Donation By Cardiac Death: When Is the Patient Dead?
An organ procurement practice, in order to obtain more organs for the needy patients, has involved obtaining organs by permission from patients who are alive but have decided to end life-supportive treatment but also want to donate their organs after death. The procurement of organs, in keeping with the ethical "dead donor rule" cannot begin until the patient is pronounced dead. The process is called DCD (donation by cardiac death) and the procedure is to terminate life support (ventilators, blood pressure support, etc.) and wait until the patient's heart stops but if the heart does not spontaneously stop within an hour or so, the patient is no longer a candidate for donation (because of deterioration of organs beyond an hour) and is given comfort care until the patient dies. If the heart has stopped within the hour, then the patient's physician must wait for usually 5 minutes before pronouncing the patient dead.
Here is the issue with DCD: Is the patient really dead after 5 minutes with no heart beating (and associated no breathing)? It has been fairly well established that the heart will not resume beating on its own and without physician resusitation after about 5 minutes. So therefore if no mechanical/electrical resusitation is attempted by the physician, could the physician honestly and with confidence pronounce the patient dead? When the patient is pronounced dead by the attending physician, the procurement surgeons are then given permission to begin removing organs. But at that point is that patient really dead? At 5 minutes, the brain is working to some degree even if the patient is unconscious. And if the physician at 5 minutes actually attempted to restart the heart and it started beating, how would that be consistent with a dead patient?
Moreover, suppose the heart had stopped beating in the donor patient and was removed and eventually transplanted into the recipient patient and then began to beat and function in the recipient's chest, would that mean that, in essence, when the still heart was removed from the donor patient, that patient was actually alive and not dead?
These are all questions which continue providing consternation to doctors, lawyers and ethicists.
What is death, when does it really happen and when can an essential organ, like the heart, be removed from a patient for transplant without the fear that that very act of removal is in essence killing the patient? These are not just philosophical and medical or legal questions that can only be answered by ethicists, physicians or lawyers. There has to be a societal consensus of everyone like my visitors for "donation by cardiac death" to be an acceptable way of fairly, ethically and legally obtaining those very much needed organs for the sick. This process for obtaining organs must be publicly in the open and not in any way made secret.
Please write me your answers to these questions. I will describe without identification your responses to a bioethics listserv so that physicians and ethicists and lawyers there learn what the public thinks. ..Maurice.
posted by Maurice Bernstein, M.D. @ 7:51:00 PM
6 comments
6 Comments:
Your questions are so hard they make my head hurt.
I believe, but I am not sure, that each state has a description of what death is. In some states it is the cessation of brain activity, in others it's the cessation of heart activity.
My brother in law met an early death in an auto accident. He was "alive" on a ventilator. His heart was beating. He was taking no breaths on his own. A cold caloric test and several EEG's showed he had no brain activity. He was dead. Was his heart beating? Yes. Was his blood pressure at adequate levels? Yes, by the grace of medication. Was he alive, could he think, open his eyes, communicate? No, and he would never be able to do so. His skull, thus his brain had been shattered beyond repair.
The "life tests" gave the family an opportunity to prepare for his "death" and say good bye, but he was gone already.
My brother in law's family, (my sister and his two sons) took great pride that even in his death, their husband and father saved 2 people with his kidneys, and one person with his heart and lungs.
Wow, what a legacy to leave behind for your children.
Death by neurologic criteria or previously called "brain death" is a pronouncement of death which most commonly supports vital organ procurement for transplant. Because the heart is still beating in that patient along with mechanical ventilation, the patient is warm, pink and doesn't appear dead. This criteria for meeting the dead donor rule (no organ procurement until the patient is pronounced dead) still has a number of scientists, physicians, ethicists and members of the public and families uncertain about the certification that the "brain dead" patient is really dead. However, as you point out with no chance to resume contact with the world and personhood and also by the fact that after days or weeks even on the ventilator the heart will stop, the patient is for the purpose of organ procurement essentially dead.
The issue with the "donation by cardiac death" is what and when is cardiac death. And this issue, as I have noted, is also not fully resolved.
However, in either case, you are absolutely correct by recognizing the wonderful legacy that the donor leaves behind to those who know him or her and to those patients who by this donation are given a chance to live. ..Maurice.
The concept of brain death and mechanisms to determine the irreversible cessation of function of the entire brain is well described and accepted by most. Questions arise when the diagnosis is made hastily.
The concept of "donation by cardiac death" troubles me. As I understand it, it is a process geared mostly to organ procurement. The concepts of brain death and treatment withdrawal originated from an attempt to preserve the dignity and assure comfort of the dying individual, avoiding futile and intrusive treatments that will not change the outcome. These concepts facilitate "death with dignity" without the intrusive intervention of medical science. Once the patient is dead, organ donation can proceed.
If the brain is not dead, withdrawing treatment will eventually lead to cardiac death. When that occurs, organ donation is acceptable if agreed upon. The intent of treatment withdrawal, however, was to allow "natural" death.
The intent of "donation by cardiac death" as I understand it, is to facilitate the process for the sole purpose of organ donation...an altruistic but also a profitable enterprise. I can visualize the patient, in the OR, surrounding by the transplant team, scalpel at the ready, waiting for the heart to stop beating, counting the five minutes and....go! (the stuff nightmares are made off).
If the brain is not dead when the heart stops, brain death will occur some time later. We really do'nt know when that happens and the best one can provide is an educated guess (or an expert opinion).
The old, usual procedure was to allow the patient to expire after removing life support, then contacting the transplant team and proceeding with organ donation. That means that some organs cannot be harvested. But what are we? Is our mission to assure that organ harvest is pure, pristine and organic? Or is our mission to protect the comfort and dignity of a patient who is dying in spite of our best efforts?
Raul, your comments are pertinent and insightful. "Donation by Cardiac Death" (DCD)was designed only to have available a greater pool of fresh organs for transplant. How the procedure prior to the death pronouncement is carried out sets the ethical and humanistic appearance of the whole process. When DCD was first used, there were institutions who would begin organ preserving actions even prior to cardiac death which could be said to also accelerate the patient's dying. Subsequent protocols have specifically prohibited these actions. The other aspect is maintaing the dignity of the patient prior to death. Some insitutions, such as my local community hospital, direct that the patient remain in the critical care unit where the patient had been treated and continue to remain there during the removal of life support with the family present until the patient is formally pronounced dead. The deceased patient is then moved quickly to the operating rooms which have been prepared for the organ procurement. This keeps the procurement surgeons away from the patient until death and better attempts to maintain patient dignity and a more dignified death itself. A delay in procurement by this protocol may be insignificant in terms of organ health but in any event very important as an ethical process. The recent legal action taking against a transplant surgeon and hospital staff behavior with a DCD patient in San Luis Obispo, California I am sure could have been prevented if the patient was not monitored for death off life support in the hospital's operating room with the surgeon in attendance. ..Maurice.
My spouse is on a transplant list and was called this week for a transplant. The potential donor was a DCD. The information that we got was that the criteria established left a small window of time for the heart to stop after withdrawal of support. If it did not stop within that window, the organ would not be harvested. The donors heart was still beating at he the one hour mark. It was disappointing to us and I'm sure to the donors family as well. They wanted to do something to help others and that was limited by the standards that are set. The donor would not have survived with any quality of life yet those organs that could have been lifesaving for multiple other people were not used. I completely understand that guidelines and restrictions must be a part of the process but on some level if we are looking to increase the "pool" of healthy organs, we should not be wasting those that in the end will serve no one because of a time frame not being met. I have the donor designation on my drivers license and if the time comes, I expect those in charge not to waste what I am offering to others. Anne
Anne, physicians cannot always predict correctly the heart of which patient will promptly stop beating when life-support is removed and which will continue to beat. One would expect cardiac arrest in a patient who needed full mechanical respiratory ventilation (because the patient could not breathe at all without it) should have a cardiac arrest promptly after discontinuing ventilation. However, some patients are felt to be candidates because an "apnea test" (where the patient is taken off the ventilator for a brief period to predict whether the patient will not breathe without the ventilator)is positive, however it may turn out that the test was in error and the patient is still able to breathe sufficiently without the ventilator to keep the heart beating. It is tragic circumstance for the potential recipient, however to transplant a potentially damaged heart would be much more than a tragedy, it would also be malpractice. ..Maurice.
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