Authors

  • Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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Comments

rlbates

Very nice post. Thanks

Dave Undis

It would be a real shame if the Dr. Hootan Roozrokh case caused people to refuse to register as organ donors. We need all the organ donors we can get.

Over half of the 98,000 Americans on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate about 20,000 transplantable organs every year. Over 6,000 of our neighbors suffer and die needlessly every year as a result.

There is a simple way to put a big dent in the organ shortage -- give organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Chris

I had a case of DCD as an intern in a community ICU. Fortunately, she passed peacefully, but I remember it being difficult to explain to the family that she was dead (the a-line was flat) while there was still electrical cardiac activity. Of course, the longer I waited to declare (to avoid confusing the family), the less-perfused/suitable the organs). Wished I'd had a little supervision on that case. I think I maybe even have a blog entry about that...

Wouter

Here in the Netherlands, the patient is usually taken off ventilator on the icu and only transported to the or after the hands-off period. Interestingly the hands-off period varies greatly around the world, from 1 to 20 minutes.

T.

What a brilliant post! These are important that should be talked about but AREN'T. Thank you for having the courage to articulate these thoughts and for doing so with such aplomb.

Gibbitt

China seems to have no problem in defining what qualifies as a suitable organ donor. In the limbo of lowering the bar, they win!

Mike O'Connor

Time has passed, but my desire to comment on this post has not.

First, it is a terrific post, and thought provoking in a way that the peer reviewed literature about this subject has not been.

- In this instance, the transplant coordinator showed up and assumed care of the donor. This happened because a. it is the standard of care for brain dead donors and b. the hospital had no experience managing this process. This should never have happened, but, as everyone involved was accustomed to ceding control to the harvest team, they did. The implementation of a DCD program requires the establishment of a completely new and strict procedures. Easy on paper, hard in practice.

- The ICU and OR personnel should never have let the transplant team have access to the patient until he had been pronounced dead. In theory, this is easy. In practice, as Mitch points out, it can be very difficult.

- As you might expect, the facts of the case are in dispute. There are printed allegations that the sedation ordered included large doses of lorazepam (on the order of 40-80 mg) and morphine (on the order of 100-200 mg). Is the administration of such large doses over such a short time-frame (in a patient who does not manifest any signs of discomfort) to a 40 kg patient appropriate? I have withdrawn care on a substantial number of patients in the ICU, and have on occasion titrated in substantial quantities of various medications, but have not yet given doses like these.

http://bmartinmd.com/2008/02/nyt-discovers-california-and-r.html

- The issues of coercion and informed consent still need to be ironed out here. Who should obtain it? Some might contend that the OPO and transplant surgeons have an insuperable conflict of interest. How much contact should they be allowed? Should they be allowed to call the family every day? Should they be permitted to utilize presumptive language (akin to used car dealers) in their discussions with these vulnerable families?

http://content.nejm.org/cgi/content/full/358/12/1209

- The OPOs of our world are increasingly aggressive in their efforts to obtain organs. In some states, OPOs have pushed through legislation that transforms declarations of intention to donate organs into legally binding contracts. If you live in such a state and have checked the 'Organ Donor' box on your Driver's license, your organs can be harvested no matter what your family might want. Their power-of-attorney over you ends when you are declared dead! I am obviously not a lawyer, but in theory (and perhaps in practice), you might be construed as having consented to DCD. Does this sound over-the-top? Maybe, but read the details of this case: they aren't what anyone involved in crafting these policies intended.

Van Sales

I visited this blog first time and found it very interesting and informative.. Keep up the good work thanks..

cardiology emr

Interestingly the hands-off period varies greatly around the world, from 1 to 20 minutes.

Kevin

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