Coronary angiography and bronchoscopy on brain-dead donors: is informed consent required?

Brain-dead potential organ donors are an important source of organs in transplantation medicine. After declaration of brain death, it is often necessary (depending on donor age, diagnosis and risk factors) to assess organ suitability for transplantation. To this end, coronary angiography or/and bronchoscopy can be requested by the transplant team [1]. Coronary angiography and bronchoscopy are generally not specifically mentioned in consent forms for deceased organ donation [2, 3]. These two procedures are thus included in sentences such as “I understand and agree that...organ specific and routine organ function testing will be performed and drugs administered” [2]. This is surprising, considering the fact that less invasive procedures, such as blood samples, are usually mentioned in the written informed consent form for organ donation [2, 3]. It appears that oral information concerning bronchoscopy and coronary angiography is usually given to the family. In the United Kingdom, for instance, according to the National Institute for Health and Clinical Excellence (NICE) guidelines on organ donation, it is necessary to provide information to the family on “what interventions may be required between consent and organ retrieval” [4]. Invasive procedures normally require specific consent [5]. Here, however, we face a different situation, for two reasons: (1.) these two procedures are conducted on a dead patient, and (2.) these two procedures are conducted for the benefit of a third party. As the patient is dead, he or she is not able to experience any kind of suffering. Damage to bodily integrity is a risk of coronary angiography or/and bronchoscopy. However, compared with organ retrieval, an already accepted procedure, the damage to the body will be minimal. However, psychological harm to family members is possible if coronary angiography or bronchoscopy is performed without their knowledge. A family could accept organ donation, but nonetheless become uncomfortable seeing their loved one transported to the cardiac catheterisation laboratory, for instance, particularly if they have not been informed about the procedure. It is likely that any family that was clearly informed about a procedure that is essential to facilitate donation would agree to it (provided they supported donation in principle). Transparency around all organ donation procedures is essential to maintain family trust concerning organ donation. Thus, the medical community should perform these two invasive procedures on brain-dead potential organ donors, only when the family has been informed (or when their consent has been obtained, in the case of patients who are not registered donors). Obviously, these two procedures should be performed only if they are necessary to assess the suitability of organs for donation [6]. It is our view that in order to avoid inflicting any psychological harm on the family, the possibility of invasive procedures such coronary angiography and bronchoscopy should be discussed while explaining the organ donation process to the family members. Although oral consent is probably the rule in most hospitals, we recommend that consent for possible bronchoscopy or coronary angiography should be included in the written informed consent form for deceased organ donation, as is the case for blood samples. This will strengthen family trust and ensure good medical practice.