Donor: Before or After Death?

Excerpt from “Death and the Organ Donor” [Comment: Truog, et al. have been advocating organ harvesting before death for many years. Non-heartbeating organ donation (now called DCD here) has been going on since the early 1990s and I’ve been writing about this unethical practice since the late 1990s (see excerpt from my 2009 article “Death and the Organ Donor” below) but the whole issue has received little media attention. Now it seems that the “bioexperts” are finally ready to go public. As usual, this controversial issue is portrayed as “just” taking the kidneys with the excuse that this is harmless to the person. Really?? But look at the comments! Almost all the current ones are against this. Even without knowing all the facts about DCD, it seems most people have basic common sense. N. Valko RN] Excerpt from “Death and the Organ Donor”, online at http://www.wf-f.org/09-01-Valko.html : “The Council’s (the President’s Council on Bioethics) white paper admitted that the legal definition of irreversible cessation of heartbeat and breathing used to justify DCD/NHBD has problems. Most people would consider “irreversible” in this context to mean that the heart has lost the ability to beat. But in DCD/NHBD, “irreversible” instead means that there is a deliberate decision not to try to restart the heart when it stops and that enough time has elapsed to ensure that the heart will not resume beating on its own. However the Council had to admit the dearth of scientific evidence supporting this determination. In some cases involving babies, for instance, the heart is harvested and actually restarted in another baby. “The Council also admitted that...

Non-Brain Death Organ Donation, Part One

Most people who sign organ donor cards assume that they will be carefully diagnosed as “brain dead” before their organs are donated. That was generally true years ago, but a new non-brain death organ donation procedure was developed in the 1990s even though the language on organ donor cards did not change. The current non-brain death organ donation policy started with ethics journal articles in the 1990s. At that time, it was called “non-heart beating donation” and promoted as a way to increase the supply of organs for transplant beyond the usual “brain death” organ donations. This was made possible by linking organ donation to withdrawal of treatment decisions from people considered hopelessly ill or dying but who did not meet the criteria for “brain death.” This change in policy came in the wake of court decisions upholding the right to refuse treatment for incapacitated patients like Nancy Cruzan, a brain-injured woman said to be in a so-called “vegetative state.” Since Dr. George Isajiw and I presented the following paper (“Non-heart beating organ donation” and the “vegetative state”) in 2004, the term “non-heart beating organ donation” has been changed to “donation after cardiac death” (DCD) and now around 5% of organ donations are from nonbrain death organ donors.[i] The numbers are expected to increase with organ donation policies such as the following: In June 1996, the American Medical Association issued its opinion that non-brain death organ donation was ethical.[ii] Eventually, the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) required all hospitals to develop policies for DCD, effective January 2007, while the United Network for Organ Sharing (UNOS)...

Non Heart-Beating Donation (NHBD): 5 Articles 2006-07

1. Palliative Care and Organ Donation http://www.pallimed.org/2006/03/terminal-patients-in-icu-and-organ.html Monday, March 20, 2006 Terminal patients in the ICU and organ donation In my job as a palliative medicine doctor, I am frequently talking with patients and families about the potential of withdrawal of ventilators/pressors/dialysis in the ICU. Obviously this is not the only thing I talk about, but it often comes up in discussing dignity and futility and all the things that demonstrate our limits with modern medicine. One of the things I have not seen implemented well (in person or in literature) is a way to make organ donation and palliative medicine work a little closer together. An article in the current Intensive Care Medicine describes a pilot project to develop a program for non-beating heart donors (NBHD) after withdrawal of life support. This Swiss study was prospective and identified 73 of 516 deaths that might be appropriate for NBHD of kidney, liver or lung. While they found that there was too much variability in how patients died in the ICU after withdrawal to implement their program, they did come up with some interesting data and discussions. Part of the dilemma in implementing a NBHD organ procurement program was the variability of time after withdrawal of intubation or pressors. They note it would be hard to have a surgical team on standby for a variably prognostic cardiac death versus a brain death where the organs are procured in the OR after the aorta is clamped (from my ancient 1998 knowledge during my organ transplant rotation on surgery). But this does give some helpful prognostic information for professionals dealing with near-death...

Trend in Organ Donation Raises Questions (3/07)

NEW TREND IN ORGAN DONATION RAISES QUESTIONS: As Alternative Approach Becomes More Frequent, Doctors Worry That It Puts Donors at Risk. The number of kidneys, livers and other body parts surgeons are harvesting through a controversial approach to organ donation has started to rise rapidly, a trend that is saving the lives of more waiting patients but, some say, risks sacrificing the interests of the donors. Under the procedure, surgeons are removing organs within minutes after the heart stops beating and doctors declare a patient dead. Since the 1970s, most organs have been removed only after doctors declared a patient brain dead. Federal health officials, transplant surgeons and organ banks are promoting the alternative as a way to meet the increasing demand for organs and to give more dying patients and their families the solace of helping others. Some doctors and bioethicists, however, say the practice raises the disturbing specter of transplant surgeons preying on dying patients for their organs, possibly pressuring doctors and families to discontinue treatment, adversely affecting donors' care in their final days and even hastening their deaths. Nevertheless, the number of these donations is on the rise. It more than doubled from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 additional kidneys, livers, lungs, hearts and other organs. "It's starting to go up exponentially," said James Burdick, who leads organ-donor efforts at the federal Department of Health and Human Services. The trend is expected to accelerate this year. For the first time, the United Network for Organ Sharing, which oversees organ procurement, and the Joint Commission on...

Brain Death or NHBD – Important Distinction

For the past several years, a little-known but disturbing revolution has been occurring in organ donation. In the understandable but sometimes alarming zeal to obtain more organs, the procedure called non-heart-beating organ donation (NHBD) has been quietly added to brain death organ donation in more and more hospitals all over the country. Although “brain dead” is a term many people erroneously associate with a coma-like condition or use to humorously describe an ignorant person, brain death is a legal and medical term that describes the irreversible loss of total brain function, even when the body can be kept going for a while using technology such as a ventilator. Since 1970, every state has added brain death to the legal and more familiar definition of death as the irreversible end of breathing and heartbeat. The addition of brain death as a legal definition of death revolutionized organ transplantation, because waiting until a person died naturally to harvest organs often resulted in organs too damaged for successful transplant.  With brain death, organs could be taken before breathing and heartbeat stopped, and organ transplantation became commonplace. But when brain death did not meet the demand for organs, NHBD was invented in the 1990s as a way to obtain more organs. NHBD is very different from brain death organ donation.   While brain death organ donation means the person is legally dead but still has a heartbeat when organs are harvested, the potential NHBD patient is alive but termed “hopeless” or “vegetative” by a doctor, usually soon after suffering a devastating condition like a severe stroke or trauma and while still needing a ventilator...