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.