Organ donation after Cardiac death

Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death. Bouchek, M et al. New England Journal of Medicine. 2008: Volume 359:709-714.

A report in the NEJM describes a paediatric non-heart beating donor programme for cardiac transplants. This has not been done previously as the ischemic time between cessation of cardiac output and declaration of death has thought to be too great. The program shortened this time to 1.25 mins, justified as being longer than the 60 seconds maximum reported time for auto-resuscitation. Arterial cannulae were placed prior to death to allow rapid infusion of heparin and cooling solutions. There are 3 editorials to accompany the article debating the ethical questions that the program raises. Bernat and Veatch argue that the program makes explicit the conflict within non-heart beating donation, i.e. it may require either additional treatment of the donor, or require a change the definition of death. Donation relies on the dead donor rule – i.e. the donor must be dead before donation of the organs can take place. Death statutes require the irreversible
cessation of circulation and respiration or the irreversible cessation of brain functions; the former constitutes an adequate criterion for death because, in the absence of cardiopulmonary resuscitation (CPR) or auto resuscitation, it inevitably leads to the fulfilment of the brain criterion. Does the fact that a heart is restarted in another patient prove that the patient’s cardiac death was not irreversible? Loss of function must be permanent & irreversible (c.f profound hypothermia which therefore doesn’t meet brain death criteria). Meeting these criteria for other organ donation seems straight forward, the circulation may be permanently & irreversibly stopped before ischemic damage to kidneys & liver prevents transplantation. I think if the heart can be restarted then the patient cannot be dead according to cardiac criteria! Veatch argues that a legal change is required. Either

  1. Donation from alive but rapidly dying patients is made legal.
  2. The definition of death is changed to loss of higher neurological function (consciousness).

These changes raise many ethical, practical, legal and political questions of their own. In reality the withdrawal of treatment in these neonates is very likely being done because of severe brain injury that doesn’t meet brain death criteria. Truog argues the criteria for brain death have served us well, although he then questions some of the underlying assumptions (critically the fact that brain stem death leads inevitably to cardiac death). He then argues that the dead donor rule is actually undermining belief in the ethics of donation as it leads to the possible gerrymandering of definitions. Furthermore that whether the cause of death is withdrawal of ventilation or withdrawal of organs that the principles are the same – and based on valid & informed consent of patient or surrogate. I don’t agree, there is a difference between withdrawal of treatment leaving the patient & pathology to proceed unhindered, and actively determining that process. I would argue that organ procurement in this situation is euthanasia, which may have an ethical argument in its favour but which has no place in a transplant program.

All of these articles are available in full free text from the links, and I recommend them. In addition there is an excellent round table discussion available from nejm as a video or pdf, which explores these issues and more.

Dr. Dan Harvey

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3 comments so far

  1. dgardiner on

    The Denver experience in heart transplantation from DCD / NHBD donors was presented to the 4th International Meeting on Transplantation from Non-Heart Beating Donors: London 15-16 May 2008. See for a report: http://journal.ics.ac.uk/pdf/0902206.pdf

    There the speaker from Denver during question time defended the chosen time frame for declaring death by claiming that such a short time was “in the best interests of the recipient”. There I think we have perfectly phrased the ethical divide between DCD (donation after cardiac death) and DBD (donation after brain death).

    These ethical differences between DCD, concentrating on Maastricht III DCD (withdrawal on ICU) v DBD may be summarised in point form as:
    1. Historical differences
    a. DCD donation was the first form of solid organ necro-donation but was abandoned due to the warm ischaemia inherent to DCD.
    b. Although it is often claimed that the diagnosis of brain death was linked to the first cardiac transplantation by Christian Barnard it is more appropriate to see the recognition of the phenomenon and development of criteria to diagnose brain death as arising in parallel with solid organ donation. Thus there was a need for diagnostic criteria of brain death independent of the need for organ donation.
    c. The re-emergence of the debate of when cardiac death can be certified is driven entirely by the need for solid organ transplantation. Indeed I can remember being told as a junior doctor not to rush to certify the newly dead but to allow extra time to pass to ensure that the dead stay dead. In DCD such time luxury is impossible.
    2. Conflict of interest
    a. Diagnosis v decision: Brain death or brain stem death rests on a diagnosis; DCD rests on a decision to withdraw. This decision can be debated.
    b. The compacted timeframe to diagnose death in DCD can lead to pressure to declare death prematurely to minimise organ ischaemia. In DBD there is no such necessity to rush.
    c. The manipulation of medications during the dying process following withdrawal in DCD allows for great conflict of interest between the interests of the patient (donor) and the recipient. Dr Roozrokh is a San Franciscan transplant surgeon standing charges in a DCD case highlights the potential for conflict of interest.
    3. Dead Donor Rule: Is is my belief that ALL DCD violates the Dead Donor Rule (DDR)
    a. DBD and the provisions leading up to DBD can all wait until after death has been certified. Therefore the DDR is not violated. Moves to involve organ donor co-ordinators early in potential DBD risk violation.
    b. DCD requires alterations of the dying process even in conservative programs like the UK of – timing of withdrawal, extubation (near 100% in DCD but not in usual ICU practice) and a change of attitude to the patient whereby they are treated as a donor before death is certified – that violates the DDR. (awaiting publication in the Cambridge Quarterly of Healthcare Ethics)
    c. It is possible that such changes to the treatment of the dying is illegal in the UK.
    d. The practice in the USA of pre-morbid cannulation and heparinisation makes this violation even more dramatic.
    e. The certification of death in DCD depends on a definition of irreversible that, as noted in the NEJM perspective articles, is difficult to defend in heart transplantation from DCD.
    f. Auto-resuscitation and the Lazarus Phenomenon
    i. Despite the claim that no auto-resuscitation is possible after ~60 seconds (of PEA NOT asystole) this is inconsistent with the case reports of Lazarus Phenomenon
    ii. Although not spontaneous an auto-resuscitation during lung DCD (greater than five minute asystole) was presented to the 4th International Meeting on Transplantation from Non-Heart Beating Donors (see above link)
    g. The use of extracorporeal circulation whilst awaiting DCD has the potential to resuscitate both the heart and brain. Prevention requires the use of a thoracic balloon blocker which in one USA institute was no longer routine and the heart was often seen to restart. (see link)
    h. There have been calls to abandon the DDR but this should be seen as a radical departure from the ethical norm.
    4. Consent
    a. If the DDR rule is abandoned than the primacy of informed consent should be emphasised.
    b. The current UK Organ Donor Register has minimal mention of DCD and certainly does not meet the requirement for informed consent. Under the Human Tissue Act (2004) families have no legal right of veto and if their loved one was on the ODR they have therefore legally consented to the manipulation of their death for the purposes of facilitating DCD. It is difficult to sustain this position and neither can UK Transplant (for a discussion on the HTA see page 42-44: http://journal.ics.ac.uk/pdf/07_02.pdf
    c. Even surrogate consent as practiced in the USA is suspect when Mrs Navarro the mother of Ruben Navarro (the DCD case involved in the Dr Roozrokh case) says “They mistreated him and they abused him and they took advantage of him and me.” And “He didn’t die with dignity, and I didn’t have the chance to really say goodbye to him. I don’t think it’s right. These people need to pay for what they did to him.”

    Dr D Gardiner

  2. danharvey on

    Thanks for a great post Dale. This paper has also been discussed at QMC ICU journal club – a copy of a ppt presentation by Dr. Lizzie Robinson can be found in the blue box labelled “nmbd nejm 2008 presentation”.

  3. danharvey on

    The above papers are making waves outside of the medical establishment (as they should), see this article from the Economist which discusses the legal position, and upcoming religious discussion over non-heart beating donation.


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