Donation after Cardiac Death: Is mostly dead slightly alive?

"There's a big difference between mostly dead and all dead. Now, mostly dead ... is slightly alive."

-Miracle Max, The Princess Bride.(1)

In Jainism, a gentle devout sect of Hinduism, the sanctity of life is taken to an extreme. Jains are vegetarians. The most devout Jains will not eat fruits and vegetables that are harvested; they prefer to eat produce that has fallen naturally from the vine or tree.

Which brings us to the euphemistic "Donation after Cardiac Death," or DCD. For those of you who have wandered into this blog, a little history. In 1968 a Harvard committee headed by Henry Knowles Beecher (Harvard Professor of anesthesiology) defined Brain Death. This led naturally to the notion that with proper consent, the organs from such unfortunate ex-individuals (individuality being lost once the person died) could be of utility to society and potential organ recipients. These potential donors are the poor folks who have fallen off the vine of life, but for whom some organs still possess vitality. But, there were problems, the main one being that as the industry advanced, there just weren't enough organs to meet the burgeoning demand.

So, the transplant industry, with transplant surgeons and organ procurement organizations (OPOs) in the lead, set aside decades of careful philosophical and ethical reasoning behind brain death in favor of a utilitarian formulation; they lowered the bar for donation...

Where is that bar? No paraphrasing here; let's get it straight from the horse's mouth. The horse, in this case, is the prestigious Institute of Medicine, and the United Network for Organ Sharing, the non-profit organization of Organ Procurement Organizations (OPO). According to the policy:

"A patient . . . who has a non-recoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for donation after cardiac death. Other conditions [may] include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury." (2)

In donation after cardiac death, consent is obtained from the patient or  responsible family members/guardians. The patient is taken to the operating room with the organ procurement team standing by. Support (typically, mechanical ventilation) is withdrawn, and the patient (hopefully?) stops breathing. Hypoxia causes asphyxia, which is closely followed by cardiac death. Then, the patient is pronounced dead and the organs are harvested...

For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list  also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness  is specifically not a necessary component for inclusion. But let's set aside that philosophical curiosity for the moment in favor of some nuts-and-bolts aspects of this process.

There's the matter of predictability. It's frustrating to summon the family, the out of town harvesting surgeon, the anesthesiologist, and when support is terminated, the patient does not cooperate with a pacific cessation of breathing followed by fibrillation/asystole. In fact, almost one half of the time, the patient/donor doesn't die on schedule, and the harvest must be abandoned.

And what to do when a patient fails to die with the tempo necessary to facilitate organ harvesting? Well, of course, since harvesting is theoretically incidental to the withdrawal process, the patient's caregivers shouldn't much care. If they do care, they have gone a long way towards violating the firewall that is  supposed to be maintained between the withdrawal/dying process and the harvesting/donation process. Any feelings on the part of the donor's caregivers for the concerns of the harvesters and potential recipients represents a corruption of the sanctity of the process, and ought be eliminated. And sanctity is the right word.

But of course, that's easier in theory than in fact. Biz-jets are chartered, busy important transplant surgeons have their schedules and sleep disrupted. Potential recipients become hopeful; the pressure of expectation and momentum becomes inexorable. Even the families of the soon-to-be-deceased can be part of the pressure. Meanwhile, the OR team is participating in a death vigil, with a possibly struggling patient. And they are being asked to perform interventions on the potential donor; anti-coagulation, blood pressure manipulations, line placement; interventions that can only benefit the organ recipient.

The critical care team's responsibility is to the patient. Not society. Not the potential recipient. not the OPO. That would represent dangerous dual-agency, and would cast mistrust on the patient-physician relationship at a critical juncture in the patient's life.  All that should matter to the intensivist and ICU staff at that time is the best interests of the patient-and if that means withdrawal of support, so be it. Organ donation must be incidental to the main thrust of the care. But by its very nature, it isn't.

It is extraordinarily uncomfortable to watch a patient struggle following withdrawal of ventilator support.  The administration of sedation in sufficient doses may relieve the apparent suffering, but enhances respiratory depression; in the rarefied air of ethics, this act represents a "dual effect" situation, where in theory the intention to alleviate the suffering justifies the potentially harmful effect. While it is true, the ethical concept is of slight consolation to those caregivers who only hours before were fighting to save that life.

So, even though the intensivist/anesthesiologist may be giving drugs to relieve suffering, they may also be hastening the patient's demise. Besides the obvious psychogenic discomfort because the act borders on euthanasia, there is the legal ambiguity inherent in society's inability to know what is in the intensivist's  heart;  intentions are everything in a dual effect act, and those intentions are "subject to interpretation" by say, a district attorney who might decide that the act respresents an intentional hastening of death (euthanasia) for the convenience of a harvesting team.

As a safeguard, those participants who stand to benefit from the patient/donor's prompt demise are theoretically excluded from any direct care of the patient; they cannot intervene until the patient is pronounced dead. On the other hand, the transplant surgeon and OPO can use their presence, their authoritative voices, to influence the proceedings. Only in theoretical ethical constructs do those parties consistently maintain the distant, disinterested air which is the ethical ideal. Having spent a lifetime with surgeons, and knowing how difficult it can be to "push back" against  powerful, willful superiors, the assumption that the harvesters will placidly wait for the "fruit to fall off the vine" might reasonably leave one a little non-plussed. In fact, it sounds like a scenario cooked up by (frankly), clinically naive ethicists who have never witnessed a showdown between a driven surgeon on a tight schedule, and a lowly anesthesiologist/intensivist assistant professor. For example, listen to this exchange between Dr Delmonico, chief of transplant at Mass General, and Dr Grodin, an extremely articulate psychiatrist, ethicist and full professor at Boston University, with careful attention to the tones and attitudes... While Dr Delmonico is undoubtedly a paragon of virtue and probity, many of his colleagues are equally as self righteous without the redemption of profound morality.

So it is no surprise that the transplant surgeon  Dr. Hootan Roozrokh, who had flown down to San Luis Obispo from San Francisco, took charge of the patient/donor against every procedural tenet, which he undoubtedly understood, and ordered the administration of sedation/respiratory depressants. (calling it "candy" was an extremely unfortunate lack of reverence for the donor and caregivers, and was a window into his intentions) At least, he didn't try and use a paralytic...

Which raises another point. One way to ensure a "successful" withdrawal is to be sure the patient is pharmacologically paralyzed; no muscles-no breathing. No struggling. Now, few would advocate the use of paralytics to facilitate withdrawal, which might make it appear like euthanasia. But what about folks that are already pharmacologically paralyzed to aid in tolerance of mechanical ventilation? Should they be reversed and allowed to struggle (with that struggling alleviated by sedation if possible), or should they remain paralyzed so that they present a peaceful appearance to the assembled team as they promptly, predictably expire?

In general, you can tell when you are on the ethical slippery slope if you find yourself grasping for intellectual details to steady yourself. The literature is replete with policies and conditions designed to rationalize and moralize the DCD process. These are not the technical details of determining brain death, but a sort of sophisticated application of advanced ethics "technology," which, if one were cynical, might be mistaken for sophistry...

The intent of DCD certainly makes utilitarian sense, but so do arguments that have been made in the past for forced sterilization of the genetically impaired; utilitarianism is not moral justification. This is not to say that DCD is immoral, but perhaps the process is not yet sufficiently refined to pass the test of common moral sense.  Like many aspects of the current medical environment, DCD imposes a dual agency status on caregivers; the patient's physician is expected to consider societal good as well as the patients interests in decision making. Many critical care and anesthesiology colleagues express a restless discomfort with this process, even as the Joint Commission is mandating that every hospital have policy in place facilitating (or justifying why they don't do) DCD...

And where are the evangelicals and pro-lifers?

Finally, there ought to be a neutral referee in this process, who represents none of the interested parties; not the patient, not the organ procurers, not the hospital. Their job would be to monitor for fair play and non-coercion, and they should come from the judicial sector, like an independent guardian-ad-litem. Considering all the other trouble/expense/uncertainty associated with this process, it seems like a modest modification with tremendous up-side benefits for society.

"The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function."

-F Scott Fitzgerld

1. While I am a huge Princess Bride fan, I must acknowledge that the first use of this quotation in the context of organ donation came from Gail Van Norman in this 1999 Anesthesiology article.  Dr Van Norman also wrote an overview of DCD in Anestehsiology 2003 available here

2.) Organ Donation after Cardiac Death, Steinbrook, NEJOM 7/19/2007.

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