New Trend in Organ Donation Raises Questions
As Alternative Approach Becomes More Frequent, Doctors Worry That
It Puts Donors at Risk
By Rob Stein
Washington Post Staff Writer
Sunday, March 18, 2007; A03
The number of kidneys, livers and other body parts surgeons are
harvesting through a controversial approach to organ donation has
started to rise rapidly, a trend that is saving the lives of more
waiting patients but, some say, risks sacrificing the interests of
the donors.
Under the procedure, surgeons are removing organs within minutes
after the heart stops beating and doctors declare a patient dead.
Since the 1970s, most organs have been removed only after doctors
declared a patient brain dead.
Federal health officials, transplant surgeons and organ banks are
promoting the alternative as a way to meet the increasing demand
for organs and to give more dying patients and their families the
solace of helping others.
Some doctors and bioethicists, however, say the practice raises the
disturbing specter of transplant surgeons preying on dying patients
for their organs, possibly pressuring doctors and families to
discontinue treatment, adversely affecting donors' care in their
final days and even hastening their deaths.
Nevertheless, the number of these donations is on the rise. It more
than doubled from 268 in 2003 to at least 605 in 2006, enabling
surgeons to transplant more than 1,200 additional kidneys, livers,
lungs, hearts and other organs.
"It's starting to go up exponentially," said James Burdick, who
leads organ-donor efforts at the federal Department of Health and
Human Services.
The trend is expected to accelerate this year. For the first time,
the United Network for Organ Sharing, which oversees organ
procurement, and the Joint Commission on Accreditation of
Healthcare Organizations, which accredits hospitals, are requiring
all hospitals to decide whether to allow the practice. In response,
medical centers are scrambling to develop policies, sometimes
sparking intense debate, especially at children's hospitals.
"It's an example of pushing the envelope to get more organs," said
Stuart J. Youngner, a bioethicist at Case Western Reserve
University. "Whenever we do that, we tend to step on various
traditional social taboos."
The approach, known as "donation after cardiac death" (DCD),
usually involves patients who have suffered brain damage, such as
from a car accident or a stroke. After family members have made the
difficult decision to discontinue a ventilator or other
life-sustaining treatment, organ-bank representatives talk to them
about donation.
Sometimes, the donor is suffering from an incurable disorder such
as Lou Gehrig's disease and wants to donate his or her organs after
deciding to forgo further care.
Once the decision has been made, a transplant team waits nearby so
surgeons can begin removing organs soon after the heart stops.
Because the heart can sometimes restart spontaneously, doctors wait
a few minutes after pronouncing death before allowing the surgeons
to begin. If the heart does not stop quickly, usually within an
hour, the procedure is aborted and the patient is taken back to his
or her room until death comes.
The practice was the norm before brain death became the standard
for pronouncing death in the early 1970s and surgeons began keeping
the donor's body functioning with life-support machinery until
transplantation could begin. When surgeons resurrected what was
then called "non-beating heart" donation in the 1990s, critics
called it ghoulish and said it raised a host of ethical questions.
Some called it tantamount to murder.
The National Academy of Sciences' Institute of Medicine examined
the practice, however, and concluded that it is ethical as long as
strict guidelines are followed, including making sure that the
decision to withdraw care is independent of the decision to donate
organs and that surgeons wait at least five minutes after the heart
stops.
"People are dying on the waiting list," said Francis L. Delmonico,
a transplant surgeon at Harvard Medical School, speaking on behalf
of the United Network for Organ Sharing. More than 95,000 Americans
are waiting for organs. "This is vital as an untapped source of
organ donors."
Nancy Erhard's 25-year-old son, Bo, became a DCD donor at
Massachusetts General Hospital in Boston in November 2005 after a
burst artery caused devastating brain damage.
"There was no hope. He would never regain conscious thought,"
Erhard said. "This gave his life so much more meaning in the end
because he was able to help so many others."
While some doctors and ethicists who initially questioned the
practice have become more comfortable with the procedure, others
remain troubled.
"The image this creates is people hovering over the body trying to
get organs any way they can," said Michael A. Grodin, who directs
Boston University's Bioethics and Human Rights Program. "There's a
kind of macabre flavor to it."
Some say the practice can interfere with patients' dying
peacefully, surrounded by loved ones, and can deny the family
sufficient time to grieve. Many hospitals have responded by
withdrawing life-support devices and other care in the
intensive-care unit or allowing families to accompany loved ones to
the operating room so they can be at the bedside when death
occurs.
But many experts remain concerned and worry that the practice blurs
the definition of death.
"The person is not dead yet," said Jerry A. Menikoff, an associate
professor of law, ethics and medicine at the University of Kansas.
"They are going to be dead, but we should be honest and say that
we're starting to remove the organs a few minutes before they meet
the legal definition of death."
In response to such concerns, most doctors wait five minutes after
the heart stops before pronouncing patients dead. But doctors at
some hospitals wait three minutes, others two. In Denver, surgeons
at Children's Hospital wait 75 seconds before starting to remove
hearts from infants, to maximize the chances that the organs will
be useable.
"A lot of us are not particularly happy about cutting that line
particularly close," said Gail A. Van Norman, an anesthesiologist
and bioethicist at the University of Washington in Seattle.
Van Norman and others also worry that the practice could pressure
family members and doctors to discontinue care, perhaps before it
is undeniable that there is no hope. Those fears are particularly
acute in pediatric intensive-care units, where the same nurses and
doctors frequently care for both potential donors and potential
recipients.
While many hospitals are adopting DCD policies, others have delayed
because of objections. Some are opting out. One hospital chain went
ahead but then instituted a moratorium because of concerns that the
local organ bank was becoming too aggressive.
In addition to giving DCD donors morphine, valium and other drugs
to make sure they do not suffer as life support is withdrawn,
doctors often insert a large tube into an artery and inject drugs
such as the blood thinner heparin to help preserve the organs. Some
say those measures may hasten death.
"It's worrisome when you stop thinking of the person who is dying
as a patient but rather as a set of organs, and start thinking more
about what's best for the patient in the next room waiting for the
organs," Van Norman said.
In California, police and state medical authorities are
investigating whether doctors did anything to speed the death of a
donor in San Luis Obispo last year.
David Crippen, a University of Pittsburgh critical-care specialist,
asked, "Now that we've established that we're going to take organs
from patients who have a prognosis of death but who do not meet the
strict definition of death, might we become more interested in
taking organs from patients who are not dead at all but who are
incapacitated or disabled?"
One fear among health experts is that such concerns will discourage
people from signing organ-donor cards.
Supporters, however, argue that hospitals have stringent safeguards
are in place. Each case is reviewed by an independent panel, and
the decision to withdraw care is separated from the decision to
become a donor. They also argue that DCD patients meet the legal
definition of death because there is no intention of reviving them,
and that there is no evidence that anything done to the donors
hastens their deaths.
"We are saying that if it is feasible and we can do it in a way
that does not harm the patient, then we should do this," said
Michael A. DeVita, a professor of internal and critical-care
medicine at the University of Pittsburgh. "We believe it's the
right thing to do for the patients who want to donate and for those
who need organs."
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http://www.washingtonpost.com/wp-dyn/content/article/2007/03/17/AR2007031700963_pf.html
This is worse than our HOTA..