital”, and “Euthanasia is often performed in the ICU as its personnel are familiar with organ donation”. However, a conscious, vulnerable VAD patient is very different from an unconscious patient undergoing withdrawal of life‐sustaining therapy in the ICU.2 The authors appear to neglect that VAD and DCD are separate patient pathways, with their own ethical considerations, requirements and circumstances. Most VAD patients see the ideal situation as dying in the private surroundings of their home and not being confronted again with hospital environments.3 Moreover, the limited available information on rare instances of VAD and ODE for conscious patients in ICUs shows that ICU health care workers experience the process as stressful.2

The statement that “Given that a person must request VAD themselves, it is unlikely that there will be any potential for coercion” ignores possible undue pressure on patient autonomy after the initial VAD request. A patient who is having second thoughts might feel pressured not to withdraw during contact with organ donation stakeholders.2 The introduction of ODE at home in 2017 in the Netherlands, Canada and Spain has mitigated these problems, with the patient falling asleep at home at the start of the procedure, and achieves the same organ quality results.2,3

The roundtable also recommends developing national best practice guidelines in the Australian context, but without making the mistake of omitting patient and VAD provider perspectives.3,4