Crossing the life line

A new procedure called ‘donation after cardiac death’ is being used to make more organs available for transplants
Saturday, June 9, 2007 | 12:00 a.m. CDT; updated 1:12 p.m. CDT, Tuesday, July 22, 2008

Dave Chrystal spent 171 days in a University Hospital bed waiting for a heart transplant to save his life.

“You sleep and just wait,” he said. “You don’t know if you’ll wake up in the morning. You just try and keep your spirits up.”

After nearly six months of waiting, he received notice that he would be getting a heart from a 24-year-old Kansas suicide victim in what Chrystal called “the most emotional moment anyone could ever experience.”

More than 96,000 Americans live through similar uncertainty, forced to wait for an organ donor, according to the United Network for Organ Sharing. Even as technology improves, more Americans remain waiting for transplants because of a shortage of donors.

A re-evaluation of organ donation procedures seeks to close the gap between donors and those seeking organs, but many doctors and hospital ethicists are concerned about issues surrounding an increasingly used procedure to curb the shortage called “donation after cardiac death.”

Before September 2004, when the first donation after cardiac death procedure was performed at University Hospital, organs were taken from patients determined to be “brain dead,” which refers to a complete and irreversible loss of brain activity.

The typical organ donor suffers a sudden traumatic injury, usually from a car wreck, assault or stroke, and is stabilized at the hospital. If the treating physician then determines all brain activity has ceased, the patient is considered dead. Blood still is circulated through the body as respiration is maintained by life support systems, preserving organs in a transplantable condition for up to several days. If the deceased was relatively young and didn’t have any conditions affecting desired organs, the person is confirmed as a potential organ donor, and the family is consulted about the donation option after being told of their family member’s death.

Because the number of people who meet these requirements is far less than the number of people who seek organs, hospitals and organ banks are turning to lesser used procedures such as donation after cardiac death to deepen the pool of available organs.

A donation after cardiac death begins in the same way as a traditional brain death donation — with a sudden, violent injury that results in hospitalization. After examination, the treating physician determines that, while the patient might not meet the criteria for brain death, injury to the brain is so massive that the person will likely remain in a lifelong coma, unable to live independently of life support.

At this point, “We’ve seen enough to determine they’re not going to come back,” said Mark Wakefield, one of the six transplant surgeons at University Hospital. “There’s enough anecdotal evidence to suggest people can recover, but what you don’t hear about are the 99.9 percent of people who eventually die of other causes, such as infection from pneumonia or bed sores.”

This is the point where critics raise most of their objections to donations after cardiac deaths. After a severe brain injury diagnosis, the family has to choose between allowing their loved ones to remain on life support or discontinuing care and allowing them to die.

Critics worry that the option of organ donation may influence this choice and the care of the living patient. Further complicating the matter are the differing obligations of the personnel involved in the process: physicians and nurses, who have a responsibility to provide the best care for a living patient, and representatives and surgeons from an organ procurement organization, who have an obligation to find organs for as many needy people as possible.

The Joint Commission on Accreditation of Health Care Organizations responded to these concerns by requiring hospitals to adopt policies on organ donation by Jan. 1.

University Hospital prohibits organ bank staff from being directly involved in the process until the family has decided to discontinue life support.

“It’s analogous to the separation of church and state,” Wakefield said. By keeping the two medical teams ideologically and physically separated, the hospital hopes to avoid any conflict of interest and allow the family to make its choice based solely on the treating physician’s diagnosis.

After the prognosis is given by the treating physician, if family members decide to discontinue life support they are presented the option of organ donation. The surgical teams are not allowed access to the patient until cardiac death has been declared and confirmed by the treating physician.

“We’re called when the family has decided to withdraw care,” said Jeffrey Reese of the Midwest Transplant Network, the Westwood, Kan.-based organ procurement organization that serves Columbia. “We’re here to make something good out of something bad.”

Reese credits “better training and better publicity” for boosting families’ acceptance rate from about 50 percent to about 75 percent over the last few years, leading to donations after cardiac death making up about 10 percent of all organ transplants overseen by the Midwest Transplant Network. The organ bank hopes to reach 20 percent in the near future.

“(Donation after cardiac death) has a lot of potential to increase the number of available kidneys,” said James DuBois, director of the Center for Health Care Ethics at St. Louis University.

National statistics collected by the United Network for Organ Sharing, which organizes national organ procurement efforts, report that donation after cardiac death procedures accounted for 1.2 percent of all recovered organs in 1995 and has risen to 8 percent in 2006.

Critics, however, feel the proliferation of donation after cardiac death procedures is premature.

“(Donation after cardiac death) represents a big change for the whole organ donation process. There hasn’t been anywhere near enough public discussion on this,” said Carol Bayley, vice president of ethics and justice education for Catholic Healthcare West, which operates 42 hospitals in Arizona, Nevada and California.

“For the organ procurement organizations to promote donation after cardiac death as noncontroversial is wrong,” she said. “Cardiac death isn’t something that just happens to you; it’s a product of negotiation and quite different from donation after brain death.”

Bayley and other critics also have concerns about taking physicians away from other health-care work. If a family decides to proceed with a donation after cardiac death, a licensed physician must pronounce death after life support is discontinued and before the organs are removed. The physician must remain nearby so that organs can be removed as soon as possible after the patient dies, minimizing the chance of the organs going bad.

“There are times when a patient doesn’t die within one to two hours,” DuBois said. Pulling aside a physician for a long period of time, he said, “can be fairly taxing on a hospital and disappointing to families who are motivated to donate.”

The treatment patients receive can be stressful for hospital staff as well. Some medication could interfere with the organs intended for donation. Hospital staffs must decide which medicines to continue and which to stop in anticipation of a transplant, forcing them to balance comfort of the patient and preservation of the organs.

“(Donation after cardiac death) is always going to be at least as controversial as withdrawing life support,” DuBois said.

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