Some find donor protocols “extremely troubling”

Expanding pool ethically is issue

While Americans typically support organ donation, data show the number of actual donations is actually quite low and cannot keep up with demand, says Leslie M. Whetstine, PhD, an assistant professor of philosophy at Walsh University in North Canton, OH. “The fear that patients may not be given optimal care if they are organ donors, or that organs will be removed before one is actually dead, remain pervasive,” she adds. “It is difficult to dispel these concerns when Uncontrolled Donation after Circulatory Determination of Death [UDCD] protocols give credence to what were once merely urban legends.”

UDCD is a method of organ procurement used when death is unanticipated, says Whetstine. For example, a patient in cardiac arrest arrives in the ED and, after resuscitation fails, death is declared based on the irreversible cessation of circulation. A waiting period of two to five minutes elapses before organs are removed.

“The reason there is any waiting period at all after a declaration of death is to rule out autoresuscitation (AR). If a person were to autoresuscitate, then they were clearly not irreversibly dead, and removal of organs would be akin to homicide,” she says. “If the procurement process is initiated during the time in which AR is possible, then a dying patient may be mistaken for a dead one.”

Whetstine says the ethical question is whether providers can rely on the circulatory criterion required by donation after cardiac death (DCD) to determine death when the need for speed is paramount and still maintain the integrity of the Dead Donor Rule. A 2010 study surveyed the existing literature on AR and reiterated the need for prospective studies, and a 2007 study concluded that patients should be passively monitored for at least 10 minutes after the cessation of cardiopulmonary resuscitation before confirming death.1,2

“DCD conflates a prognosis of death with a diagnosis of death to the extent that imminently dying patients may be treated as dead, which violates the Dead Donor Rule,” says Whetstine. “We obviously know that lack of circulation doesn’t make one instantly dead. Resuscitation is premised on the fact that such cessation is not always irreversible.”

DCD focuses on a criterion of death that claims cessation of the organism as a whole can be determined by loss of circulatory function only, independent of brain status, which is “simply erroneous,” says Whetstine. “It is disingenuous at best, and potentially lethal at worst, to claim that we know the precise moment of death after cessation of circulation.”

Patient “dying but not dead”

Whetstine says that some new UDCD protocols that initiate chest compression and artificial ventilation after a declaration of death in order to circulate preservatives that extend organ viability throughout the body are “extremely troubling. To prevent the possibility of return of consciousness, such UDCD protocols have instituted highly contentious and creative techniques.”

In order to avoid cardiac or brain perfusion, such protocols implement a balloon catheter to occlude the thoracic aorta. This is a serious ethical dilemma, according to Whetstine, because the transplant team clearly understands that circulatory function has not been irreversibly lost, and brain perfusion and subsequent reanimation would be possible, which means the patient is dying but not dead.

There are some unique ethical considerations with UDCD because the patient’s death is unanticipated, unlike DCD, in which there is a planned withdrawal of support expected to result in the patient’s death, says Alexandra K. Glazier, Esq., vice president and general counsel at New England Organ Bank in Waltham, MA, and chair of the OPTN-UNOS Ethics Committee. For example, there is an ethical concern that UDCD could conflict with, or undermine, the priority that patients receive all possible life-saving measures before organ donation is considered.

Because the declaration of death in UDCD circumstances will be based on the irreversible absence of circulation, there has also been ethical debate regarding protocol measures that artificially restore circulation in the donor after death has been declared, says Glazier. For example, under some UDCD protocols, after the patient is declared, extracorporeal membrane oxygenation is instituted to perfuse the organs in an effort to improve transplant outcomes. “The ethical question is whether such measures negate the validity of the death declaration in the first instance,” says Glazier.

Glazier gives these recommendations to address ethical concerns with UDCD:

UDCD protocols should ensure that the patient receives aggressive resuscitation measures that meet or exceed current accepted medical standards and legal requirements before death is declared.

“All resuscitation efforts must be exhausted so that it is clinically clear the patient will not and cannot recover,” says Glazier.

UDCD protocols should require that the death declaration follow accepted medical and defined legal standards.

This addresses ethical concerns regarding death declaration, given the rapid nature of UDCD, says Glazier.

As with DCD, the declaring physician must not be associated with the donation or subsequent transplantation of donated organs.

“This separation of duties helps to reduce any potential conflict or the appearance of a conflict,” says Glazier.

DCD is a widely accepted practice endorsed by the Institute of Medicine, says Glazier, noting that last year 13% of all organ donations in the United States were DCD, and this number has steadily increased over time. “Many of the initial ethical concerns surrounding DCD have been resolved,” she says. “Donation is not discussed as an option until the family and the health care team agree that further measures are futile, and the decision to withdraw support has been made.”

References

  1. Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after cardiac arrest. Crit Care Med. 2010;38:1246-1253.
  2. Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. J Royal Society Med. 2007;100:552-557.

Sources

  • Alexandra K. Glazier, Esq., Vice President/General Counsel, New England Organ Bank, Waltham, MA. Phone: (617) 244-8000. E-mail: Alexandra_Glazier@neob.org.
  • Leslie M. Whetstine, PhD, Assistant Professor, Philosophy, Walsh University, North Canton, OH. Phone: (330) 244-4697. E-mail: lwhetstine@walsh.edu.