Not brain-dead, but ripe for transplant

[gwenith]

In June, Ottawa Hospital in Canada announced its first organ transplant in recent history from a patient who hadn't been classified as brain-dead, but whose heart had stopped - so-called "donation after cardiac death" (DCD). By switching to this definition of death for transplant purposes, doctors hope to increase the number of healthy organs available and the number of potential donors from which they can be harvested. For example, the Australian Health Ethics Committee (AHEC) is considering recommending legislation to enable more DCDs, as part of a drive to turnaround Australia's flagging organ donation rates. A similar shift is taking place in the US, where a limited number of DCDs already take place. There, the number of DCD kidney transplants has increased fivefold since 1995 to over 500 in 2004, and numbers are expected to increase sharply over the next decade.

http://www.newscientist.com/article/mg19125633.400-not-braindead-but-ripe-for-transplant.html

This I feel may be a disturbing trend and I would like to see more ethics investigation prior to going down this road.

[AliRae]

I don't like the term 'harvest' at all. It strikes me as macabre. Ugh, I picture a room full of people on life support, disembodied brains, and Frankensteinian doctors with wild-eyed looks in their eyes, ready to bring in the harvest.

I'm not an OR nurse, but from what I've heard, that's not too far off the mark. I've heard some vicious stories of surgeons pushing each other out of the way to get their organs first.

I still shiver every time I have to place the call to the Sharing Network. I'm such a softie...

[GardenDove]

That's why I will never be an organ donar. I'm not really in favor of the whole thing, too much room for abuse. I don't trust the medical system, which is all about making money.

[AliRae]

That's why I will never be an organ donar. I'm not really in favor of the whole thing, too much room for abuse. I don't trust the medical system, which is all about making money.

Not to try and change your mind, but, heck ... I'll be dead, and I could care less if they all go crazy over me at that point. =) I had a cousin who died at the age of 17 and I think one of the only things that's helped me come to terms with that is that fact that others are alive and can see because of his organs and corneas. Personal experience will always colour our opinions, eh?

[traumalover, RN]

All the organ donations I have worked with (ten or so) have been heartbreaking trauma patients that something positive came out of....people received vital organs that let them stay with their family. In all cases it was the family's decision-and these were all patients who had zero chance of surviving...We do dcd, and my best friend is an OR nurse and has been in dcd situations and as never expressed discomfort. not disagreeing just giving my viewpoint!

[RoxanRN]

We have had several DCD donors (and a few brain death) over the last several months. Working with our local organ procurement organization (OPO) has been quite interesting. They are a wonderful resourse to address your questions and concerns. If a nurse doesn't understand why the OPO wants to do something, they (the OPO) are always very willing to explain the rationale.

On a little bit of a more personal note..... I cared for patient who had a massive brain hemohrage. There was no hope of recovery, but unfortunately, this patient couldn't be declared brain dead because they were still overbreathing the vent as well as other things. The plan was DCD (family aware and quite cool with the idea - in fact had already said their good-byes). We supported the patient to support eventual retrieval of the liver and kidneys (only organs possible (I think) in DCD). However, a few hours later, the patient's heart rate skyrocketed and their BP plumitated and they quit over breathing the vent. An apnea test was eventually done and brain death was pronounced. We switched to brain death retrieval and organ support. It was awesome to watch and listen to the transplant coordinator call around the region to offer/place the organs (kidneys were placed quickly; the liver was soon after; the heart and pancreas would be offered/placed later after some studies were completed).

All that to say this...... It really made me think about those families whose lives were about to be changed yet again - the first time with the diagnosis of organ failure and now a phone call will change it for a second time. Life is now full of the possibilities of being able to play with the other children for the first time in a long time, to see their daughters/sons grow up and be married, to see and enjoy their grandchildren, to be able to have a full and happy life. This one patient was able to enhance the lives of at least 5 different families!! I don't know how much better things can get!!

[Dinith88]

I hope they remember to check the EKG in two leads!!

LOL! Reminds me of a famous scene from monty python's holy grail ('i'm not dead yet!'...).

I could just see it '..wait! wash the betadine off and put away your razors...a lead was off!)

On a more serious note... i recently took care of a patient who suffered several massive embolic cva's from a left-ventricular clot...wiped out 'most' of his brain (entire right hemisphere, ~1/2 of his left...but brain stem was intact). 'Perfect' candidate...no chance of a 'meaningful' recovery. (so...not 'dead'...but being 'primed' for 'harvest') Family wanted to let him die and donate organs...and the organ recovery people were all over it.

The hitch was that the family wanted him extubated and sent to a more 'private' room out of icu(cant blame them). I may be wrong here...but there was something to do with a 90 minute window from time of death(maybe for some organs? 10minutes for others???)...Due to his stem being intact, the guy kept ticking after extubation (as expected). The organ-harvesters were kinda pissed as they wanted him left on the vent because in the 'event' of cardiac death, he could be pronounced dead...then 'resucitated' (all the acls stuff) and more effectively harvested. Kinda macabe. Organ donation is a WONDERFUL thing for the recipients...but i get a creepy feeling sometimes about the harvesters...like buzzards circling...

[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!

[txspadequeenRN, BSN, RN]

i was thinking the very same thing!!!

i don't like the term 'harvest' at all. it strikes me as macabre. ugh, i picture a room full of people on life support, disembodied brains, and frankensteinian doctors with wild-eyed looks in their eyes, ready to bring in the harvest.

[bluesky, BSN, RN]

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]

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.

[GrnHonu99, RN]

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...