The attempt to increase the organ donation pool has led to an increased use in “heart death” procurement protocols, known as “non heart-beating cadaver donors.” Under what has been called the Pittsburgh Protocol, obtaining organs via this method involves, 1) Planned removal of ICU-type life support; 2) Waiting for full cardiac arrest; 3) A time interval, generally 2-5 minutes. 4) Declaration of Death; and, 5) Organ procurement from the cadaver. Death is declared on the basis that there has been an “irreversible” loss of cardio/pulmonary function. (This is known as Donation after Cardiac Death, or DCD.)
There have been problems reported. For example, too short wait—only 75 seconds—between cardiac arrest and procurement, as well as ethical violations of failing to keep the medical team and their treatment of the patient isolated from the transplant team—the latter of which are to have no input whatsoever in the patient’s care or the decision to withdraw life support.
Now, an important article in the Journal of Intensive Care Medicine calls into question the entire concept of DCD. For example, withdrawing life support often doesn’t lead to immediate cardiac arrest, and some patients don’t die at all. From the article:
There is a misconception that withdrawal of ventilatory and hemodynamic support will result in immediate or imminent death in the ICU. A survey of withdrawal of mechanical ventilation in the critically ill adults at 15 ICUs found that 21 of 166 patients (13%) survived to ICU discharge after withdrawal of life support.Of even more concern, the proper care of such patients may be compromised by concern for protecting organ viability:
This can lead to actual compromises in proper end-of-life care:
In circumstances involving possible organ donation, it can be difficult not to manage patients as potential donors rather than as dying patients. Some institutions have permitted onsite in-house coordinators from procurement organizations to engage in donor surveillance and management in the ICU before donation consent and without families’ knowledge to increase donation rate.
Because of the financial interests of health care and health care-related industries the institutional ethos in established transplant centers become subordinate to transplantation practice, which can introduce the risk of unconscious identification with the program.
The summary worries that these protocols have compromised the dead donor rule:
The need to procure viable organs can undermine the type and quality of EOL care offered to prospective organ donors. DCD requires the transfer of patients before or upon death to the operating room for organ procurement. Opioids and sedatives may be withheld to avoid hastening death before withdrawal of life support and completion of preparation for organ procurement.
Another concern has also been expressed that upon withdrawal of life support, excessive doses of opioids and sedatives may be administered for early onset apnea and pulselessness to shorten the warm ischemia time for organ procurement. Likewise, the administration of heparin to prevent the formation of blood clots in the solid organs of a potential organ donor may precipitate internal hemorrhage and hasten the donor’s death. The administration of vasodilators to promote solid organ perfusion can exacerbate hypotension and the onset of cardiocirculatory arrest on withdrawal of life support.
There is little evidence to support that the DCD practice complies with the dead donor rule. The likely high false-positive rate of the UW evaluation tool can expose many dying patients to unnecessary perimortem interventions. The use of medications and/or interventions for the sole purpose of making the organs more viable can have unintended negative consequences on the timing and quality of organ donors’ EOL care. Recipients of marginal organs from DCD may suffer higher mortality and morbidity than recipients of other types of donated organs.Beware: Rather than use this information to more carefully manage organ procurement protocols—and we still need nationally uniform rules—some bioethicists and organ professionals will instead use it it as a club to destroy the dead donor rule itself. As I have noted often, there is a drive underway to open the door to explicit killing for organs. We must resist such instrumentalization of human life.