Conflicts of interest in the context of end of life care for potential organ donors in Australia

End-of-life (EOL) care has become an integral part of intensive care medicine and includes the exploration of possibilities for deceased organ and tissue donation. Donation physicians are specialist doctors with expertise in EOL processes encompassing organ and tissue donation, who contribute significantly to improvements in organ and tissue donation services in many countries around the world. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring organ and tissue donation is considered according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by clinicians, institutions and health care networks. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU. In this paper we review current controversies around EOL care in the ICU, including the use of palliative analgesia and sedation specifically with regards to withdrawal of cardiorespiratory support, the usefulness of the so-called doctrine of double effect to guide ethical decision-making, and the management of potential or perceived conflicts of interest in the context of dual professional roles. •Discomfort in intensive care patients during end-of-life is common and should be actively anticipated, monitored and treated using individualised palliative sedation and analgesia.•There is evidence in the literature that the routine use of sedation and analgesia for end-of-life care in patients who are close to dying does not hasten or precipitate death.•The doctrine of double effect is not an essential tenet for the provision of good symptom control during end-of-life care in ICU, but it may conceptually provide reassurance and protection for health practitioners.•Donation physicians could be considered to encounter ethical challenges when managing the dual obligation of caring for dying patients and their families while ensuring consideration of organ and tissue donation is performed according to best practice.•Perceived and potential conflicts of interest need to be carefully understood and managed and institutions should have policies on withdrawal of life support and end-of-life care in ICUs, which clearly outline the role of the donation physician.