CHW’s Position on Donation After Cardiac Death Carol Bayley VP Ethics and Justice Education Ethics Champion Program

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Galloping History of Transplantation 1955 first major organ transplantation (DCD) 1962 immunosuppressive drugs 1968 Harvard Brain Death Criteria 1976 Quinlan allows withdrawal of life support 1992 Pittsburg protocol; KIE Journal issue Minutes 1997, 2000 IOM reports

Dead Donor Rule 1997 IOM Report In order to procure (“recover”) organs from a person, the person must be dead. Seems obvious, but…

Language has changed (Brain dead donor=Heart-beating donor) Non heart-beating organ donor (NHBD) Donation after Cardiac Death (DCD) Asystolic organ donation

Language, cont’d Organ “harvest” “procurement” “recovery” Organ recovery is the politically correct usage, but “Patient allowed to die in a way that facilitates recovery.” What?

There is a difference between old DCD and new DCD Old DCD: “uncontrolled” Patient found dead; organs recovered. New DCD: “controlled” Patient in whom recovery is extremely unlikely has life- support removed under in a controlled environment; organs recovered.

Old vs New Old DCD Death happened on its own terms Organs recovered but sometimes not in good condition New DCD Organs recovered in better condition Death is negotiated

Case 19 year old man hung himself; he was expected to “progress” to brain death followed by organ donation; did not die. OPO suggested DCD 10 days later, DCD performed Patient taken to OR; life support removed 20 minutes later, heart stopped beating; organs taken

Arguments in support of DCD Organ donation saves lives Pool of recipients has grown more quickly than pool of donors 90,000 on waiting list; 6,000 die each yr DCD may honor pt/family wish Family may find comfort in donation Donation nurtures altruism* DCD supported by transplant community

Arguments opposing DCD Conflict of interest DCD manipulates definition of death Pro literature first argued that Dead Donor Rule not violated; now same authors argue that violation of DDR is justified. Is it two, five or ten minutes? Permanent and irreversible: depends on intentions of those in OR

Arguments opposed, cont’d Do No Harm DCD procedures prior to taking organs may not be in the patient’s best interest. (Ex) Sometimes it doesn’t work Patient is returned to floor to die Families may be disappointed Pressure to succeed; strain on resources

Arguments Opposed, cont’d. Informed Consent Families are not told that testing procedures may hasten death. Families are not told that there is a ethical debate—OPOs do not believe there IS ethical debate. Substituted judgment difficult: very few individuals understand what is involved in process. People with pink dot signed up for something different.

Camel’s nose under the tent… 15,000—35,000 persons in PVS. Almost 2/3 of medical directors and neurologists think PVS patients appropriate for organ donation (1993) “Controlled suicidal donation” High C-fracture, conscious patients

Delicate Consensus on End of Life Care may be jeopardized Withdrawal of treatment is difficult Some resist because they think we are trying to save money, or that the loved one’s life is worthless DCD could backfire, resulting in fewer donations overall

What is our duty? Hold to CHW’s policy of no DCD; transfer when family requests. Increase donations from brain dead patients (e.g., St John’s); increase number of organs recovered from each donor by following protocols and calling OPO promptly.

Moral(s) of the Story Dying patients are not a means to another’s end, even a good end. Some things take time. Birth takes time; death takes time. Patients are persons, not an assemblage of spare parts.