It has been 10 years since the first organ donation after euthanasia (ODE) was performed in the Netherlands. Since then, many procedures have been carried out and we have learned about the possibilities and potential hazards of this procedure. In this issue of the Netherlands Journal of Critical Care, Bollen et al. give an overview of ODE, including legal aspects and history of organ donation after euthanasia, the practical aspects of this combined procedure, its impact on the intensive care staff, and future challenges.[1]

While ODE has increased the number of organs (kidneys, livers, lungs, pancreas and recently also hearts), the possibility of organ donation after euthanasia has yielded many (potential) problems. Firstly, the starting point was that organ donation would have no effect on the practice of euthanasia. This is, however, impossible to maintain, as patients with a wish to voluntarily end their life can be informed about the possibility of organ donation and this possibility may influence their decision regarding euthanasia. Especially in the group of patients with psychiatric disease, it is conceivable that patients may reach the conclusion that through organ donation their body can be of more value to someone else than to themselves, thereby in theory influencing the decision to request euthanasia. While some may not think this is a problem, we need to consider this aspect, as patient groups are well informed and organised and aware of this possibility. So, a person could think that their death and subsequent organ donation would give their existence more meaning, thereby providing an extra or even decisive argument for euthanasia.

In euthanasia, the possibility of organ donation comes up before the occurrence of a catastrophic event leading to brain damage or brain death rendering the person incapable to decide for themselves whether or not to be an organ donor. This makes the potential organ donor a collocutor, and we need to speak with these patients about their wishes and expectations. These expectations may be very different from what we are able or willing to offer. Some who wish to end their life voluntarily do not want to die in hospital. How can this demand be met? A possibility is to bring a team to the person’s home, let them say their farewells to their loved ones, then give the anaesthetic, intubate and ventilate the patient and bring them to hospital while under anaesthesia to perform the euthanasia.[2]
While this is a possibility, it is not without problems: which physician will perform these procedures outside the hospital? Under whose responsibility? Who pays for the extra costs that are involved?

These practical issues can probably be solved. There are, however, other problems: patients have the right to change their plans if they want to, and may postpone the date of their voluntary death. However, this makes it difficult to plan all the steps necessary to perform organ donation and transplantation. Another problem is the potential psychological burden for caregivers. They are dealing with a person who is about to die, and while in many cases this wish to die may be understandable, in some it is not so obvious, especially in patients with psychiatric disease who request euthanasia. This can make the work for organ donor coordinators and the intensivists involved demanding.

And lastly: will the practice of organ donation after euthanasia affect the actual practice of euthanasia? When ODE was started, one of the assumptions was that there should be no effect, and the established practice of euthanasia would not be compromised. Moreover, the need for an arterial line to closely monitor the circulation in order to establish time of death and limit duration of warm-ischaemia may lead to new insights in the regular practice of euthanasia and the drugs used, as we may observe remnant circulatory activity using the arterial line, while there may be no breathing observable and no pulse palpable.[3]

In conclusion, while ODE has many benefits, both for patients on the transplant waiting list and to bring a form of meaning to the voluntary death of the donor, there are also potential problems we need to be aware of in order to prevent negative effects on both euthanasia and organ donation.