Comment: Note that some of these radical organ donation proposals are already happening in the US, according to this article. N Valko RN
A BMA report has revived the debate about how far doctors should go to help save the lives of patients with organ failure.
Patients could be kept alive solely so they can become organ donors, hearts could be retrieved from newborn babies for the first time, and body parts could be taken from high-risk donors as part of an urgent medical and ethical revolution to ease Britain’s chronic shortage of organs, doctors’ leaders say .
Hearts could also be taken from recently deceased patients and restarted in those needing a cardiac transplant, under controversial proposals from the British Medical Association intended to stop up to 1,000 people a year dying because of the country’s chronic shortage of organs.
A new BMA report on ways to increase the supply of organs, which it has shown to the Guardian, has revived the intense ethical debate about how far doctors should go to help save the lives of the growing number of patients with organ failure.
The BMA wants a debate about the use of an ethically contentious practice called “elective ventilation”, in which patients diagnosed as dead using brain stem tests – such as those who have suffered a massive stroke – are kept alive purely to enable organ retrieval.
While such patients are usually put on artificial ventilation for a short while to enable their relatives to say goodbye or for organ donation, the report says, “elective ventilation is different in that it involves starting ventilation, once it is recognised that the patient is close to death, with the specific intention of facilitating organ donation”.
This procedure led to a 50% jump in the number of organs available when it was carried out by the Royal Devon and Exeter hospital from 1988, but it was declared unlawful by the Department of Health in 1994. However there are fears that elective ventilation could induce a persistent vegetative state, and concern it is unethical to give patients treatment to benefit other people rather than them.
“I worry about it. It’s very difficult,” said Dr Kevin Gunning of the Intensive Care Society, which represents staff. But Dr Vivienne Nathanson, the BMA’s head of ethics, said the practice might be deemed permissible, at least for patients who had signed the organ donor register.
Spain and the US already use the technique, said Nigel Heaton, professor of transplant surgery at King’s College hospital, London. “People have qualms about it. The concern is that you are prolonging or introducing futile treatment that has no benefit for the patient.
“But I expect that views will gradually change around this [in its favour]. It’s an ongoing tragedy that so many people are still dying in this country for want of an organ,” he said.
One of the report’s other most radical suggestions is that – with the permission of the deceased’s family – surgeons could remove the heart of someone who has just suffered circulatory death, maintain its function by putting blood and oxygen into it, and give it to a patient who needs a new heart.
“The fact that an individual is declared dead following cessation of cardio-respiratory function but the heart is subsequently restarted and transplanted into another person is a difficult concept and one that requires careful explanation,” the report says. At the moment only livers, kidneys and lungs are retrieved from such patients.
The surgery, which has been used successfully in the US, is “an acceptable and important area of research to pursue” and “represents a possibility of both increasing the number of hearts available for donation and also facilitating the wishes of more people who wish to be donors”, the report says.
Nathanson said: “When it’s well explained, relatives understand that their loved one’s heart isn’t being jumpstarted and going back to normal or near-normal function in the way that it is with someone with an arrhythmia, the way you see it in Casualty or Holby City.”
But the report admits that some intensive care doctors oppose the practice, “questioning whether frustration over the falling number of DBD [donation after brain death] donors has resulted in ‘interventions that could jeopardise professional and public confidence in all forms of donation’ and arguing that such practices are ‘at the very edge of acceptability'”.
However, Heaton said the technique was “an important development”, which was the subject of much ongoing research and that “it will come through into clinical practice” eventually.
Gunning said the restarting of hearts would need strict safeguards, but could help overcome the severe lack of donated hearts.
Sally Johnson of the NHS’s Blood and Transplant agency said the critical shortage of organs meant it was “keen to engage in any discussions about increasing the donor pool and availability of healthy, viable organs”. But she warned: “Many issues, ethical and clinical … need to be considered and addressed before anything can be introduced in relation to heart donation from donors after circulatory death.”
Sir Bruce Keogh, the NHS’s medical director, said the BMA’s report was “a welcome contribution to the debate about how we encourage more people to be organ donors”.
A Department of Health spokesman said: “Any action taken prior to death must be in the patient’s best interests. Anything that places the person at risk of serious harm or distress is unlikely to ever be in the person’s best interests.”
The BMA said it welcomed recent increases in organ donation, but wanted more action, including a switch to an opt-out system, where everyone would be assumed to be a willing organ donor unless they explicitly said otherwise.
“At the moment between 500 and 1,000 people die each year from a treatable condition because they don’t get the transplant because there aren’t enough organs. Society should decide if it’s prepared to tolerate that repeated loss of life or take action to stop it,” said Nathanson.
The report also suggests:
• Bringing in a test for brain stem death in newborns aged less than three months so the UK can retrieve hearts from babies who have died, for example of birth asphyxia, and stop importing hearts for this age group.
• Easing the exclusion criteria that forbid some people from donating because of their age or medical history. “Slightly stretching” eligibility rules, particularly revising the upper age limit, could cut the 7,800-strong transplant waiting list.
• Encouraging A&E staff to identify more dying patients who might donate, as relatives of up to 400 people who die in A&E each year are not being asked about it.
• Advertising campaigns to reduce the 35% refusal rate among families who are asked to allow their loved one’s organs to be retrieved.
• Action to highlight the “moral disparity” of those who say they would accept an organ but would not donate one.
• Extending the obligation, introduced last summer, to answer a question about donation when applying for or renewing documents, such as a driving licence or a passport, tax returns, registration with a GP or even admission to the electoral roll.
Gunning said that while many of the BMA’s ideas were “controversial”, all deserved an airing and many were of merit.
Despite a big increase in organ donation since the Organ Donation Task Force kickstarted improvements in 2008, the UK still lags behind many countries in its low donation rates. He backed the BMA’s call for more intensive care beds, and claimed that “the UK has the lowest number of them in the western world”.
Refusal rates are “a huge problem”, said Heaton, and accessing more kidneys would save the NHS “huge amounts of money” as each patient on kidney dialysis – as 85% of those on the transplant waiting-list are – costs the service about £25,000 a year.