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.

[bluesky, BSN, RN]

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, BSN, RN]

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.

[newohiorn, BSN, RN, EMT-P]

Hi,

We do this procedure at my hospital and it is very difficult and very rewarding. The process is usually initiated by the family members. For instance, there is no hope for Jane Doe to ever recover and she needs agressive life support. However, she did not advance to brain death for a variety of reasons. The family has decided to withdraw support, and the patient will likely die within minutes as she is requiring ventilatory support and pressors. However, she is not brain dead and therefore cannot be an organ donor as she had wished. The family is devestated. But, there is a ray of hope to bring meaning to the death of this young girl, DCD. The family is grateful, the organs are donated, and several other people get to lead much better lives.

Each case should be followed by a debriefing for those involved. Each case is extremely individual. But for families, it is a blessing. Can you imagine praying one day for your son to live, and the next that his brain will herniate so he can be an organ donor. This gives families a real sense of meaning when it is time to withdraw support.

This is also done at my hospital just as kindaquazie described. I don't have a problem with it and would want my family to do this if I weren't technically brain-dead.

[jtrauma]

Brain dead is brain dead, there is not hearing there is no feeling of pain, the brain is not receiving blood flow or oxygen so therefore those sensory functions are lost. So why you would give morphine to a brain dead patient is beyond my comprehension because the body is feeling nothing.

DCD (Donor after Cardiac Death) is, I think, a very important part of saving peoples lives. A family has decided to withdrawl care and take away ventilatory support but wants to help others and the patient would want the same. This is something we consider and do a lot in the hospital I work in and it is very rewarding for everyone. The family get to stay at the bedside after care has been withdrawn and be there with their family member as he/she passes. If he/she does not pass in, if I remember, 30 minutes then the donor process is ceased and they are transferred to a private room to pass. If they do pass within that 30 minutes then the family is allowed to say goodbye and the patient is taking to the OR. To me this is no different then just letting someone pass after withdrawling care and checking for heart tones as we do all the time its just that in this case the patient is able to provide for others.

Julia

[judytheoldrn]

Sorry, I wasn't suggesting we give MS to brain dead pts, I was saying that I have less of a problem with DCD than when docs order high doses of MS on NON-brain dead, non organ donor patients to "hurry them along." Wonder how they would feel if they were the ones with the syringe in hand? But that's another thread, didn't mean to hijack this one!

[subee, MSN, CRNA]

Sorry, I wasn't suggesting we give MS to brain dead pts, I was saying that I have less of a problem with DCD than when docs order high doses of MS on NON-brain dead, non organ donor patients to "hurry them along." Wonder how they would feel if they were the ones with the syringe in hand? But that's another thread, didn't mean to hijack this one!

Oh please do "hurry me along". I don't want my children's generation to pay for futile care, nor do I want to keep my family at the bedside one minute longer than necessary. Morphine is God's gift and should be used wisely. For me, this would be a wise use. I don't want to linger. Any extra time spent hovering around the inevitable is time better spent on other patients who have a chance to leave the hospital fairly intact.

[jtrauma]

I'm totally all for giving MS to make the passing more "hurried". I agree it keeps the patient from suffering more than necessary the family as well, I would think watching someone die for days is a lot more torterous than watching them for a couple of hours and they are comfortable.

[TulsaTime]

We just recently did the first DCD at our hospital. Our unit has a very very high number of donors as we are a neurosurgical/trauma unit & in one month we had 10 donors, one of which was DCD. It was very complicated, initiated by the family, and very rewarding to accomplish. Our OR is 4 floors below us so we withdrew support in the OR and the patient died there. I personally see it as an excellent alternative to families who wish to donate but their family member does not progress to brain death. We all worked extremely hard on that patient and just recieved a letter that 10 people benefited from the recovery!