IN AN EFFORT to honor family requests to donate the organs of a family member who may die shortly after the elective withdrawal of life-sustaining treatments, Baltimore hospitals in conjunction with the Transplant Resource Center of Maryland are developing new protocols allowing the harvesting of organs from donors who have been declared dead by cardiopulmonary criteria. Because the hearts of these patients will not be beating at the time of organ procurement, these protocols are called Non-Heartbeating Donor (NHBD) protocols. The implementation of these protocols began in the late 1980s and they are now present in more than 30 transplant centers in the United States.
Non-heartbeating donation is also seen as a means of alleviating the current shortage of donated organs. It is estimated that widespread use of NHBD protocols can save the lives of 25 percent of the approximately 4,000 patients who die each year waiting for a transplant.
Presently, the vast majority of organ donation in the United States is from donors whose deaths have been established by brain criteria, but whose cardiopulmonary functions are maintained artificially (i.e. beating hearts), which prevents organ damage by allowing organs to receive oxygenated blood prior to procurement. While there are ethical and psychosocial issues relevant to both types of organ donation, non-heartbeating organ donation raises more complex and problematic issues than does donation following death declared by brain criteria. Here are the issues:
When does death actually occur? Compared with brain criteria, cardiopulmonary criteria for establishing death are far less clinically established. For example, there is no consensus on what should be the time interval between the detection of cardiac arrest and the declaration of death. This question is motivated by a concern with autoresuscitation of the heart, which if it occurs results in the procurement of organs from patients who are still alive.
Unfortunately, very little data exist regarding how long to wait after the heart has stopped beating before declaring death and harvesting organs. Consequently, different transplant centers embrace variable time intervals before confirming death. Such variation between centers engenders the concern that death is being manipulated to maximize the chances for organ procurement (a shorter time observation after cardiac arrest minimizes organ damage). The NHBD protocol used in Baltimore has a time interval of five minutes, a period recommended by a recent Institute of Medicine report.
Can potential conflicts of interest be managed? Compared with donation following brain death, where the timing of death cannot be controlled, donation after cardiac death intensifies concerns about conflicts of interest for health care providers and health care institutions.
Strong safeguards are needed to ensure that the interest in procuring organs does not compromise the care of patients who may become, or already are, designated donors.
To ensure that patient care concerns remains paramount, safeguards require separating major decisions and discussions in patient care from those involved in organ donation. Accordingly, existing NHBD protocols require that a) a discussion of organ donation does not occur until after the family makes a decision to withdraw life support and b) members of the transplant service are not involved with any family discussions about donation, and are not involved with the declaration of death.
Furthermore, the hospital's ethics committee is involved to ensure that the process has been followed as outlined in the protocol and that patients and families have adequate understanding of the protocol.
Is it ethical to give drugs to the dying that only benefit the recipient?
In the case of the brain-dead donor, any treatments or procedures performed on the donor to enhance organ viability do not adversely affect the patient because death has already occurred. With non-heartbeating donation, medications and procedures necessary for maintaining organ quality may be administered before death, without benefit to the patient, which raises concerns about possible harms to the patient, including even the possibility of hastening death. For example, to enhance organ viability, some NHBD protocols allow the administration of heparin, a blood thinning agent, prior to death to help preserve circulation to the organs. A concern, however, with heparin is that it may cause an intracerebral bleed and subsequent death. As such, death has been caused by active means rather than passively achieved by the withdrawal of life supports.
This adverse effect from heparin administration is enhanced if the patient does not die immediately after the withdrawal of life-supports.
Safeguards can defuse the concern with heparin administration.
First, the person giving consent for donation is informed about the infusion of heparin and its potential side effects.