[bluesky]

Originally Posted by talaxandra

The term 'harvest' is falling out of favour in organ transplantation literature for the reasons already mentioned - the unpleasant connotations for staff and more importantly (from an organ procurment perspective) families.

There is growing concern in the health ethics field about the validity and application of brain death in general, and its close ties to organ donation in particular. I recently attended a conference where the plenary speaker (Allan Kellehear, Prof of Sociology at the University of Bath) spoke passionately about this for an hour and a half.

It's possible that cardiac death may alleviate some of these issues. Though, as Gwenith points out, it potentially opens the door for equally troubling issues.

And this is why health ethicists will never be out of work!

I have had exactly 3 patients whose organs were donated during my career as a nurse. Unfortunately they were all young traumas. I assure you the families (most notably the mothers) could of cared less about word choice. All felt sadness, relief, dignity and purpose in what they were doing. How is it more ethical to just let these viable organs (not to mention all the lives that weren't saved) just go to waste despite explicit and determined decisions? I think the "abuses" argument is a complete red herring based less on reality and more on science fiction. Has anyone ever seen a patient linger for days or weeks with a trach and a Morphine drip while essentially dying of thirst and starvation? Not that pretty, or ethical either, if you ask me.

[talaxandra]

Originally Posted by bluesky

I have had exactly 3 patients whose organs were donated during my career as a nurse. Unfortunately they were all young traumas. I assure you the families (most notably the mothers) could of cared less about word choice. All felt sadness, relief, dignity and purpose in what they were doing. How is it more ethical to just let these viable organs (not to mention all the lives that weren't saved) just go to waste despite explicit and determined decisions? I think the "abuses" argument is a complete red herring based less on reality and more on science fiction. Has anyone ever seen a patient linger for days or weeks with a trach and a Morphine drip while essentially dying of thirst and starvation? Not that pretty, or ethical either, if you ask me.

NB: Although I'm responding to one members' post, the following is general and not aimed at anyone or intended as an attack

Though individuals may not have a problem with the terminology, large scale surveys and follow up have consistently demonstrated that, for at least some family members, the term "harvest" was distressing, and in some cases contributed to the decision not to donate.

Family members who decide against organ donation do so for a complicated variety of reasons, of which word use (ie "harvesting") is only one aspect. Even if every suitable organ was utilised we would fall well short of the number of organs needed - a number that grows almost exponentially every year.

Ethics concerns around transplantation include economic rationalist arguments. For example:

- with the exception of dialysis, transplantation is significantly more expensive that other treatment modalities; though not often explicitly mentioned, this incorporates the fact that patients who die don't cost money (ie compare cost of anti-rejection meds, support and follow up with shorter life expectancy)
- for the cost of one transplant and follow up you can introduce health initiatives that reduce the risk of disease (eg renal failure) for a larger population, thereby benefiting more people

However there are also significant concerns about the well-being and treatment of donors/potential donors. There are a growing number of reliably documented cases of patients who were declared brain dead without meeting the criteria - in one case (described by anesthetist Gail van Norman in "A matter of life and death" Anesthesiology 91(1):275-287, July 1999) a woman was on the table when an anesthetist intervened; she sustained some neurological injury but walked out of the hospital.

While we may argue that being in a persistant vegetative state in a nursing home isn't really living, it isn't right to say that it's the same as being dead.

The plight of people who linger for days isn't ethically unproblematic either (though research indicates terminal dehydration is significantly less unpleasant that dying with hydration and without nutrition), but I'm uncomfortable with the implication that this alone is sufficiently good reason to take organs.

[ELKMNin06]

I am a nurse. I am not an organ donor. I suppose I still have issues with death. I commend the work that the OPAs do but at times it does make me uncomfortable. By law we have to call the OPA anytime we have a GCS of 5 or less and since I work neuro that happens alot...even if we have reasonable thought that the pts. gcs will increase.

[talaxandra]

Wow - I work in neuro, too, and we'd have an organ donor co-ordinator here every other day in that case! And yet I can't think of many patients I've had with a GCS of 5 or less who'd be appropriate donors.
I'm not officially an organ donor - I've spoken about it with my family, and wouldn't really have any objections (I don't really care what happens to my body after I'm done with it), but I also work in transplant medicine and some of the recipients I've had...

[bluesky]

On the neuro unit I am currently working on, we call the transplant consortium to talk to the family about possible donation when the pt is GCS 3, no cough no gag no breathing above the vent, no occulocephalic, no corneals, unequal fixed and dilated plus other important historical findings such as perfusion studies and angios that show that perfusion is not the main issue, tisue death is, and lastly a failed apnea test. I just don't know how much more brain dead a body can be!

[judytheoldrn]

I have more of a problem using a morphine drip in high doses when life support is D/C'd than I do with DCD.

[bethem]

In my hospital, DCD is being phased in. Strangely, the families and patients will not actually be told about the possibility of DCD unless they specifically ask for donation options for patients who are not brain dead. At a recent conference where DCD was presented, only myself and one other participant believed DCD should be as publicised as 'traditional' organ donation after brain death.
I don't think we should be pushing the idea on patients and families, but a discreet poster or pamphlet, like the ones we have about organ donation in general, could help present all the options. Doesn't informed consent involve knowing all the options, their risks and benefits, and making a decision based on that?

[valkyria]

I once saw an episode on Law and Order where I well known surgeon was on trial for "harvesting" the organs of a woman whose husband was claiming she was not officially brain dead and therefore, the Doc hastened the actual death of the mans' wife. Well, it was not looking good for the prosecution, charts were lost, notes had many lines through them and names were hard to read. But, there was a charge for MORPHINE on the patients bill and the Doc could not explain why give a dead woman morphine. I am not saying all cases are that clear cut but there has to be a line in the sand. We all have to agree on what is dead. There is the Harvard Standard but that relates to brain death. Until we are all working on the same page, we are going to be dancing in a dangerous gray area. That is ok too until your Mom is the one they are "harvesting" the organs from or your sister is the one to receive them.

[kindaquazie]

Ok, the use of morphine for brain dead patients is interesting. We use it because it is psychologically better for the nurse and family. Also, pain is the perception of noxious stimuli, however, you all know what can happen when a paralyzed person has "painful" stimuli resulting in autonomic dysreflexia... Who knows what occurs at the root ganglion in response to similar stimuli in the brain dead patient? The better part of valor is to treat them with some kind of pain medication.

[bethem]

Update to my previous post: DCD is coming in shortly. Our medical director and the organ donation coordinator are finalising the policies. At present, it looks like we'll have withdrawal of treatment, a 5-minute stand down time after the heart ceases beating, and a sprint to theatre for a 'rapid laparotomy'. I'm all for it but still stand by my previous comments about truly informed consent. I believe the process should be transparent in order to minimise misinformation.